Tracing Defaulters

'Of course!' says Ivan loudly from his doorstep. 'Aaaabsolutely! I promise to come to the clinic next week!' He flashes a smile, then joins his fingers and crosses his heart boldly, like a zealous orthodox. But it is a tune and ritual Tatiana Markina - a Russian nurse who works at a TB dispensary in the city of Kemerovo - has witnessed many times before. And still Ivan has not showed up again at the clinic. Since his wife passed away four years ago, his best excuse is that he is 'too busy tending the garden alone and doing manual work around the house'.

Ivan is one of many 'defaulters' in Kemerovo - persons sick with tuberculosis who have interrupted their treatment. The problem is that besides putting their own lives at risk, those with active TB may infect 10 to 20 other individuals per year.

It is the job of Tatiana and more than 20 other medical professionals to comb the city on a weekly basis looking for such defaulters, and to try to lure them back to TB health structure. Unless winter temperatures below -40c keep her indoors doing paperwork, every Wednesday Tatiana rides the bus, then sets off by foot to knock on each defaulter's door in the district of Kirovksi.

it is a neighborhood with a bad reputation. 'Kirovski is dangerous,' explains Tatiana. 'Many ex-prisoners, alcoholics, and unemployed persons live here. So usually we go by twos - a doctor and a nurse.' The rounds must start early: 'Usually it is OK in the morning, but by lunchtime many of them are already drunk and aggressive'.

'The tracing and home visits begin as soon as the hospital notifies us that a patient has escaped,' explains the nurse. 'Many patients go home because they start feeling better, and they mistakenly think they are cured. We tell them that they will infect others and that they could possibly become chronically ill and die, but these arguments rarely help'.

The rare exceptions when persuasion works are what keep Tatiana going. Still, after three years of 'tracing', she understandably wishes that the use of force to bring patients to TB treatment centers could be legalized - 'like it was in the past,' when TB control in Russia was more strict. She also regrets that laws protecting TB patients exist only on paper but are not enforced. 'Sometimes patients are fired from their jobs because they have TB. It happens especially when they're employees in commercial companies'.


She looks down at her list: Olga is next. She lives alone in a beaten-down house, but she often has guests, who 'party and drink with her'. Today, there are three young women in Olga's living room. When the nurse enters, they look down, and one of them turns to hide her face.

Tatiana knows that Olga's brother and his son both have TB, and that her brother's wife died of the disease. But she also knows that Olga's daughter was cured, and tries to use this to motivate her: 'You have a positive, living example: your daughter who had TB but was cured' she says. Olga pulls out a plastic bag containing a mixed assortment of pills and says, 'look, I'm taking my tablets'. 'Don't take too many of them,' warns Tatiana, 'you need controlled treatment'. After the visit, Tatiana admits that even if Olga now 'complied,' it may be too late to save her life, as she has probably developed resistance to anti-TB drugs.

The indifference and denial Tatiana faces have not ceased to amaze her. Valera, for example, is a young man who, shocked when the results of a test confirmed he had active TB, ran away from the hospital and returned to his mother's home. As Tatiana has not succeeded in convincing him to come back, she has turned to his mother as a possible ally. But so far, she has found only apathy. 'it is surprising how little she seems to care,' says Tatiana. 'I don't know why. I believe she thinks my visits are just a formality. She probably thinks I get extra money to come, and she doesn't understand the severity of her son's disease'.

Neither Valera nor his mother is home today, so Tatiana heads to a poor housing project on 'Initiative Street'. Any 'initiative' among these inhabitants was killed or numbed long ago by unemployment and alcoholism. When Tatiana first came here to visit Vladimir, a 61 year-old man who stopped his treatment and now has MDR-TB, his first question to her was: 'Can I come drunk to the hospital?' 'It would be funny if it weren't so sad,' says Tatiana.

As usual, the door to Vladimir's apartment is open, and as usual, even though it is only noon, he is drunk. So is the 52 year-old woman he calls his 'girlfriend,' with whom he has lived for 15 years. The difference is that today his girlfriend - who, according to Tatiana, is usually 'in a good mood, happy and joking' - can barely sit up on the bed, and she is screaming of pain. 'I never felt like I was infected with TB,' she says to Tatiana, 'but now I'm in so much pain, I cannot even get up!'

Vladimir argues with Tatiana, who remains calm. His speech is slurred, and only some of his sentences are intelligible: 'I'll come next month, I can't come now, I have work to do! ... I'm not infectious! ... When I was in jail, the guy next to me in the cell was coughing blood, but I was fine! ... I got TB when I was fishing... it was rainy and windy, and I got a cold when I was fishing and then I got TB!'

A neighbor in his early 30's walks into the apartment and sits down on the bed. He is a regular guest. He listens to Vladimir and looks strangely at Tatiana wearing a protective mask. He doesn't know - or doesn't want to know - that his closeness to the couple, combined with the dreadful living conditions in this housing project, may turn him into the next MDR-TB victim of 'Initiative Street'.

Due to its high TB incidence rate, Kirovski was chosen as one of two districts where MSF will run a 'demonstration site' in collaboration with local authorities and other NGOs. The site will bring DOTS treatment closer to the patients' homes. Incentives - such as the distribution of food parcels - may also be offered. The Russian Red Cross and other NGOs have found that these incentives lower defaulter rates.