Tuberculosis is a major threat to the health of Romania's people, with an incidence of more than 10 times that of western European countries. In the lead up to World TB Day 2003 on the 24 March, Alice Scriven describes some aspects of the tuberculosis problem in this changing European country

I spent two months on an ERASMUS programme learning about aspects of health and health care in Romania's capital, Bucharest. My first day in the Institute of Pneumology was something of an initiation, due to it being a saint's day, with undeniably stylish celebrations. By 11 am, the mess-office-changing room (an all purpose space with broken chairs and huge grey lockers) was full of cakes and bottles of beer, and an hour later the room smelt strongly of alcohol and tobacco. A Romanian doctor joked that it smelt like an English pub, and I had to agree. After the second day, I realised that the party had been a one off, and not the average coffee break. Although the celebrations demonstrated the Romanian sociability and joviality, the day to day activities of the hospital were very different.

Like a sanatorium

The predominant health problem treated in this hospital is tuberculosis. It is a disease which not only has an obvious physical presence (most patients were there because of tuberculosis), but is also a mental burden on the staff. This is due to the devastating and worsening problem of this disease in Romania, and the frustration of trying to treat the many patients who are non-compliant with medication and who therefore become chronically ill.

The Institute of Pneumology is the centre of respiratory disease research and treatment in Romania. Although some modern equipment (such as a computed tomography scanner) was in place, I could easily imagine that I was in an old tuberculosis sanatorium. The long white and blue tiled corridors, the wards of beds crammed next to each other with no curtains dividing them, and the patients wandering the grounds in striped pyjamas, were images which combined to give me a feeling of a different time. Most tuberculosis patients in the hospital were emaciated men aged between 30 and 60, and in the hours I spent attempting to translate notes of patients I became accustomed to the phrases "with no employment" and "heavy drinker of alcohol." These are two great problems of postrevolution Romania, and they exist with high levels of poverty.

Children living in institutions are at greater risk of tuberculosis

Poverty leads to tuberculosis

Unemployment was 10% in 20001, a problem not evident in communist times. This leads to high levels of depression and alcoholism, and consequent malnutrition and overcrowding mean that conditions for tuberculosis reactivation and spread are ideal. That the disease has become widespread among men of working age gives the problem an extra economic dimension. Also much tuberculosis infection is found in children (who have the primary form of the disease), women, and also those from higher socioeconomic groups.

Inconceivably high

Romania has levels of tuberculosis that are almost inconceivable for us living in the United Kingdom. We are perhaps accustomed to hearing about devastatingly high incidences of tuberculosis in countries of Africa and of Asia, but incidences in Romania are comparable with rates in many developing countries, and considerably higher than in the surrounding European countries. In Romania, in the year 2000, the rate of notification of tuberculosis cases to the World Health Organization was 122/100 000 population, three times that found in Bulgaria and four times that in Yugoslavia. In 2001, the figure for Romania was higher still, at 134/100 000 population.2

Although the levels of infection in Romania are related to the current worldwide tuberculosis epidemic, the question of why tuberculosis has become such a major problem in Romania (more so than in other countries of eastern Europe) is an interesting one. After talking to many doctors and reading many texts (often kindly translated by the junior doctors in the hospital), I came to the conclusion that Romania's complex and incredible history could be closely linked to the progression of tuberculosis.

Prerevolution ideals

It is difficult to find accurate figures for tuberculosis incidences before the revolution that ended dictator Nicolae Ceausescu's communist regime in December 1989, particularly as Ceausescu allegedly refused to admit that tuberculosis existed in Romania. It is thought that incidences in the 1980s were low in comparison with current figures.

Some doctors attribute this to a programme of antituberculosis chemotherapy introduced 20 years ago by the Romanian School of Physiology.3 After December 1989, all aspects of life were disrupted, including health care. Tuberculosis treatment was neglected and patients were often non-compliant with medication, even if it was available. This, combined with increasing poverty, unemployment, malnutrition, and alcoholism, led to a rise in the incidence of the disease throughout the 1990s, resulting in the drastically high levels seen today.

Tuberculosis may not have been a serious health problem in the latter part of the communist era, but it is possible that Ceausescu's communism created some of the conditions that allowed tuberculosis to thrive. Many people in the cities and towns live in cramped flats in tower blocks; overcrowding is a factor that aids the spread of tuberculosis. Couples were encouraged to have many children, compounding the problem and contributing to the institutionalisation of children whose families could not look after them. The number of children in orphanages, once considerable, is now on the decline--but it is unfortunately what Romania is notorious for. Although the incidence of tuberculosis is generally lower in children, many of the cases are found in those who have been institutionalised, particularly those who have HIV or AIDS. This is often a consequence of needless blood transfusions promoted during the communist era.

Another factor involves Romania's largest minority population, the Gypsy (Roma) people. This group is marginalised, often poverty stricken, and rarely receives the same health care as the rest of the population. In addition, the travelling culture (even for most of the Gypsies who don't travel) results in a reluctance to commit to a six month course of antibiotics.

Two months in hospital

Treatment of tuberculosis in Romania is now rigorous, and many of the patients remain in hospital for the first two months of their treatment, not always because they are too ill to go home but because of social reasons and a tradition of long hospital stays. It is also a definite way of ensuring that patients take their antibiotics (according to the "directly observed treatment, short course," or DOTS, the WHO treatment strategy). For the remaining months of treatment, which are usually four, patients are required to return three times a week to the hospital or to local dispensaries. I saw whole buildings dedicated to being tuberculosis dispensaries, mostly in the north of the country, where the poverty is extreme and incidence of tuberculosis is high.

Unfortunately, it seems likely that tuberculosis incidence in Romania will continue to rise over the next few years. In 2001, WHO predicted that the incidence of the disease will increase in all countries of the world with the exception of the established market economies.4 It seems that the battle to "Stop TB" has a long way to go.

Stop TB is a global movement coordinated by the World Health Organization. Its aim is to accelerate social and political action to stop the unnecessary spread of tuberculosis. The student association IFMSA (International Federation of Medical Students' Associations, www.ifmsa.org) has events happening internationally on World TB day.

Stop TB says: "Our vision is a TB free world: The first children born this millennium will see TB eliminated in their lifetime"

Targets

• By 2005: 70% of people with infectious tuberculosis will be diagnosed, and 85% cured
• By 2010: The global burden of tuberculosis disease (deaths and prevalence) will be reduced by 50% (compared with 2000 levels)
• By 2050: The global incidence of tuberculosis disease will be less than 1 per million population

For more information, see www.stoptb.org

Tuberculosis facts

• Tuberculosis kills 8000 people a day--that amounts to 2-3 million people each year.
• Tuberculosis kills more people than either AIDS or malaria
• Tuberculosis is the biggest killer of young people and adults in the world today
• One third of the world's population is infected with tuberculosis
• If you are sick with tuberculosis you are likely to infect another 10-15 people in just one year

(From www.stoptb.org)

1. Basacopol A, Didilescu C, Plopeanu D. Influence of certain economical and social aspects on the dynamics of tuberculosis disease in Romania in the last 15 years. Presented at the second congress of International Union Against Tuberculosis and Lung Disease, Europe Region, Bucharest, April 2002
2. Stoiescu I P, Bogdan M, Corlan E, Didilescu C, Mihaescu T, Mihaltan F, et al. Tuberculosis in Europe and Romania. Presented at the second congress of the International Union Against Tuberculosis and Lung Disease, Europe Region, Bucharest, April 2002
3. Didilescu C, Marica C. Tuberculosis in Romania. Bucharest: Curtea Veche, 1998.
4. World Health Organization. WHO report 2001. Global tuberculosis control. Geneva: WHO, 2001