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In addition to HIV, Russia is beset by an epidemic of tuberculosis that is set to break world records. The country's post-Soviet economic decline and tattered social safety net conspired to breathe new life into the once-tamed bacteria. Since 1991, the number of Russians with TB has nearly tripled. The country is averaging 150,000 new cases annually. Last year, deaths due to TB — a contagious, airborne disease — rose 30%.

The source of infection, in the vast majority of cases, is a jail cell. Russia's teeming prisons rank among the world's most prodigious TB incubators. Among the country's 1 million inmates, as many as 100,000 carry the bacteria. Worse still, Russia is one of the leading hot zones in producing TB strains that do not respond to traditional drug treatments — so-called multidrug resistant, or MDR, strains.

"Multidrug resistant TB is man-made, resulting from the failed treatment of a regular TB case," says Yekaterina Goncharova, Moscow medical coordinator for New York's Public Health Research Institute (PHRI), which in 1997 launched a war on TB in Russia with $14 million from U.S. financier George Soros. In a 1999 report, Dr. Paul Farmer, an infectious disease specialist at Harvard University and a leading authority on tuberculosis around the world, reported that more than half of all TB carriers in Russian prisons are resistant to at least one anti-TB drug.

MDR cases can be treated with a 75% success rate in a new therapy developed by Farmer in Peru and endorsed by the World Health Organization in 1998. But treatment is expensive and lengthy. Drugs for a traditional case of TB cost $20 in Russia, but treating an MDR case can require up to $15,000 and two years. This winter, PHRI and the British medical relief group Merlin launched a pilot program for treating drug-resistant TB in Russia, thanks to a $4 million program funded by Soros and the European Union. Fifty inmates in a prison hospital in Tomsk are now receiving the best drug cocktails available. "It's a small beginning," admits Goncharova, "but we hope to build a model that can be replicated in other cities."

For that to happen, there must be funds. Soros is not expected to continue his largesse in 2001. The World Bank has pledged $100 million for TB programs in Russia, but that money is not expected until year's end at the earliest. At the same time, few among those who control Russia's finances realize the danger TB poses. "So far, those who are dying have died out of sight behind the prison walls," says Goncharova.

Soon that will change. Because of the scarcity of state funds, tens of thousands of prisoners are released early every year. In 1999, more than 1,000 prisoners with active TB were amnestied in the Voronezh region, site of one of Russia's largest TB prison colonies. Last summer, Voronezh experienced a TB infection rate 150% higher than the previous year's.

Experts fear Russia's epidemic because the disease knows no borders. "No country in Western Europe is experiencing as high an increase in TB," says Dr. Mario Raviglione, TB coordinator for the who in Geneva. "What Russia breeds will infect not only Russians but Europeans, Americans, even Israelis." The Tomsk project is a hopeful beginning. Yet both Russian experts and their partners from abroad agree that the battle to control TB will take years, if not decades. For many patients it is already too late, they say. And for millions more, it is only a matter of time and money — commodities in short supply in Russia's health care system.