I try not to ride marshrutkas. The mini-buses can get you anywhere in Bishkek, its true, but the fifteen-to-twenty-seat vans are often crammed with thirty, forty people. Sometimes a sheep, sometimes crates of watermelons or cabbage. But mostly people, crammed together and sweating, invading what little personal space Kyrgyzstan allows. That’s not the reason I don’t take them, though it certainly doesn’t help. The ten som it costs to ride a marshrutka, twelve som after dark, puts a dent in the little money I have. After rent, paying my growing utility bills, buying the market’s first bunches of beautiful, vitamin-filled spinach, those 12 cents add up, and I like walking.
But on the rare occasion I do hop on a marshrutka, one of two things inevitably happens. First: I get blatantly stared at, locals trying to figure out where I am from, and have to climb over shopping bags and small children and people’s knees and bodies to get out. (This week, apparently, I passed for Russian and was asked if I was Italian.)
Second: Someone lets out a phlegmy, uncovered, cough. The kind that rumbles in the base of your chest and explodes harshly and wetly into the air, the kind of cough that inspires empathetic pain in your chest when you hear it. That kind of cough.
An open cough on any public transportation makes me impulsively hold my breath. But in Kyrgyzstan the quarters are closer, the reaction of covering ones’ cough is still novel, and the air is already thick with pollution, cigarette smoke, smoke from garbage fires, and dust.
And the tuberculosis.
Tuberculosis is one of the Kyrgyz Republic’s biggest public health concerns, and one of the globe’s largest. TB has killed more people than any other recorded disease, an estimated 1.4 million every year. That works out to about 4,000 tuberculosis deaths a day in 2014.
It’s fairly simple – a highly contagious bacterial infection transferred through the air. One third of the world’s population is infected with latent, asymptomatic and non-transmittable tuberculosis. One in ten of those cases becomes active and infectious, treatable if caught early. In it’s active form, TB is the second deadliest infectious disease after HIV/AIDS, and disproportionately affects communities in poverty (95% of reported TB cases are in developing countries). Tuberculosis is also, in most cases, curable and treatable, but that treatment requires public knowledge about TB and its symptoms, capacity to accurately test and treat, and adherence to a treatment regime.
But when you are poor, and you are using coal fire to fight the cold outside, when is a cough more than just a cough? Will you spend your roughly $2,290 of annual salary on food or the medicine you need to complete your treatment (not to mention the bribes to receive it)? As a developing nation, do you spend your scarce public healthcare funds for updated TB testing equipment or clean needles? If you are a smoker, like almost half of Kyrgyzstan’s population, are you coughing from bad tobacco or worse bacteria?
Kyrgyzstan’s biggest battle in controlling TB is not the bacteria itself, but the battle for information and resources for testing and treatment. It is also a larger war about poverty and power.
First off, there simply isn’t enough medication. To more cheaply treat patients, a majority in the Kyrgyz government want to invest in tuberculosis colonies, despite the larger implications in the marginalization and broad civil rights violations of a growing number of infected Kyrgyzstanis. The federal prison system in Kyrgyzstan is a tuberculosis colony of its own – like most former Soviet countries, the unreformed and decaying prisons are unrestricted breeding grounds for tuberculosis – overcrowded, without proper sanitation or healthcare, and high turnover rates of individuals from the most at-risk groups. TB wards of hospitals, too, are overcrowded and underfunded. High relapse and reinfection rates come from open, shared wards in hospitals where running water and ventilation systems are not dependable. Contaminated testing equipment or untrained staff create high instances of false positives who are infected after their admission to the TB ward, including a large number of children. Numbers of infections are underreported and underestimated, patients are not followed up on for treatment and post-treatment testing.
Kyrgyzstan recently joined the top ten countries at highest risk for the spread of multi-drug resistant tuberculosis, or MDRTB, a formidable and expensive infection, and, according to The Global Fund, accounts for 25% of new cases of TB in Kyrgyzstan. MDRTB is a mutation of the tuberculosis bacteria, and can cost more than $7,000 to treat a single patient. A standard six-month course of tuberculosis medication costs $10 per patient.
Kyrgyzstan clearly recognizes tuberculosis as a problem, and works with many international organizations to offer treatment and improve public knowledge, but struggles to address the systemic, underlying issues putting their population at risk. Tuberculosis is exacerbated by poverty – malnutrition, limited access to healthcare, lack of information, disenfranchisement, gender inequality. TB’s economic affects are amplified when you take into account affected work force stagnating economic growth, familial financial burden to care for infected (and the likelihood that they will be infected themselves), and the cost of treatment.
But TB is curable, preventable, and simple; it takes political willpower, investment, and effort. Like most public health concerns, tuberculosis illustrates that alleviation of poverty and addressing social justice concerns are the best investments in the long-term, sustainable treatment of disease.
And that’s what I think about on those crowded marshrutka rides, when I hear a deep, wet cough break into the air.
March 24th is World Tuberculosis Day. Read this interview with Paul Farmer on #TBDay2014. And here are some official statistics about TB in the Kyrgyz Republic.