Writer Anton Chekhov died of it; so did poet Lesya Ukrainka. Until the middle of this century, tuberculosis swept off artists and musicians as well as millions of less famous mortals in Ukraine and worldwide.
An infectious disease affecting the lungs and spread by coughing or sneezing, the only recommended alleviation for TB was a stint in a warm climate. Crimean sanatoriums used to be full of sufferers, as Chekhov noted when he retired to Yalta.
Now, only 50 years after the discovery of a cure, TB is once again a killer disease on the rise, and Ukraine is one of the hotbeds of the epidemic.
At the beginning of 1998 there were 624,000 registered TB cases in Ukraine – 1.2 percent of the population – according to Yury Feshchenko, director of the Yanovsky Institute of Physiology and Pulmonology, which leads TB treatment and research in Ukraine.
And the numbers are drastically increasing. According to the institute's figures, the number of new cases of the illness has increased by 75 to 80 percent since the beginning of 1997. In the last two years the death rate has doubled. Every day in Ukraine 80 to 100 new cases of TB are registered, and 25 to 30 people die. The rate of severe forms of TB among children is likewise increasing.
'At the end of the 20th century, when deaths of TB include children here in the center of Europe, it's grievous,' Feshchenko said.
The conditions for TB to thrive sound like a quick rundown of the problems besetting the average Ukrainian today.
'Chronic stress, inappropriate nutrition, social instability, poor living conditions,' listed Yury Subbotin, who heads the World Health Organization's office in Ukraine.
Feshchenko said the main problem with treating TB here is the shortage of drugs. The accepted treatment requires four or five different medications.
'The last centralized purchase of medicine on a government level for TB happened four or five years ago,' Feshchenko said. 'A doctor may be well-trained, but if he comes to work and only has two preparations against TB, how can he treat it?'
Patients often have to buy their own medication, and they can no longer look forward to a rest in a Crimean sanatorium, which was mandatory until 1991. These days most have closed or have such unsanitary conditions that benefits to the patient are minimal.
TB is not just increasing, it is fast becoming resistant to known forms of treatment. The widespread appearance of multi-drug-resistant (MDR) TB inspired the WHO to declare tuberculosis a global threat to health back in 1993.
Unlike most infectious diseases, which can be cured in a matter of days, TB requires a long course of six to 10 months of uninterrupted treatment with antibiotics. If the treatment is incorrectly administered or is cut short, antibiotic-resistant strains of TB bacteria survive and may be passed on to other people.
'The list of known antibiotics is limited, and we have no evidence to suggest the discovery of a new generation of anti-TB drugs, so we're very concerned about drug-resistant TB,' Subbotin said. 'If we lose control of the antibiotics, then we lose control of TB itself.'
A WHO report released last year included Russia and Latvia in its list of 'hot zones' around the world where TB infection was spiraling out of control. The study found that in Latvia 22 percent of TB patients were infected by drug-resistant bacteria, and in Russia that figure was 7 percent.
No research was carried out in Ukraine for that report, but Subbotin said he believes the situation is similar to that in Russia.
The WHO answer to MDR TB is a new form of therapy called Directly Observed Treatment Short-course, or DOTS.
The principles behind DOTS are basic. Each patient, once identified, has to be observed taking each dose of correct medication by a health worker, and the progress of the treatment is closely monitored. That way, treatment cannot be interrupted or left unfinished, and the disease will not have the chance to develop resistance.
'DOTS is kind of simple and ridiculous, but it has huge implications,' said Catherine Fischer, senior health adviser for the U.S. Agency for International Development in Ukraine. 'It seems to be the main way of stopping the spread of infections.'
Simple, yes. Easily implemented, no. DOTS is labor-intensive and demands that the correct medication be comprehensively available. It therefore needs strong governmental commitment and funding for the program to work.
Staff from the Yanovsky Institute complained that the government was failing to take the epidemic seriously enough.
'For six years we've been informing the parliament, the cabinet, the president,' Feshchenko said. 'Every quarter, we call on them to do something.'
Subbotin, however, said the institute has shown no interest in DOTS and has not included the therapy in proposals to tackle the epidemic.
'The staff of the institute doesn't take DOTS therapy seriously,' he said.
The WHO has been working with the government and the Health Ministry on introducing the system in Ukraine, but so far it is unclear where the funding will come from, Subbotin said.
Those ill with MDR TB can pass the new form of the disease on to others.
Interrupted and unfinished courses of treatment are common, especially if the infected person stays at home. Patients cease to take the medication because the symptoms have already disappeared, or doctors simply prescribe the wrong combination of drugs.
The problem is exacerbated by the type of people most vulnerable to TB. Writers aside, TB is traditionally the illness of the poor and marginalized – including refugees, intravenous-drug users and the homeless – people with the least access to state help.
'Those with TB are those without social protection,' Feshchenko said. 'Half of them live below the poverty line and don't have an alternative source of aid and medicine other than the government.'
The clinic attached to the Yanovsky Institute, which has two adult and one children's ward for TB patients, deals with people from all over Ukraine with especially acute or unresponsive forms of TB.
So far, repairs to the building have not gone farther than the director's office. In the wards there are the usual peeling walls and skimpy bedclothes, and the usual complaints from the staff about poor accommodation, food and equipment.
Last week, staff were pasting up the windows with papier-m‚chИ in an attempt to keep out the cold. Patients stay at the institute for up to a year.
Ukraine has a comprehensive program of immunization for babies, Subbotin and Feshchenko said, but in contemporary conditions, that immunization is less and less effective.
The spread of TB in overcrowded prisons is of special concern in the former Soviet Union. According to figures from the Interior Ministry, there are 14,000 Ukrainian prisoners who TB.
'People don't get proper treatment in prison, and then they are released under an amnesty with the resistant form [of TB] and they infect others,' said Yelena Tarasenko, a doctor at the Yanovsky Institute. 'This is a real problem and no one controls it.'
