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While violence and the mortalities of war have been among the 20th century's greatest plagues, a more quiet structural violence has also left its mark. Structural violence may be defined as increased morbidity and mortality resulting from forms of social organization that frequently lead to groups of individuals being marginalized along social axes, often those of economic, racial, and gender inequality.1 Its effects can be seen during wars, in postwar situations, and even during times of peace; in some cases, such violence is marked by the absence of protective state institutions.2,3 Health crises associated with massive social transformations— such as the resurgence of tuberculosis in the former Soviet Union— provide an opportunity to elucidate this form of violence and its effects.
During the collapse of the Soviet Union in 1991, Tajikistan (population 6.1 million), one of the poorest Soviet Central Asian republics, was embroiled in a bloody civil war.4 In Tajikistan's easternmost province of Badakhshan (population 240,000), the cessation of subsidies and essential supplies from Moscow, exacerbated by the civil war, led to a dire humanitarian crisis. Only through the intervention of international humanitarian agencies such as the Aga Khan Foundation, Médecins Sans Frontières, and the International Federation of the Red Cross were mass starvation and death averted.5 Tajikistan's economy was also in crisis: between 1991 and 1995 gross domestic product declined 45%, and in 1996 more than 85% of the population was living below the poverty line.6 Per capita state expenditure on health care had dropped from US $300 in 1991 to less than US $1 in 1998, in a country where 5 kg of beef cost US $10 and a bar of soap US $1.7,8
With the collapse of the Soviet state also came transition from a subsidized health care system to modified fee-for-service, in which the sick often have to purchase health care on the open market. This has coincided with a downturn in vital health statistics. Maternal mortality in Tajikistan increased from 41.8 per 100,000 live births in 1990 to 65.5 in 1997.6 In Badakhshan, acute childhood malnutrition increased from an estimated 3.0% in 1994 to 5.8% in 1996, while chronic childhood malnutrition increased from 40.3% to 44.8% over the same period; the region also saw an increase in the incidence of treatable infectious diseases, including tuberculosis (TB).6
During the Soviet period, patients with TB received paid leave from work and free TB treatment. In the crisis after 1991, however, the local 40-bed tuberculosis hospital in Badakhshan's capital, Khorog (population 20,000), was faced with a shortage of TB medicines. Drugs supplied by international organizations sustained the hospital for a short period, but soon the hospital was no longer able to provide patients with an effective treatment regimen of first-line antituberculous drugs such as isoniazid, rifampin, ethambutol, and pyrazinamide.5 In 1996, in addition to a shortage of chest radiograph material, laboratory supplies, tuberculin skin tests, and a breakdown in the local surveillance system, the hospital was faced with a sixfold increase in the number of TB patients compared with a similar interval during the Soviet period (Khorog Tuberculosis Hospital, unpublished data, 1996). This is consistent with national trends showing a dramatic increase in reported TB incidence, from 30 per 100,000 in 1995 to more than 250 per 100,000 in 1997.8 Whereas during the Soviet period patients were treated with at least 3 anti-TB drugs for at least 6 months as per international recommendations, nce out-of-sequence /-->10 health personnel now often have to rely on only 2 drugs, isoniazid and rifampin. Given the high likelihood in the region of already existing resistance to one of these agents, local physicians expect, and international TB experts agree, that this situation will result in the generation and transmission of multidrug-resistant TB.11,12 In the absence of appropriate therapy, these forms of TB have the potential to overtake drug-susceptible TB.12
Effective, known therapies will stop the spread of this epidemic, yet in the face of increasingly privatized health care these services are now beyond the reach of those who need them most: the urban and rural poor. The result will hardly be surprising: increased suffering due to TB and other diseases and a quiet increase in more difficult-to-treat drug-resistant TB that will be heaped on an already overburdened population.
Keshavjee S, Becerra MC. Disintegrating Health Services and Resurgent Tuberculosis in Post-Soviet Tajikistan: An Example of Structural Violence. JAMA. 2000;283(9):1201. doi:10.1001/jama.283.9.1201-JMS0301-4-2