Maxim Dondyuk’s Images of the TB Epidemic in the Ukraine

Treatment room. Starozburevskaya Correctional Colony No. 7, July 26, 2011. Copyright: Maxim Dondyuk

Maxim Dondyuk is this year’s winner of the BD Hope for a Healthy World Best Global Health Story category. From the competition announcement: His work focuses on “the tuberculosis (TB) epidemic in Ukraine, made worse by a constant shortage of medicine and proper care in Ukrainian hospitals. Maxim immerses himself in the lives of patients deprived of proper attention, living in hospitals, prisons and the apartments of people with TB during his investigation. Maxim’s photo essays on TB have appeared in several different countries, but continue to struggle for exposure in Ukraine.”Hopefully, with Maxim and others’ persistence in documenting the problem of TB, this will change.

Like most British people of my age my upper left arm bears the scar of the BCG (Bacillus Calmette-Guérin) vaccine to protect against TB (Tuberculosis), a disease caused by the bacterium Mycobacterium tuberculosis. The vaccine was produced by weakening (attenuating) a related bacterial strain, Mycobacterium bovis. This was done by growing it in an artificial medium, taking a small sample of this culture, putting it into fresh artificial medium and growing the cultures again. This process was repeated up to 230 times over 13 years in the case of the BCG vaccine and is called attenuation by sequential (serial) passage. It is a common technique used to produce vaccines for infectious disease. BCG was first used to inoculate humans as a vaccine against TB in 1921. However, the vaccine is not 100% effective and its protective effect can vary, possibly depending on where the vaccine has been subcultured.

Despite our best efforts at vaccination and the development of multiple drug therapies TB continues to ravage the world, especially sub-Saharan Africa, Asian and eastern Europe. The emergence of multi drug resistant TB (MDR-TB) has been a significant problem for many years now as it is resistant to the drugs we use as the first line of defense, rifampicin and isoniazid. Extensively drug resistant TB (XDR-TB) has also been around for a while and those strains are resistant to three or more of the second line drugs used when the first line ones are not effective. Totally drug resistant TB (TDR-TB), which was first documented in Italy in 2003, is now becoming more widespread with its documentation in Iran, in 2009, and now India this year. It is resistant to all drugs currently used for treating TB. Maryn McKenna has an excellent rundown of the emergence of TDR-TB over at her blog Superbug on Wired. TB is the second most common cause of death from an infectious disease, behind HIV/AIDS. In fact TB is also the most common cause of death in HIV/AIDS patients, who are susceptible to it and many other diseases, due to their state of immunosuppression. Thus, TB often comes hand-in-hand in areas that have significant HIV/AIDS epidemics. In that context it is worth noting that photographer Brent Stirton received an honorable mention in this year’s Hope for a Healthy World competition with his story on HIV/AIDS in the Ukraine.

[Redacted parts of this paragraph in italics. Lansur's observation in the comments below force a different interpretation of the images that must be taken into account and noted] The first image I chose to display from Maxim’s competition winning story, at the top of this post, shows us a TB treatment room in a penitentiary. The patients are kept behind bars and wearing masks in order to protect the healthcare workers administering the treatment. This is seems to be a form of barrier nursing but in this case it shows that these patients are also prisoners. Though the green hue of the room and bars is probably a deliberate choice due to the colour’s supposed calming qualities the despair of the patients is palpable in their poses. The photograph emphasizes the harsh conditions which these patients have to endure, the stigma of their disease through their separation from others for infection control reasons, and the poor state of repair under which these practices operate in the Ukraine.

Gennady, 49 years old. Diagnosis: multidrug-resistant tuberculosis (MDR-TB) and HIV. Donetsk TB Dispensary, December 23, 2010. Copyright: Maxim Dondyuk.

In the second image, above, by superimposing an x-ray of TB-riddled lungs over a bed-ridden patient we see him through not only the lens of the photographer but also through that of his pulmonary TB. It is a sensitive image that shows us the external and internal effect the disease has. Be warned, many of the other images in this series are very graphic, and yet they are sensitive also, in their documentation of the suffering of the people whom the disease affects in the Donbass region of the Ukraine. To find out more about this series, why Maxim undertook it, and to see the rest of the images you should download the competition winners announcement pdf here, and visit Maxim’s own website, here.

This is the second year of BD’s Hope for a Healthy World competition. Last year Mary Calvert won the best story category with “Polio’s Line in the Sand”, which I wrote about here. BD’s competition offers “photographers an opportunity to tell stories using imagery on a wide variety of global health topics” not just infectious disease. Is it symptomatic of a general failure to develop effective treatment campaigns, as well as continued inappropriate use and overuse of antibiotics and antivirals, that another hugely problematic infectious disease was featured this year? Not since the eradication of smallpox have we rendered another such devastating human infectious disease completely redundant. I sincerely hope this leads to more awareness, not just locally for the problems receiving so little attention in the Ukraine, but globally. It would be interesting to find out how much impact Mary Calvert’s story had. Did it drive attention, money, or even action towards the problem of polio? It is clear that with 7 billion people on the planet now these are global “human-scale” problems and better vaccines and drugs need to be developed urgently.

The gallery of Maxim’s work as well as the others who won and received honorable mentions in the story, single image, and multimedia categories will debut at the LOOK3 Festival of the Photograph, June 7-11, 2011 in Charlottesville, VA.

For more information I suggest these links:

Maxim Dondyuk’s photography

WHO info pages on the BCG vaccine and TB

Tuberculsosis, BCG wikipedia pages.

Maryn McKenna’s Superbug blog.

This Week in Microbiology (TWiM) episode #25: Magnetotactic bacteria and totally drug-resistant TB

The stop TB partnership stoptb.org

If you’re interested in learning more about BD’s global health photography initiatives please visit bd.com/photography.”