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Refugees from Ukraine, which has a high rate of tuberculosis, are often screened for the disease. Above: Dr. Natalie Whrle analyzes the X-ray images of the lungs from a screening in Gauting, Germany, on March 12. Matthias Balk/picture alliance via Getty Images hide caption

Refugees from Ukraine, which has a high rate of tuberculosis, are often screened for the disease. Above: Dr. Natalie Whrle analyzes the X-ray images of the lungs from a screening in Gauting, Germany, on March 12.

"We have 20 patients we can't find, so we don't know if they are alive or not," says Dr. Olha Konstantynovska.

She's referring to the tuberculosis patients under her care in Kharkiv, where, as in much of Ukraine, the Russian war has disrupted lives including her own. She and her three daughters evacuated to her father's home about 20 miles away after a bomb hit a building down the street from their apartment.

Before she evacuated from Kharkiv because of Russian attacks on the city, Dr. Olha Konstantynovska treated tuberculosis patients at local hospitals. Olha Konstantynovska hide caption

Before she evacuated from Kharkiv because of Russian attacks on the city, Dr. Olha Konstantynovska treated tuberculosis patients at local hospitals.

TB a serious bacterial infection of the lungs is a big problem in Ukraine. According to the World Health Organization, the country has the fourth highest incidence of the disease in Europe. And it has one of the highest rates of multidrug resistant TB anywhere in the world.

In the tuberculosis hospital in Kharkiv, where Konstantynovska treats TB patients, about 70 of the 200 residential beds are filled. That's because at the beginning of the war, her team discharged as many people as possible to allow them to evacuate.

"I called to the hospital to speak with one doctor and she said that hospital has no potato and bread," says Konstantynovska. "We have drugs, but we have no food."

She says that before the war, "people from the whole city of Kharkiv two and a half million citizens [went] to this dispensary to be checked for tuberculosis." It's also where those with TB could receive medication, treatment and even surgery if necessary. Konstantynovska is a member of the small army of people in Ukraine who've mounted a stiff resistance against the disease, one that's been supported by the government.

But now, Konstantynovska says doctors are having a hard time getting to the hospital in Kharkiv. It's too dangerous to move about outside, and the roads are ravaged. One of the physicians walks a total of three hours each day to get to and from work. The head of a local dispensary is living in her office because her apartment was destroyed.

The view from inside the apartment of Dr. Tetiana Synenko, a TB specialist in Kharkiv, and a glimpse of the wreckage on her way to work. She's now living with 12 others in a nearby cellar. Tetiana Synenko hide caption

The view from inside the apartment of Dr. Tetiana Synenko, a TB specialist in Kharkiv, and a glimpse of the wreckage on her way to work. She's now living with 12 others in a nearby cellar.

Without intervention, people can live with tuberculosis and spread it, through the air for years. At some point, however, usually due to the stresses of hunger and injury; or a weakened immune system, it can turn fatal. Treatment consists of an antibiotics regimen that takes anywhere from six months to two years.

The contagiousness of TB is why Konstantynovska is especially worried about those missing patients. If they're on the move, she says, they're taking their TB with them, giving the disease more opportunities to spread through the air. "Eleven patients right now are in other regions of Ukraine," she adds. "They are trying to find the drugs because they stop[ped] treatment two weeks ago."

Interrupting an antibiotic regimen aimed at TB is worrisome for two reasons. First, drugs prevent someone from infecting others. So without meds, the disease has more opportunities to spread. And second, TB can become insensitive to the drugs if they're not taken regularly because insufficient dosing gives the tuberculosis bacteria time to mutate, selecting for populations of the bug that can dodge the meds. This is called multidrug resistant tuberculosis.

There's even extensively drug-resistant TB when the bacteria don't respond to the first or second lines of drugs. And once that form of resistant TB emerges, it can be passed from person to person, transmitted through the air just like regular TB. In 2020, a third of Ukraine's TB cases were drug-resistant, one of the highest rates in the world. And that number is likely to grow.

That's why Loyce Pace, the assistant secretary for global affairs at the U.S. Department of Health and Human Services, says her office is coordinating with the CDC and USAID "to track patients [within and beyond Ukraine] to understand where they are, what they need in terms of their meds and ensure that there's no gap."

To understand why Ukraine has so many TB cases, we need to rewind a hundred years.

For much of the twentieth century, when Ukraine was a republic of the former Soviet Union, tuberculosis was managed rather well, according to Tom Nicholson, executive director of the non-profit Advanced Access and Delivery. "The medical care system was quite comprehensive and was based on community medicine," he says. "It had a system of rural health posts, even in the most far-flung areas." There may not have been doctors on-site, but there were often nurses and medical technicians who could do a chest X-ray to screen for TB and dispense drugs to treat it.

The situation deteriorated with the collapse of the former Soviet Union in 1991. The economy in its republics tanked. Unemployment soared. Crime escalated, which sent a lot of people to prison. And that created a kind of "epidemiological pump," says Dr. Salmaan Keshavjee, director of the Center for Global Health Delivery at Harvard Medical School.

"Some people had TB," he explains. "It spread in the jails and in the prisons. And then they went back to their community, of course, when they were released. So the TB also went back to the communities." Tuberculosis rates soared, he says, including in some parts of Ukraine, which regained independence that same year.

During his work at a prison in Tomsk, Russia, Dr. Salmaan Keshavjee received this honey pot carved out of wood by a few of the prisoners. "It has a lot of meaning because this is where we showed that it was possible to bring [TB] mortality down close to zero if you got people the right treatment," he says. Salmaan Keshavjee hide caption

During his work at a prison in Tomsk, Russia, Dr. Salmaan Keshavjee received this honey pot carved out of wood by a few of the prisoners. "It has a lot of meaning because this is where we showed that it was possible to bring [TB] mortality down close to zero if you got people the right treatment," he says.

With government resources, Ukraine has since worked hard to build back its infrastructure for treating TB, registering a decade of declines between 2010 and 2020. But then COVID hit. Lockdowns early on in the pandemic shuttered hospitals where routine screening would take place.

Olha Konstantynovska's three daughters, afraid of an air attack, sleep in their apartment bathroom in Kharkiv. After an explosion down the street, the TB doctor and her family fled. Olha Konstantynovska hide caption

Olha Konstantynovska's three daughters, afraid of an air attack, sleep in their apartment bathroom in Kharkiv. After an explosion down the street, the TB doctor and her family fled.

"Sometimes it was impossible to check patients for TB," says Dr. Olha Konstantynovska, the physician currently living with her extended family outside of Kharkiv.

Without proper screenings and treatment, when tuberculosis did manifest and people came to the hospital, they'd be in bad shape severely underweight, a wracking cough, bleeding in the lungs.

In 2020, the percent of people receiving treatment fell dramatically from 75% the year prior to just over half. And now, in many parts of the country, the war's upended everything further.

In the chaos of battle, diseases find opportunity, disproportionately affecting people at the margins of society. Dr. Salmaan Keshavjee says, "In these moments of deprivation as a result of war, as a result of being refugees, as a result of being crowded in, not having enough food, et cetera, your TB rates go up." This isn't just true of Ukraine.

"I've spent many years working [with TB] with prison and other populations in Russia," says Keshavjee. "I have grave concerns that many of them are going to be dying. My guess is that they're trying to maintain their TB treatment programs. But Russia's under sanction. As funds and things get diverted to other efforts, you will see that the drug supply is going to drop."

Dr. Vasyl Petrenko visits a tuberculosis clinic in Kyiv before the war. Tatiana Butkivska. hide caption

Dr. Vasyl Petrenko visits a tuberculosis clinic in Kyiv before the war.

For now, Ukraine's stockpile of tuberculosis drugs is sufficient, provided they can be distributed. For instance, in Kyiv, Dr. Vasyl Petrenko, head of the physiatry and pulmonology department at Bogomolets National Medical University, says that Russian assaults on the city are limiting treatment options for patients.

When he's able to do his rounds, he tells his patients not to worry. "We are going to win," he reassures them. "The victory will be ours." He says it's crucial for morale. "It gives a lot of power, energy to every single person here."

The question is, how long will his optimism last?

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Russia's war with Ukraine is devastating for Ukraine's war on TB - NPR