TB/HIV: the duel epidemicIs HIV – the greatest

risk factor for tuberculosis ever known – fuelling an

upsurge in TB in Europe and Central Asia? Existing

programmes for each disease must be adapted quickly.

Identifying TB in HIV-positive people is extre-mely difficult. Much more so than in peoplewho aren’t. If you have HIV and develop TB

and are not diagnosed quickly, you typicallydie within three months.’

This stark description of the consequences ofTB/HIV co-infection came from Michael Luhan,of the Stop TB Partnership, on the last day ofthe September meeting in Kiev of the EuropeanRed Cross/Red Crescent Network on HIV/AIDS(ERNA).

It’s as if tuberculosis and the human immuno-deficiency virus were combining in what theWorld Health Organization (WHO) has calleda ‘considerable mutual interaction’ to form athreat greater than the sum of its parts.

In February this year, WHO’s regional direc-tor for Europe, Dr Marc Danzon, wrote to mem-ber states to ask them to ‘ensure that TB isgranted the highest priority’ on their healthagendas.

‘The expected increase in TB incidence dueto the current HIV/AIDS epidemic in EasternEurope,’ he said, could ‘undermine the effecti-veness of TB control efforts’. Danzon also drewattention to the danger of HIV and the drug-resistant TB typical of the region ‘overlapping’.

It could already be happening. The mostrecent WHO statistics, for 2004, showed morethan 370,000 new TB cases in its Europeanregion – the highest number for two decades.

Eighty per cent of them were in the formerSoviet Union and Romania.

HIV is the biggest single risk factor for tuber-culosis ever identified. It parallels directly inthe human body what poverty, poor diet andovercrowding have long been known to achievein the genesis of active TB: it lowers resistance.

Some research, cited in WHO’s 2003 ‘frameworkdocument’ for Europe and Central Asia, alsosuggests TB stimulates the HIV virus to repro-duce itself faster.

A recent study published in the Archives ofInternal Medicine found that 2.6 per cent of allnew cases of TB in Europe were attributable toHIV co-infection, while 35 per cent of all adultsworldwide with AIDS succumbed to TB.

Epidemiological time bomb‘It takes at least six years to observe an increasein TB due to an increase in HIV,’ explainsPierpaolo de Colombani, the co-infection speci-alist at WHO’s regional office for Europe inCopenhagen. ‘So we’re not seeing the full im-pact yet in Eastern Europe, but there is a bigthreat.’

‘Another issue is that many countries haven’tyet developed reliable surveillance systems for tracking TB/HIV co-infection,’ he told TheBridge. In the most pessimistic scenario,Europe is sitting on an epidemiological timebomb.

In the East generally, according to the most re-cent report available from EuroHIV, the numberof new HIV diagnoses (‘incidence’) declined in2003. But ‘prevalence’ – the overall proportionof populations living with HIV – was still rising.

EuroHIV says the situation in the region ‘re-mains alarming’ because the number of hetero-sexual infections is rising rapidly – a realitywhich quickly becomes anecdotally apparentin cities like Kiev, for example (see page 5: Anenduring tradition), and in other countriesthat first got HIV epidemics.

Yet there is also a growing consensus amonghealth professionals working in both fieldsthat they want to adapt existing programmesfor each disease to encompass measures aimedat the other; not create a third dragon – co-infec-tion – out of two existing ones and wholly newprogrammes to tackle it.

Some actually feel that as far as Europe andCentral Asia are concerned, for the time being,drug-resistant TB is the more pressing issue.This is still rising, for example, in Russia.

Since The Bridge first reported on the TB/HIVaxis in 2002, the epidemiological pairing hasrisen up the global agenda. The fourth meetingof the Global TB/HIV Working Group, in AddisAbaba last September, heard that collaborationbetween the TB and HIV communities wasincreasing.

theBridgePage 3Italy’s Villa Marainicentre helps drug-userschoose life.

Page 4Russia’s impoverished elderlypeople put healthcare high ontheir priority list.

Page 6There is a danger of doing too many things and not focusing.

Autumn 2005 International Federation of Red Cross and Red Crescent Societies, Europe Department

‘Alex Wynter

Continues on page 8TB medication for Red Cross out-patients, Belgorod,Russia. Photo: Alex Wynter/IFRC

We do DOTS best

UpFrontwhy people interrupt their course. Patients whostart but do not complete drug treatment aremore likely to develop multi-drug resistance. InKazakhstan, over 5000 cases of drug-resistant TBhave been already registered, and this isalarming.

Over the last five years the Red Crescent hasbeen filling the gap between the services pro-vided by TB institutions and individuals whohave no access to them. This year, our NationalSociety is running TB prevention and controlprogrammes in six cities.

A dangerous interactionDedicated staff and trained volunteers areinvolved in TB prevention and DOTS promotionthrough training sessions in communities andpublic-awareness activities. The youth networkhas developed a wide range of educationalprevention activities.

The Red Cross/Red Crescent model of treat-ment for tuberculosis, which we practice withthe help of visiting nurses, is proving increa-singly successful in fighting the disease. Astudy carried out last year in the three CentralAsian republics, including Kazakhstan, showed93 per cent of patients under the observationof Red Crescent nurses completed their courseof treatment. The average is only somethinglike 85 per cent.

Patients under Red Crescent observation receivefood parcels, hot meals, vitamin supplementsand hygiene kits to meet their most urgentneeds, facilitate recovery and motivate them tocontinue treatment.

The deterioration of the epidemiologicalsituation in Kazakhstan coincided withthe economic reforms of the early 1990s,when shrinking health budgets, unpaid

salaries, poorly maintained health facilities, asevere shortage of drugs and laboratory suppliescontributed to inadequate tuberculosis control.

As a result, TB morbidity rose continuously andpeaked in 2002 with 165 registered cases per100,000 people. Several factors contributed tothis, including economic recession, social up-heaval, malnutrition, poor living conditionsand the social stigma that prevents peopleseeking treatment.

The need to strengthen control over the spreadof disease in the country became obvious. InKazakhstan, the national programme aimed atprotecting the population from rapidly spread-ing tuberculosis was first developed in 1998.

Central Asian countries implement the DOTSstrategy recommended by the World HealthOrganization. This cures patients, saves lives andreduces disease transmission. DOTS has alreadycontributed to a stabilization of the TB situationin Kazakhstan, Uzbekistan and Kyrgyzstan.

But prevalence and mortality remain highbecause of insufficient resources, inadequatehealth facilities, unreliable drug supplies andthe poor health literacy of population. In thewest of Kazakhstan, where the TB burden isgreatest, the incidence recorded in 2005 ismore than 240 per 100,000, according to theMinistry of Health Coordination Council.

Not all patients have access to treatment,especially in remote areas. This is one reason

InBriefOne life, keep it

Four Toyota cars which criss-crossed Europe over the summerto promote the third year of

the European Road Safety Campaignconverged on Brussels on 13 Sep-tember at the end of the tour.

The cars left Greece, Malta,Poland and Portugal in June anddrove more than 40,000 kilometresthrough each EU membercountry, where the drivers joinedlocal Red Cross workers to giveroad safety and first aid messages.

The 2005 campaign was coor-dinated by the British Red Cross,whose chief executive Sir NicholasYoung told the ceremony inBrussels that if first aiders arrivedat accidents quickly enough, ‘atleast half’ the lives lost could besaved.

Jacques Barrot, European Commis-sioner for transport, said the EUwas still far from the objective ithad set of halving the number ofroad deaths and governmentsneeded to try harder.

The 2005 tour was the highlightof the third road safety campaign.The theme: One Life, Keep it. It waspartly funded by the EuropeanCommission and sponsored byToyota.

The campaign helps NationalSocieties raise awareness aboutroad safety measures and promotefirst aid skills.

Toyota wants to improve road infra-structure and raise safety aware-ness through the Toyota Fund forEurope. � Claudia Arnold

Central Asia provides new survey evidence that visiting nurses get the best results

steering TB patientsthrough treatment.

Now the Kazakh Red Crescent plans

to train them to address TB/HIV

co-infection too.

theBridgeAutumn 2005

A publication of theInternational Federation of Red Cross and Red Crescent SocietiesPO Box 372,CH-1211 Geneva 19,SWITZERLANDwww.ifrc.org

Produced byRegional Delegationfor Central Europe,Zolyomi lepcso 22,H-1124 Budapest,HUNGARYPhone: 361 2483300Fax: 361 2483322Email: anja.toivola@ifrc.orgWebsite: www.ifrc.org

EditorsAlex WynterMichaela ToldMartin Fisher

Funded byHungarian Red CrossNorwegian Red CrossSwedish Red CrossSwiss Red Cross

Layout and printingHavas & Co. Budapest

© International Federation of Red Crossand Red Crescent Societies 2005

The opinions expressedare the contributors’ ownand not necessarily those of theInternational Federation of Red Crossand Red Crescent Societiesor the International Committeeof the Red Cross

2

Today’s Solferino

The final report of the Federa-tion of the Future process,which was being presented to

the General Assembly in Seoul inNovember, describes the globalchallenges facing the Red Cross/Red Crescent Movement as ‘today’sSolferino’.

‘AIDS is killing over 8000 peoplea day,’ the report says. ‘More thanhalf the world’s population live on less than $1 a day. And accessto basic health services and cleanwater is still a dream for themajority.’

The report is the outcome of atwo-year consultation process onthe main issues facing the Interna-tional Federation and includes ablueprint to help it achieve theaims of Strategy 2010 and remain‘relevant and effective’.

‘The Federation of the Future isabout renewing our commitmentto scale-up our work and make adifference to the lives of vulne-rable people everywhere,’ saidJohn McClure of the British RedCross, who co-chaired the gover-nance panel which led theprocess. ‘The world expects theInternational Federation to useits global network of NationalSocieties to achieve a greaterimpact.’

The process identified ten areas forimprovement, a five-year frameworkfor action and a ‘Global Agenda’for better planning and more effec-tive programmes and resourcemobilization. � Philip Tamminga

We have also been developing the programmeand have explored providing psychological sup-port to out-patients. A special room was openedby the Red Crescent in Almaty earlier this yearfor those seeking expert advice, or just the com-pany of people experiencing similar troubles. Wevalue volunteer assistance from formerpatients who are good at promoting DOTS.

We are now seriously concerned about risingHIV/AIDS which increases the spread of TB.Areas with high rates of tuberculosis overlapinteraction. It’s predicted that every year,10 per cent of HIV-positive individuals willdevelop TB.

The Kazakhstan Red Crescent, in collabora-tion with the national AIDS centre and acade-mic experts, has designed a programme toaddress this issue. We plan to provide 85 percent of co-infected people with Red Crescentsocial and psychological support.

At least three groups of visiting nurses willwork with out-patients and their families. Forthat we need to develop the existing curricu-lum to train nurses, volunteers and medicalstaff. The training will include the problem ofstigma, which prevents many people seekingtreatment.

We also hope that by being part of the CountryCoordination Mechanism of the Global Fund toFight AIDS, Tuberculosis and Malaria, we willbe able to attract additional funding to imple-ment the programme more effectively. �

Dr Erkebek Argymbaev is President of theKazakhstan Red Crescent

A year of torment

The people of Beslan held threedays of ceremonies at the begin-ning of September to mark the

first anniversary of the violent endof the siege at School Number One,in which nearly 200 children died.

Elena Rubaeva, a Red Cross psy-chologist, says virtually none of thesurviving former hostages could besaid to have ‘got over it’ in any realsense. And in grieving for a lostchild, a year is but a fraction of asecond.

Most people are still deeply trau-matized and afraid that it couldhappen again. ‘Fear is king in thistown now,’ says Rubaeva.

Families are going through newcrises of their own, she adds. Manyparents’ relationships have brokendown and they are on the verge ofdivorce; children have becomeaggressive and difficult to live with.

A Red Cross social worker saysmany child hostages, who had todrink their own urine in the siege,now cannot sleep without a bottleof water nearby.

After an international appeal, theRussian Red Cross set up a centrefor psycho-social support where32 people serve as visiting nurses,social workers or psychologists.About 400 local people attend art,computer or sports classes.

‘The entire population of Beslanis suffering and we want to try tohelp revive normal life and socialties,’ says Stanislav Tsagaraev,director of the centre. It’s anambitious goal. � Rita Plotnikova

Supporting psychology

P sychological support must befirmly on the agenda for the2006 European regional confe-

rence in Moscow. This was theconclusion of the European Net-work for Psychological Support(ENPS) conference in Budapest inSeptember, which included repre-sentatives from 26 NationalSocieties.

After demand for psychologicalsupport for migration, healthemergencies and in the wake ofterrorist attacks, the ENPS calledfor a higher profile for Red Cross/Red Crescent contributions topsycho-social support, and increa-sed management support for thework in the field.

ENPS promotes the holistic app-roach to health defined by the WorldHealth Organization’s constitutionas a ‘state of complete physical,mental and social well-being, notmerely the absence of disease orinfirmity.’

The European network is also deve-loping a database that includestraining, volunteer-selection, assess-ment and evaluation tools.

‘The present situation shows the need to increase the value ofbasic psychological community-based support in our work, asopposed to just psychothera-peutic treatment,’ said MaureenMooney-Lassalle of the network’ssecretariat at the French RedCross. ‘This will increase localcapacity-building and touch morepeople.’ � Rita Plotnikova

Dr Erkebek Argymbaev

Walking into Villa Maraini’s impres-sively wooded and peaceful groundsfrom the streets of central Rome,you move altogether from one world

to another. Yet although the atmosphere insidecould not be less like the surroundings, theprogrammes the buildings house are verymuch in tune with the city’s darkest corners.

I spent four days there in the summer, watch-ing social workers and Red Cross volunteershelping people choose life.

The Fondazione Villa Maraini was set up in1976 as a joint venture with the Italian RedCross by Dr. Massimo Barra, the dynamic vice-president of the International Federation and aman who believes life can be successfullyreclaimed even from the depths of heroinaddiction.

Barra argues that drug rehabilitation therapiesmust be tailored to the individual, not viceversa. ‘Villa Maraini has never refused anyone,’he has said. ‘If a drug user who wants to giveup is to be considered sick, whoever is unwil-ling to give up is twice as sick and needs extraattention.’

He also says harm reduction work with drugusers (‘death reduction’ he calls it) has beatenback HIV in Spain, France and Italy and couldprovide a model for Central Europe.

Apart from the wide range of residential andout-patient services available, free, in the VillaMaraini complex itself, the foundation alsooperates two harm reduction ‘camper vans’ –at Rome’s Termini train station and in TorBella Monaca, one of the city’s most deprivedneighbourhoods.

Many of Villa Maraini’s patients are first refer-red to the centre by the police. About half its

Villa Maraini in Rome has long been a trailblazer

in harm reduction for drug users. Now its services

could offer a model for National Societies

battling disease spread by needle-sharing.

3

Death reduction: Fondazione Villa Maraini

on wasteland beside a busy motorway. ‘It’sfundamental to my job to know everyone’shabits,’ he explained as a car pulled up andLuigi, a middle-class professional on his lunchbreak, well-dressed and clearly nervous, step-ped out and approached. Marcello gave himtwo clean syringes and a small bottle of sterilewater.

‘He’ll stay a couple hours but won’t take anyrisks,’ said Marcello. ‘With other people I can’tbe sure they won’t overdose.’

It’s a different story, most of the time, at Terministation, as darkness sets in and the Villa Marainimobile team prepares for its night’s work. Adishevelled woman in her early thirties wasthe first client during my visit. Marcello knowsshe is a heroin addict but she has started theevening on pills of some kind. ‘Stay near thevan so we can keep an eye on you,’ he tells heras he hands over a needle. She reappears afterfive minutes, looking shaky but not obviouslyoverdosing.

There is an international consensus in favourof harm reduction as an effective public healthmeasure – the Red Cross/Red Crescent 2002Berlin regional conference, for example, unani-mously supported harm reduction. But this doesnot mean it will never again be controversialanywhere, inside the Movement or outside it.

The last few years have seen intense discussionabout drug policy in Italy, with – according tothe European Union’s Lisbon-based drugagency – a shift in favour of prevention, withharm reduction initiatives ‘not designed tolead away from drug use’ being discouraged.

But the agency’s annual report last year saidheroin use had stabilised in many countriesand the ‘trend in drug-related deaths is nowdownwards after many years on the rise.’ TheHIV epidemic among injecting drug users maybe slowing in some new EU member states, itadded, at the same time as ‘measures to reducedrug-related harm are intensifying’.

Group therapyAnna Maria Ruggerini, a psychologist who runsVilla Maraini’s helpline, says persuading usersthey need to give up their drug, to them possibly‘the most beautiful thing in the world’, is thehard part. ‘These days, drug addiction cuts acrossall social lines, and many people are secretaddicts, especially to cocaine.’

The people who use Ruggerini’s service, whichshe compares to a day-hospital, ‘can’t or won’tattend a therapeutic community’. Instead theyfollow a weekly programme that includes aninterview with a psychologist and a group the-rapy session, usually for three years.

Some of the foundation’s most importantwork has been done in prison since 1979, whensocial workers and Red Cross volunteers startedorganising support activities for drug-depen-dent prisoners in the Rebibbia and ReginaCoeli jails.

But one of the newest services is the emergencyunit, begun in 1994, largely as a result of theexperience of the mobile team at the Terministation, whose staff repeatedly witnessed thehorrors of both overdose and opiate withdrawal.After six months, the emergency unit wenttwenty-four-hours and now intervenes to easethe agony of ‘cold turkey’ and save people fromdeath through overdose.

Increasingly, Villa Maraini is creating a modelfor the rest of the world. Many National Societiesfrom Eastern Europe and Central Asia havevisited. The original Villa Maraini buildingsdate back more than a hundred years and wereused in the last century to treat tuberculosispatients, at a time when that disease afflictedRome as much as it now does the newly-indepen-dent states of the former Soviet Union. After TBwas conquered in the west, Villa Maraini becamea home for children orphaned by the SecondWorld War.

It would be fitting if the beautiful buildings– a haven from the bustle of Rome but in thevery midst of the city – evolved to meet theneeds of the new larger Europe. The ItalianRed Cross is co-funding similar projects withsister National Societies from Honduras, Nica-ragua, El Salvador, Bangladesh and India, andplanning more. �

Martin Fisher is co-editor of The Bridgeand a former Budapest-based Reporting Officerfor the International Federation.

Villa Maraini’s beautiful grounds are a haven fromcentral Rome, where its mobile units operate.Photos: Ilona Ostis

Martin Fisherstaff – and this is Villa Maraini’s greatest strength– are former intravenous drug-users themselveswho escaped the lure of ‘mainlining’.

They are walking, talking adverts for rehabili-tation.

Marcello, a former heroin addict in his earlyforties who works in the mobile units, explainsthat ‘swapping needles spreads diseases likeHIV/AIDS and hepatitis – persuading peoplenot to is our role.’

He tells drug-users to return their needlesand put them in a special bin strategicallyplaced alongside the van’s passenger door.Most do.

A way out of drugsMarcello and his fellow social workers are a vitalbridge to the drug-user community. As child-hood friends from Magliana, another tough Romedistrict, they started injecting heroin togetherand turned to petty crime to pay for it. Inevi-tably this led to jail. But one of them, Roberto,found a group run by Villa Maraini’s prison ser-vice, and then recruited Marcello, Antonio andGino. Together they found a way out of drugs.

The make-up of the Villa Maraini mobile teamsis the same in both locations: a social workerwho is a former drug-user, a doctor, a psycho-logist and Italian Red Cross volunteers.

There is, of course, only one way to do ‘needleexchange’, as harm reduction is often referred tofor short. Villa Maraini’s services are dispensedin a completely neutral fashion, driven only bythe humanitarian imperative. There is noattempt to distinguish between ‘deserving’ and‘undeserving’ cases.

On the day I went out with them, Marcello satpatiently in the Tor Bella Monaca van, parked

Street credibility. Villa Maraini social worker and former drug-user distributes sterile injecting equipment. Photo: Ilona Ostis

4

regularity, has improved. But older people areangry that a lifetime’s labour should be rewar-ded by what are still meagre payments – thelowest just over 30 US dollars a month.

There is anger that pensions do not providesufficient compensation for labour; that decentpensions are more a reward – for veterans of theGreat Patriotic War, for example – than a right.

Even some people on the highest pensions,about 3000 roubles a month, described spend-ing around 1100 on utilities. Most agreed thatat least half their income is given straight backto the state for bills.

What is left of a pension does not qualify asa ‘safety net’. Most said there was just enoughfor a poor diet, boosted by produce from anallotment. The trouble starts when anythingadditional to food and utilities is required.

Rude doctorsSome of the elderly people we spoke to actuallyput access to health care and the cost of medi-cines above the size of their pensions as themain concern of their lives.

In Karelia, a republic on the Finnish borderwhose timber industry suffered badly from theloss of subsidized Soviet supplies, problems be-gin with patchy bus services and stops too farfrom the polyclinic. There older people wait inlong queues fighting their way through thefirst-come, first-served system.

‘I never went to our hospital before but theywere so rude to me I’ll never go again,’ saidone pensioner. ‘All the good doctors have goneprivate and you can never get to see the oneswho are free.’ Interviewees also said hospitalswere reluctant (and sometimes refused) tohospitalize older people.

Pensioners have to collect prescriptions fromhospitals, free but valid only for ten days. Ifthey can’t find a helpful chemist, the wholeexhausting nightmare of visiting the polyclinichas to be repeated. Often the ‘free’ medicinehas run out and the elderly are forced to payfor a commercial substitute. This issue cameup in every focus group in Karelia.

Participants also referred to the experiencesof having to pay for such supposedly free care.According to one: ‘I have to pay every time Iget a test. Last week I gave some blood and itcost 35 roubles.’

SocietyRussia’s elderly: the battle for dignity

The Red Cross has been working with

local government and veterans’ associationsto find out what Russia’s

impoverished elderly people really think.

The ground-breakingresearch found access

to healthcare with dignityhigh on the list of priorities

Iset my alarm for five in the morning.Although I’m so full of fear and tensionthat I never get any sleep. I catch the firstbus to the polyclinic. The path to the

entrance is a slope of ice in winter. Still I getthere as early as I can to collect my numberin the queue. Then the hours of waiting begin.’

Throughout our research, elderly people spokeof accessing health care as one of the greatesttraumas of their lives. It is not just a questionof resources. Often the facilities are there; it’susing them that’s the problem.

Some elderly people we interviewed spokehighly of individual doctors, but a majoritytold of very negative experiences. Again andagain, older people described the humiliationthey suffered at the hands of medical staff, andhow seeking treatment was an emotionally pain-ful process deeply injurious to their dignity.

Appreciation of the Red Cross often centredon nothing more than the simple kindness ofits nurses (see opposite page: An enduringtradition).

Over the past 12 months, the InternationalFederation and the Russian Red Cross (RRC),together with veterans’ associations and localgovernment agencies, have been carrying outdetailed research into the plight of Russia’selderly and their continuing battle for dignityin a society barely recognizable from the onethey grew up in.

This ‘Participatory Action Research’ (PAR) – inTomsk, Karelia, Belgorod, Samara, Ingushetiaand Chukotka – was also designed to promotedialogue between the state, the Red Cross andother agencies and older people themselves.It’s hoped it will lead to a national strategy forRRC work with older people.

The research allowed the Red Cross to seethe world through the eyes of older peoplethemselves. It included sensitivity training forpeople who work with the elderly, as well asfocus groups and home interviews with olderpeople and group discussion.

Humanitarian concern for Russia’s elderlypeople has historically focused on the inade-quacy of pensions, and the consequences ofthe loss of savings in the economic and cur-rency reforms of the early 1990s.

Over the past five years the ‘big picture’ onRussian pensions, in terms of their size and

4

Some went as far as to accuse the governmentof deliberately making health care inaccessibleto older people because ‘they want to get ridof us’. In Tomsk, western Siberia, our inter-viewees spoke of the unreliability of ambulancesand the fear they would not come. ‘If they hearyou’re over 70,’ said one, ‘they don’t rush.’

Yet it was felt there is no government policyof active exclusion – just an array of bureau-cratic and economic circumstances that com-bine to thwart the elderly.

Older people who enjoy the support of familyand friends or are still able to generate someincome independently are better off, as arethose whose pensions have been increased asa reward for services in the war or for being aveteran of labour. Those with pasts less distin-guished in the eyes of the state are likely to bemore vulnerable.

Interviewees included older people who hadnever worked, or done so only briefly, becausethey had spent their lives caring for loved ones.‘For 52 years I looked after my deaf, blind anddisabled daughter and never had a chance towork,’ said one. ‘As a result my pension is only1000 roubles.’

Just copingWhen survival strategies were discussed, mostpeople said they were ‘just about coping’, butit became clear this entailed significant hard-ships. One elderly person told us: ‘In the secondhalf of the month we economize strictly tomake sure we have enough left for bread. Weeat meat even the dogs won’t touch.’

Such strategies apply to utilities too: ‘Wewatch TV in the dark,’ said another. ‘Anythingto keep the costs down.’

Such references to ‘coping’, we came to rea-lize, did not imply a reasonable quality of lifebut a continuing and scarcely credible Russiancapacity to endure. Stories emerged of theterrible experiences of Soviet citizens duringthe twentieth century: exile, slave labour,camps, hunger, war and bereavement.

‘I went eight years without eating bread,’one elderly person remembered. ‘We used tomake dough out of potato peel and sawdustand eat that. Nowadays whenever I buy bread I clutch it to my chest, bury my face in it andthank God it’s mine.’

What can be done? In our discussions witholder people there was never any desire forhandouts or additional services. The emphasiswas always on how existing structures couldbe made more receptive to the elderly, andhow older people could have more say.

Essentially, concerns were grounded in theexisting relationship between older peopleand the state, and particularly with its healthservices.

Older people also want support in negotiatinghealthcare from non-state agencies. Participantsasked for advice on medicines and – a parti-cular worry for old people targeted by door-to-door con men – how to avoid fake medicines.

Many interviewees, worried at the prospect of becoming housebound, requested both stateand non-state actors make homecare a priority.

They asked for opportunities to tell officialsabout the impact reforms are having. This wasa recurrent theme throughout the research:the inability to influence the people and struc-tures that decide so much about the lives ofthe elderly.

Many pensioners were proud of having stoodup to the government recently and won conces-sions on the monetisation of benefits. Otherswere barely aware it had happened. There wasa consensus among participants that thereneeds to be better information about the bene-fits available to older people, and that radiowas the best medium for disseminating it.

Much of the discussion focused on ways thatolder people could enjoy life more and find itmore rewarding. Many participants spoke of adesire for social events, for excursions, foropportunities to meet people and interact.There was a general desire to stay active andfor opportunities that would allow olderpeople to be creative and feel needed. �

Alexander Matheou is Head of Delegation withthe International Federation in Moscow. (Thecomplete PAR reports are available from himon alexander.matheou@ifrc.org)

A woman counts her money at the bank. Many elderlypeople were pauperized by the inflation and currencyreforms of the 1990s. Photo: Heidi Bradner/Panos Pictures

‘Alexander Matheou

55

V alentina Merculova, a Russian Red Cross(RRC) visiting nurse, has kept bees as ahobby all her adult life. When collective

agriculture finally ended in 1994, the Gopkinbranch of the Red Cross acquired ten hivesfrom farms that were closing and gave them toher to manage.

Now they produce some 200 kilogrammes ofhoney a year, which is sold to help support local

One point about the Red Cross quicklyemerges from the Participatory ActionResearch carried out in various Russian

republics over the past two years (see oppositepage: Russia’s elderly).

Compared to the state medical staff – often atbest abrupt, at worst downright hostile – pen-sioners find themselves dealing with, Red Crossnurses are models of warmth and kindness.

The Red Cross visiting nurse is a Soviet-eratradition, whose relevance some might nowassume to be in decline. The opposite is true.

Vitaly Vasileivich, 55, is deputy head ofsocial services in the southern Russian city of Gopkin, and very much a veteran of theSoviet welfare system. Gopkin is also a placewhere, to some extent, the old stipendiarysystem of government funding of Red Crosswork has been restored.

The Belgorod Red Cross branch, of whichGopkin is a part, was on its knees financially inthe mid-nineties and almost had to suspend ope-rations altogether. Then the local governmentreached into its pockets in 1996. When askeddirectly why he prefers to allocate some of hisbudget to the Red Cross rather than just hiremore social workers, Vasileivich says visitingnurses ‘are willing to do both social and medicalwork, to give injections and pay electricity bills.’

In modern parlance, they are multi-skilledand don’t pay too much attention to the letterof their job descriptions.

It is a similar story in the sprawling WestDistrict of Moscow, where the branch presi-dent, Tatyana Strongina, points out that hernurses have an ‘If it needs doing, do it’ attitudeto their clients. They will, for example, helpdisabled people fight their way through thenightmarishly complex Russian procedure foracquiring official disabled status.

The West District’s client register includes the most desperate cases – the people whomthe authorities will not or cannot help, sheexplains: ‘People in the late stages of terminalcancer, the severely mentally ill, the bed-rid-den, deep alcoholics.’

The local hospital discreetly reserves a fewprivate rooms for the Red Cross branch, inwhich its nurses care for people otherwiseregarded as beyond assistance. If one werelooking for a tangible definition of what RedCross humanitarian auxiliary work meant inpractice, this would be hard to beat.

Interestingly, staff turnover among theMoscow West nurses is low. Strongina canonly think of two or three who aren’t veteransof several years standing.

The visiting nurse service survives in all the countries which, after 1991, formed newNational Societies out of the branches of theold Soviet Red Cross, and beyond.

On this page, we profile three such women,from Russia, Ukraine and Kyrgyzstan. Thereare thousands more across the region,anonymous local heroes, with a reach itwould be difficult to reproduce. �

L ena Khajinskaya lives on the front line of Kiev’s battle against HIV in more sensesthan one.

As a visiting nurse in the Kiev Red Cross HIVprogramme, she has become used to cases likeDasha’s – an HIV-positive 8-year-old who lostboth her parents to AIDS and is now herself ondouble antiretroviral therapy.

Her medical condition is, at least, no worse thanit was two years ago when the Red Cross found her.

The Kiev visiting nurses think of Dasha oftenbecause she is part of a phenomenon morecommonly associated with Africa than Europe:‘AIDS orphans’. And also because she had to bewithdrawn from a state institution after a monthwhen both staff and other children shunned her.

But Khajinskaya also worries, as any motherwould, for her three sons, who are 8, 19 and 21.

‘I took them with me to our centre,’ she says,‘where they saw people who were healthy, beauti-ful and HIV-positive.’

Kiev’s youngsters, still mildly intoxicated bythe heady political street-party atmosphere inthe city, have trouble believing you can be bothbeautiful and infected with the HIV virus, saysKhajinskaya.

She suggested both her sexually active grown-upsons and their girlfriends got tested. They did;the results were negative.

Khajinskaya, 40, simply does not view preachingabstinence as a viable anti-HIV strategy when itcomes to young men in their late teens and earlytwenties. ‘I make sure there are always condomsin the house.’

Also trained as a laboratory technician, Khajins-kaya joined the Red Cross because of a simplehouse move. Her husband is a pathologist.

Like many Ukrainian families, they feel theyhave no choice but to be 100 per cent upfrontabout sexual matters and the dangers of inject-ing drugs – especially now that HIV is seen ashaving broken out of the drug-user communityinto the wider population through hetero-sexual transmission.

‘If we want to live in a democratic society,’ shesays, ‘everyone has got to have the right to thefull facts about these things.’

Khajinskaya, whose Red Cross work involvesmainly adults living with HIV, speaks of somemarried friends of the family. The wife is HIV-positive; the husband, who knew this beforethey got married ‘but was very much in love’,

isn’t. ‘They are waiting to see if they can havechildren.’

No one in Ukraine thinks the arrival ofantiretroviral therapy has reduced the urgencyof HIV prevention. For people with a medicalbackground like Lena and her husband, thismeans being totally frank with their children.

‘I spend time talking to the boys about theway things are,’ she says, ‘including the eight-year-old. A lot of time.’ �

S vetlana Sooronova is one of four Red Cres-cent visiting nurses in Bishkek carryingout direct observation of home-based TB

patients – the vital DOTS strategy that has helpedstabilize tuberculosis in many countries.

‘We help sick people in high-risk groupscomplete treatment,’ says Sooronova. ‘Mainlythey are socially vulnerable people: the unem-ployed, alcoholics, homeless, and ex-prisoners.Many do not have enough money to get to hos-pital or a doctor. Their relatives reject themthrough fear of getting infected. They rely on us.’

As the patients improve, they come to theRed Crescent canteen to get the medicine andhot meal. It is an essential support for poor andlonely people, according to Sooronova.

‘The main thing is to keep hope of recoveryalive,’ she says. ‘Then the treatment will work.’

Red Crescent societies implement tuberculosiscontrol programmes in 14 locations in Kazakh-stan, Kyrgyzstan, Tajikistan, Turkmenistan andUzbekistan. Observing and recording goes onfor up to eight months.

This significantly decreases the risk of treat-ment being interrupted, which can lead to themulti-drug resistant form of the disease that is

far more difficult to cure. The educational workdone by Red Crescent nurses and volunteersplays a key role.

Three days a week Sooronova picks her waythrough the slums of Bishkek, crowded withpeople who have moved from Kyrgyzstan’s eco-nomically devastated south to look for work inthe booming capital.

The living conditions are straight out of thetextbook on how TB spreads. ‘These people arejust too poor to have a chance of being healthy,’Sooronova explains. ‘They live on bread and tea.’

We pass through a tiny yard where childrenplay in the dirt and settle in a dimly-lit shack.Sooronova introduces Meirim Oldzhobaeva, afrail and gaunt woman who looks much morethan her 20 years. A TB patient with the classiclook of the consumptive.

Yet Sooronova rejoices in Meirim’s progresson DOTS. ‘When I first saw her four months agoshe was very weak, bed-ridden and plagued by ahacking cough.’

The family live in a space of about six squaremeters. Two out of seven in the family havealready contracted TB. The other is Meirim’sfather, Akhmatbek, who is also now better.

They initially moved from their home in aremote village to a tobacco plantation but couldnot makes ends meet and came to Bishkek.Akhmatbek was the first to get sick. Doctorsdiagnosed TB and he was hospitalized. Thefamily savings went on his treatment.

When Meirim too fell ill things did not lookgood. But three months on DOTS under RedCrescent supervision have turned her round. �

Lena Khajinskaya Ukrainian Red Cross

Svetlana Sooronova Kyrgyz Red Crescent

Visiting nurses...

An enduring tradition

Soviet-era poster for visiting nurses. Courtesy SovietRed Cross Museum, Moscow

Red Cross welfare work. It also goes to familieson welfare and patients as aid in-kind.

Merculova points out bees are quick to punishhaste or clumsiness. In spring the hives have tobe thoroughly cleaned, and bees are not the mosteasily evicted of creatures.

In summer, they put the hives out in fieldsaway from houses; the area is famous for its wildflowers. It’s hard work and bee-keeping requiresa very deft touch.

Yet a third demand on Merculova’s energy arethe two grandchildren she is raising herself tohelp out a chronically sick daughter-in-law.‘Work,’ she says, meaning her patients, ‘feelslike a holiday.’

Merculova was born during the second worldwar. Her father was killed fighting ‘somewherein Germany, we don’t know where, the letterdidn’t say,’; her two older brothers, also in theRed Army, survived.

Trained as a medical nurse, she began her RedCross career as a teacher in camps for YoungPioneers. She won her first prize ‘for good works’from the Russian Red Cross in 1971, and theSolovyov award for charity in 1998 – the highestthe RRC can bestow.

Merculova does not feel the changes of the past15 years in Russia too deeply. ‘Our work in theRed Cross is much the same as it always was,’she says.

Belgorod region, with iron-ore mining andthriving agriculture (all now privatized andtaxed), did well under communism and it doeswell now. It is visibly a world away from the‘shooting galleries’ of Irkutsk or the economi-cally devastated far north-east.

Merculova’s main concern is her fellow pension-ers, and she does not seem to believe the 2002pension reforms are enough: ‘The governmentreally needs to pay more attention the elderly.’

Yet demographic change has had its effect.Local young people are drawn away to the brightlights of Moscow and St Petersburg, or even theregional capital, Belgorod.

‘This village is dying,’ says Merculova, standingamid her hives in Melovoye, in the super-fertilearea of the country Russians call the ‘blackearth zone’.

‘There are only old people left,’ she says. ‘But Idon’t complain. I can work, I can move around,and once in a while I can go to Moscow myselffor conferences of bee-keepers.’ �

Valentina Merculova Russian Red Cross

Alex Wynter, Ilmira Gafiatullina

most needy people. And in this country we are the only people who can get to those whoare truly needy and marginalized. And we’resure there will be more and more of them,especially people needing help in their ownhomes.

Tanevska: I really like the work the Red Crossis doing. For sure there is a space for impro-vement. Maybe the improvement of partner-shipbuilding with different stakeholders canbe one answer, but it varies from country tocountry.Do you think the Red Cross/Red Crescent iskeeping up with the times, especially in itswork with the young?

Morzsanyi: We’ve been able to facilitate thedevelopment of the Hungarian Red Cross youthbranch, which can act quite independently andrun its own programmes. They rely on adultsfor some things and do not want to be fullyseparate from the Red Cross. Our society is opento new ideas. Openness is the key to our adapta-bility, and this is where Red Cross youth are vital.

Mukhamadiev: Most members and volunteersare young people – students and teenagers. Weare proud of our new generation of volunteerswho work in communities, carrying out healthpromotion activities and disaster preparedness.The issue of recruitment was raised at the lastRed Cross/Red Crescent Youth Conference,which concluded that the Movement could bemore modern and flexible and provide moreopportunities for young people to make a dif-ference where they live and work.

Shishkina: Our projects are still popular withyoung people. First aid training is popular.Events we hold to mark things like World TBDay, and so on. We say, come to the Red Crossand you will be able to realize your potential.Russian youngsters are trying to find theirplace, like everywhere. Young people might get their first chance to be leaders in the RedCross, through simple things like organizingworkshops.

Tanevska: I know many cases were youth arereally the main actors in the realization of

health and care projects. The Romanian RedCross TB project, for example, and the Macedo-nian Red Cross drug prevention project, or theAlbanian Red Cross TB/HIV prevention project,and many others. But there could be greaterinvolvement of youth in project developmentand better volunteer management.

What do you hope the Moscow conferencenext year will achieve?

Morzsanyi: This is the regional conference forEurope, so what we would like to achieve is forit to be clear to everyone that there is only oneEurope – no ‘EU Europe’ and then the rest.Programming should also go in this direction. Mukhamadiev: I hope Moscow will maintainthe spirit of Berlin 2002 and make a signifi-cant contribution to our service to the mostvulnerable communities. The conference willprovide an opportunity for European NationalSocieties to understand the needs of people inthe newly independent states.

Shishkina: We’re looking forward to presentingthe new model for working with TB patientswe’ve been developing. We took an active partin Berlin in 2002. I was the chair of the TB group;I felt we achieved a lot. I hope we can sustainthe momentum.

Tanevska: Agreements among nationalsociety leaders to put greater efforts intohealth and care programmes. �

6

leaders to promote a healthy lifestyle. Now wecan say, yes, it works. People start to listen. Thesigns are good.

Shishkina: Well as far as the distribution ofclean needles is concerned, the main experienceof harm reduction we have is the project inIrkutsk. The early signs are encouraging. We’reconfident it works.Tanevska: Changing policy and improving soci-ety’s response to these communities has beenshown to happen. And needle exchange toge-ther with other assistance like psychologicalsupport and referral to social institutionsdirectly improves the quality of people’s lives.

Is drug use really a humanitarian issue?

Morzsanyi: Drug use has a humanitarian im-pact, so what we do is to participate in educa-tion from the youngest ages through Red CrossYouth. We never treat drug addicts as criminalsand avoid stigmatizing them. The Red Crossalone cannot solve it. National Societies inEurope should exchange best practices anduseful information, but at the same time workwith health authorities and other actors.

Mukhamadiev: This issue has often been dis-cussed at conferences and meetings. Differentorganizations can hold conflicting opinions.From the Red Crescent point of view, I believedrug use is a grave humanitarian issue. Weshould send a message, especially to our youth,about the negative impact of drug abuse. Formy country, right on the ‘heroin trail’ fromAfghanistan to the West, it raises seriousconcerns.

Shishkina: As the Red Cross we have to try to help people addicted to drugs, to keep themalive until they can snap out of it. That’s not to say harm reduction isn’t controversial inRussia, as it has been elsewhere.

Tanevska: Certainly. The Red Cross shouldalways look to the most vulnerable. Very often,their lifestyle means drug users are excludedfrom society and they generate problems thathave an impact on the community. The ques-tions are: who are the drug users and whatkind of problems are they facing?

Given the range of health and socialproblems, is the Red Cross/Red Crescentstruggling to stay focused?

Morzsanyi: I think this is a fundamental ques-tion for today’s Red Cross. Problems may bedifferent from one branch to another. I amquite confident that the answers given at locallevel are appropriate because they are the oneswho know the specific problems and their owncapacity. At headquarters level we should notinterfere with the liberty of the branches.There is a danger of doing too many thingsand not focusing. We have many programmesin social welfare and health. They are justified;there is a need for them and we have thecapacity to do them. But a better focus and abetter concept of how to identify the mostrelevant would be beneficial.

Mukhamadiev: Since 1999 the Red Crescenthas paid a lot of attention to health issues.Community-based activities include healthpromotion and first aid implemented by bran-ches. Every year we train more than 2000 ruralvolunteers. Prevention of TB and HIV/AIDSthrough education and awareness campaignsand community-based health promotion(including water and sanitation) are our mainpriorities.

Shishkina: Our priority groups are defined in our strategic plans. In Russia like elsewherethe Red Cross now really has to select the

ForumTowards Moscow 2006

In this first issue of The Bridge to cover thewhole of the European and Central Asian re-gion, we asked some key players to describethe health challenges they face.

With its unique ground-level network of volun-teers and nurses, few organizations are betterplaced to confront the twin evils of TB and HIVthan the Red Cross/Red Crescent: the povertythat fuels the former, the needle-sharing that –in this region – still mainly fuels the latter, andthe deadly axis they form.

How worried are you about the combina-tion of HIV and TB?

Eva Morzsanyi, Secretary General, HungarianRed Cross: In Hungary we are fortunate becausein the early 1980s there was a very successfulnational prevention campaign, so we couldstop the spread of AIDS. The number of peopleinfected in Hungary is not more than 1000. Sowe do not see a direct relationship between HIVand TB. At the same time, the appearance ofhomelessness and poverty has caused a reap-pearance of TB. We have to consider the poten-tial for coincidence of the two infections.

Davron Mukhamadiev, Vice-President, KyrgyzRed Crescent: An ‘alliance’ between HIV and TB became a major concern in the formerSoviet countries that faced severe socio-econo-mic crisis. Poverty, chronic unemployment,poor access to health services and education,an increased flow of drugs – all these factorsare causing TB and HIV epidemics in thecountry. The Tajik government works withthe Global Fund through its Country Coordi-nation Mechanism. The Red Crescent, as apart of the latter, has initiated health educa-tion in communities, especially among themost poor who are at real risk from deadlyinfections.

Valentina Shishkina, Head of Operations,Russian Red Cross: We have implemented HIVand TB programmes separately, but we arenow trying to develop strategies to deal withco-infection. Russia is a country where bothTB and HIV are very urgent. Health ministryfigures show that in 2003 there were 3133 re-

gistered case of co-infection; 7678 last year.We do fear HIV is going to fuel TB, becauseHIV is growing very fast and latent TB iscommon.

Sonja Tanevska, Regional Health Delegate,International Federation, Budapest: It is veryimportant for National Societies to developcomprehensive plans and form partnershipswith NGOs and governments. In that sense,they should follow up the development of bothdiseases and react. I agree it’s very importantto strengthen each of the programmes for HIVand TB, and then if needed create a link bet-ween them, but certainly not develop anothernew programme. The International Federationis ready to help.

Is harm reduction working as a strategy toprevent the spread of HIV?

Morzsanyi: There is a correlation between harmreduction and strategy. Prevention is a part ofharm reduction, and what the Hungarian RedCross does through the youth programme inmore than 80 schools is approach young peoplewith information about sex, condoms and familyvalues. I believe this is what the Red Cross hasthe capacity to do.

Mukhamadiev: In Tajikistan, this approachwas first introduced two years ago. We adaptedthe practice of our Italian colleagues at VillaMaraini. We involved community and religious

At the 2002 Berlinconference, the Red Cross/

Red Crescent set itself the task of working with

‘people in the shadows’.Next year’s regional

gathering in Moscow will provide a chance

to review progress.

Eva Morzsanyi: We shouldn’tinterfere with the liberty of branches.

DavronMukhamadiev: Drug use is a gravehumanitarianissue.

ValentinaShishkina: We’re the only people who can reach the truly needy.

Sonja Tanevska: There are manyprogrammeswhere youth are the mainactors.

Many governments in this re-gion don’t realize we simplyhave to work with drug

addicts,’ according to Dr AndersMilton, the president of the RedCross/Red Crescent EuropeanRegional Network on HIV/AIDS(ERNA), speaking to The Bridgeat its Kiev meeting in September.

Delegates spent a whole day dis-cussing ‘harm reduction’: counsel-ling and the no-questions-askeddistribution of condoms and cleanneedles intended to reduce thedamage done to people by druguse. Dr Milton said the first stepin the advocacy battle to promo-te harm reduction was ‘grabbinggovernments by the lapels’.

Lynette Lowndes, head of theInternational Federation’s Europedepartment, told delegates the

7

Round and About

E ighty-year-old Kina Yakimovalives in Lovech, a small townnorth-east of Sofia, and her

situation is typical of many of her generation. After four decadesof hard work, she is alone. Hermeagre pension of around 45 eurosa month goes nowhere. In wintershe cannot afford heating.

Now the Swiss Red Cross hashelped the Bulgarian Red Crossintroduce a home care service inLovec and four other locations inthe country, mobilizing clients to meet and do things together.

‘Solitude is the worst disease,’ saysYakimova. ‘Before, I cried everyday. Now, sometimes, I feel almosthappy, waiting until they come.’

‘They’ are the nurses and homehelps who visit several times aweek, fetching Yakimova’s shop-

Kiev9th ERNA meeting applauds harm reduction work

single most moving experienceshe’d had in the region was‘going round Irkutsk in Siberiawith Anna Zagainova and hercolleagues from the Russian RedCross while they distributedclean needles to sex workers.’Irkutsk is the only place in theRussian Federation where theRussian Red Cross does needleexchange; there is also a projectfor HIV prevention through peereducation in Krasnodar.

Zagainova, a 20-year Red Crossveteran and the manager of theRed Cross harm reduction prog-ramme in Irkutsk, told The Bridgecheap heroin from Central Asiawas first noticed in the city in1999. Young people quickly beganto inject, rather than smoke orsnort it, ‘through sheer ignorance

Bulgaria‘Solitude is the worst disease’

and because that’s what pusherstold them to do.’ Sharing needles(the most efficient way of trans-mitting the HIV virus) became ‘akind of adolescent rite of passage,a blood-brother ceremony,’ sheexplained.

In the space of only a few yearsthe city was in the grip of an HIVepidemic that threatened to cutdown many of its young peoplebefore their adult lives had evenbegun. Yet Zagainova says thatthe tide may have turned againstHIV in the past two years. No onecan prove scientifically it’s becauseof harm reduction, she says, butthe statistics are encouraging andthe anecdotal evidence strong.

Professor Gerry Stimson of theInternational Harm ReductionAssociation, which provides tech-nical advice to governments, citedthe example of the UK, wherethere is a nearly 20-year-old bipar-tisan consensus in favour ofneedle exchange.

A total of 2000 needle exchangepoints have been established inBritain, he said. The evidence basefor harm reduction was still notconclusive; only ‘a few’ academicstudies showed a drop in actualHIV prevalence as a result of it,Professor Stimson told ERNA dele-gates. But in Britain the preva-lence of HIV among injectingdrug-users had stabilized ataround one per cent.

Delegates from 36 NationalSocieties split up into five workinggroups to agree messages forMoscow 2006. Three put ‘pursu-ing governments’ on harm reduc-tion at the top of their agenda —including getting laws changedon the basis of evidence gatheredby community workers like RedCross branches.

One group wanted a call fordrug addiction to be reclassifiedas a ‘public health problem’; an-other concluded harm reductionfor the Red Cross/Red Crescentwas ‘possible but difficult’.

The ERNA meeting, its ninth,was hosted by the UkrainianRed Cross. � AW

They are a forgotten footnoteto a conflict largely forgottenby the outside world: Kosovo’s

Roma, who fled their homes du-ring the war six years ago afterthey were seen as siding with theSerbs.

Those still inside Kosovo live inmakeshift camps never meant tobe permanent. They rarely ventureoutside KFOR-guarded areas, limi-ting access to employment, health-care and education even moreseverely than usual.

Since 1999, the local Red Cross,the ICRC, KFOR, Caritas Kosovo,the Voice of Roma and other NGOsand UN agencies have been sup-porting Roma people with foodand other aid in camps likeZitkovac, Cesmin Lug and Kablar.

But specialist Roma groups saythe international community haslargely failed the most vulnerablemembers of Europe’s most vulne-rable minority, especially in thehealth field.

You don’t have to be a doctor torecognize that northern Kosovo’sRoma camps are unhealthy places.

KosovoHealth education for Roma

They barely qualify even as shanties.There is no sewerage. Motherscomplain their children sufferfrom chronic skin diseases andlice. People look anaemic. Stenchand squalor are everywhere.

The depth of poverty seems moretypical of Africa or Asia than Europe.Unemployment is the norm.Organized education and health-care are extremely limited. In the-ory, Roma children have access toschools in the north; few attendregularly.

A local Red Cross doctor doesvisit the Roma camps to checkconditions, and a nurse appointedby the authorities in the northerntown of Mitrovica, which came tosymbolize Kosovo’s ethnic divi-sions, visits every weekday. Butthis effort is far from enough.

The national and internationalauthorities responsible for Kosovoalso seem no closer to solving theacute problem of lead pollution,which has killed at least one Romachild, according to the WorldHealth Organization (WHO), pos-sibly many more.

Hundreds of Roma have beenliving next to a disused but stillcontaminated lead smelter inMitrovica, their flimsy wooded hutsonly a few hundred metres fromtoxic slag heaps. The wind blowspoisonous dust through the camp.

WHO describes the situation asan environmental disaster, but therefugees have yet to be moved.Some of them say they are afraidto go anywhere else.

Although supposedly free, health-care often ends up costing moneyin Kosovo. This highlights the needfor income-generation program-mes as much as humanitarianrelief.

It’s hard to know where to breakinto the cycle of poverty, poorhealth, lack of education and dis-crimination that so afflicts theRoma, in Kosovo – if it were pos-sible – worse than elsewhere inCentral Europe. �

By Vjosa Macula, OrganizationalDevelopment and YouthProgramme Manager,International Federation, Kosovo

‘

ERNA delegate and local hero. Anna Zagainova, Russian Red Cross, Irkutsk. Photo: AW/IFRC

Roma camp, northern Kosovo. Photo: Shpend Emini/IFRC

Nurse and patient, Bulgaria. Photo: Patricia Mauerhofer/Swiss Red Cross

ping, cleaning her apartment,paying bills, doing whatever needsto be done. As she suffers fromhypertension and diabetes, theyalso take her blood pressure andgive her insulin shots. Yakimova isalso looking forward to a house-warming party the Red Crossbranch is planning.

But the men and women ofBulgaria’s elderly self-help groupsare also contributing to the well-being of others. Last Christmas,they brought presents to elderlypeople and disabled in residentialcare near Lovec. And as Red Crossvolunteers they helped to sort outclothes and food for flood victimsa year ago. �

By Patricia Mauerhofer, Swiss RedCross

in favour of internationally-agreed strategies isvital, both for TB and TB/HIV.’

De Colombani’s Copenhagen-based colleague,Dr Risards Zaleskis, WHO’s regional adviser fortuberculosis control, says that many countriesin Eastern Europe and Central Asia are facing‘real epidemiological deterioration, not justbetter reporting, and this is mostly due to thesocial and economic situation and disruptionof health systems.’

‘The task now is to implement the agreed stra-tegy for TB,’ he says, ‘but we still face problemsbecause of resistance in some countries fromdoctors and administrators who cling to the oldSoviet system.’

Mars, VenusWHO has grouped the 52 nations of its vastEuropean region – stretching from Portugal toKazakhstan – into three categories for eachdisease. All the countries which are ‘high pri-ority’ for both – Russia, Belarus, Estonia, Latvia,Lithuania, Moldova and Ukraine – are formerSoviet republics.

The International Federation has been combin-ing its TB and HIV/AIDS programmes in EasternEurope for several years now. And the ongoingRussian TB programme includes ‘heavy HIV-AIDScomponent’, according to programme officersin Moscow and Geneva.

Russian health ministry figures show that in2003 there were 3133 registered cases of co-infection; this rose to 7678 last year. ValentinaShishkina, head of operations for the RussianRed Cross, says her National Society is now ‘try-ing to develop strategies to deal with co-infection.We do fear HIV is going to fuel TB, because HIV isgrowing very fast and latent TB is common.’

There is also no doubt that both HIV preven-tion work and TB treatment supervision (DOTS)are the kind of labour-intensive, community-based work that the Red Cross specializes inand excels at.

But in sub-Saharan Africa, Asia and EasternEurope, of those who need it the proportionwith access to the full package of collaborativeTB/HIV activities remains low.

Above all, this is emphatically a time when, likethe SARS outbreak, the world needs the WorldHealth Organization, with which the Interna-tional Federation reached agreement earlierthis year to step up cooperation in several keyhealth sectors. It has often been observed thatTB, especially, and HIV are ‘diseases withoutborders’.

In 2004 WHO published its ‘interim policy oncollaborative TB/HIV activities’. ‘Interim’ becauseof the research gaps in this field – centred aboveall on whether encouraging results found intests with individual drugs on small sampleswill translate to the public health context, andalso on how new antiretroviral and TB drugsinteract.

The interim policy – undoubtedly the singlemost important public document in this area(available at www.who.int) – describes itself as a ‘rolling policy which will be continuouslyupdated to reflect new evidence’.

It recommends greatly increased collaborationand increased case-finding of each disease with-in programmes for the other, although basedon voluntary HIV testing.

The preventive TB drug isoniazid should be gi-ven to HIV individuals with latent infection withMycobacterium tuberculosis in whom active TBhas been safely ruled out – a ‘critically important’step possibly not feasible in developing count-ries, according to WHO. (The diagnosis of TB stilldepends on microscope work with smears – acentury-old technique – by skilled technicians.)

Co-trimoxazole therapy, which has been foundto prevent several bacterial and parasitic infec-tions in people living with HIV, would mean-while be given to TB patients.

TB/HIV is a new area in terms of policy. Accord-ing to de Colombani: ‘Changing people’s minds

The main lesson the African experience

of TB/HIV holds for Europe is that

professional synergy in programme work

is possible.

8

Letter from Brussels

Here’s a question: if just over 60 per centof pre-enlargement EU National Socie-ties do fieldwork in the battle againstHIV/AIDS, what proportion of the 2004

EU joiners do? The answer, which will probably surprise no

one, is 100 per cent, at least as far as our researchshows.

Young people, especially, pay a high price forHIV in Europe, according to the most recentstatistics from EuroHIV: in 2003 under-30s re-presented 29 per cent of new HIV cases inwestern Europe, 45 per cent in central Europeand 73 per cent in eastern Europe.

Is the Red Cross addressing the challenge?The Red Cross/EU Office wanted to find out

exactly how the Movement is deploying itsresources to meet this and other health issuesin Europe. Our survey questionnaire was sentto all health departments of the EuropeanUnion National Societies, and we got respon-ses from eight accession and twelve pre-enlargement EU National Societies.

The findings update a similar health-activitymapping exercise from 2002.

The mapping aims to provide an overview ofpriorities in the health field, identify areas ofcommon interest for future cooperation, iden-tify health challenges National Societies arefacing in the EU, and facilitate networkingamongst them.

First aid and blood donation are still the lead-ing common denominators in health amongNational Societies across the EU. But expandedinvestment in psycho-social support since the2002 mapping exercise has pushed it into thirdplace, ahead of health education and care, andcultural activities and prevention work.

We found important East-West differencestoo, which reflect the different histories and

economies of the regions. All but one of the eightnew EU National Society respondents workedin ‘food and nutritional aid’, organised volun-tary blood donations and trained for emergen-cy preparedness, compared to between half andjust over half of the pre-enlargement group.

On the other hand, many more of the pre-en-largement National Societies ran programmesto integrate refugees and asylum seekers (mig-ration in the EU is still overwhelmingly west-ward) or maintained visiting services, comparedto the new members.

Four new EU National Societies applied forfunds from the European Commission in thepast year and three were successful. But sixwanted also more information on fundingopportunities in Brussels. The questionnaire –which has generated up-to-date contact detailsand information on relevant field of activitiesfor each National Society – will help us to plugthese gaps.

The 2007–2013 Health and Consumer Protec-tion Programme, for example, could provideNational Societies with a programme fundingsource.

Complete well-beingThe 1946 constitution of the World HealthOrganization (WHO) defines health as ‘a stateof complete physical, mental and social well-being and not merely the absence of disease orinfirmity.’ We asked National Societies to choosebetween that and the public health definition:‘the health of a population, the sanitation situ-ation of a community, the general sanitary ser-vices and the administration of care services.’

All but one (the Swedes) of the pre-enlargementNational Societies opted for WHO’s holisticdefinition; five of the new members chose thepublic health definition. (The Slovenian Red

Health in the new EU Cross wanted to use both and the Latvian RedCross chose a different one altogether.) TheRed Cross/EU Office will examine this defini-tional question in some detail. ‘Health’ is lesseasily defined than might be first thought.

Asked what they saw as the main challengesfor the future, National Societies clusteredaround these in particular: demographicchange and ageing; financing health and careand the general increased demand for theirservices; reform; and the fight against socialexclusion and inequality.

Three national societies saw advocacy as achallenge for the future, then one or two alsoopted for each of HIV/AIDS, support for refugeesand asylum seekers, quality control, training,organizational issues, epidemiological develop-ments, family, mental health, drugs and lifestyle.

All these issues have been listed by the Euro-pean Commission as priorities and should beincluded in the next Health and ConsumerProtection Programme.

13 ‘old’ EU National Societies (the Austrian,Belgian, British, Danish, Finnish, French,German, Hellenic, Italian, Luxembourg,Netherlands, Spanish and Swedish Red Cross)responded to our questionnaire, as did eight‘new’ EU ones (the Czech, Estonian, Hunga-rian, Latvian, Lithuanian, Polish, Slovak andSlovenian Red Cross).

We hope the mapping exercise will be a goodstarting point for National Societies to developpartnerships with others active in a particularspecific field. And we also welcome the settingup of a Working Group on Elderly People,coordinated by the Austrian Red Cross. �

Luc Henskens is Director of the Red Cross/EUOffice. Nathalie Marchioro-Holzer is its Programme Officer for health.

The Red Cross/EU Officehas been looking

at how National Societiesdeploy resources in thehealth field. It found the new EU members

are in the front line of the fight against

HIV/AIDS.

Professor Peter Godfrey-Faussett, a leadingexpert on TB/HIV co-infection in Africa based atthe London School of Hygiene and TropicalMedicine, explains that ‘top-down medical’tuberculosis and community-based HIV prog-rammes have traditionally come from differentperspectives. Or as the report on the Addis meet-ing put it: ‘TB programmes are from Mars, HIVprogrammes are from Venus.’

‘But the main lesson Europe might take fromthe African experience,’ says Godfrey-Faussett,is that ‘there is huge synergy that emerges whenthe two sets of professionals get round the tableand work out what they’re trying to achieve.’

This may be what has started to happen inRussia, where a coordinating body for TB/HIV,including the ministries of health and justice,WHO, the International Federation’s Moscowdelegation and the development NGO Globus,held its first meeting in September.

In some areas, Russian doctors were begin-ning to be at least neutral between optimismand pessimism about TB. ‘The situation hasstabilized – no more,’ says Dr Bonchuk Stefano-vich, chief physician at the regional TB dispen-sary in Belgorod. ‘1997 was a turning point, butwe are still not back to the pre-1991 situation.’

Drug resistance, as ever, is the big fear. Dr Stefa-novich added: ‘If out-patients drop out of theircourse, someone will try to fetch them. But thisis difficult work. The law provides for manda-tory treatment, but there’s no real practicalmechanism for it.’

Historic popular ambivalence about TB inRussia – that it got ‘treated in the spring andforgotten in winter,’ as one health worker put it – has always been a hurdle. Co-infection, andthe threat TB poses to the ever-growing numberof people living with HIV in countries likeRussia, Estonia and Latvia, will concentrateminds anew. �

Alex Wynter is co-editor of The Bridge

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Luc Henskens, Nathalie Marchioro-Holzer