August 14, 2003
In the chaos that followed Georgia's independence and the conflicts that wracked the country between 1991 and 1994, the TB incidence rate has tripled, from 29 new cases for every 100,000 population in 1988 to 89 in 100,000 in 2001. In 1995, Georgia adopted the World Health Organization's standard strategy of directly observed treatment short-course (DOTS) to combat the disease.
Recognizing TB as a disease of poverty, DOTS requires the treatment to be free, and to that end the German government has been donating TB drugs to Georgia since 1995. But in the impoverished Black Sea, state where a doctor's monthly salary -- if it is paid -- is $50, cash, rather than a cure, is on many doctors' minds. Some patients said they were paying far more than the actual $50 a standard course of DOTS costs.
As a result, the uncontrolled distribution of anti-TB drugs has created the perfect breeding ground for MDRTB, dubbed "ebola with wings" by a Harvard medical school study. "Doctors will charge TB patients that come to them without referring them to the specialized TB facilities, and treat them for 'pneumonia' or 'bronchitis' with one or two TB drugs, when they should be using four or five," said Annabel Baddeley, of the British aid agency Merlin, which is working to adapt DOTS to Georgia's rural areas. The patients will eventually wind up at a TB facility with advanced TB, having developed drug resistance to the expensive package they have paid for, said Baddeley.
Treatment for MDRTB, DOTS-Plus, is about 100 times more expensive than DOTS. And WHO will not sanction the use of second-line drugs until the primary strategy is up and running. "A country that has such a low level of success in treating with DOTS cannot bring in DOTS-Plus," said Professor George Khechinashvili, director of Georgia's national TB program.