Estonia: TB and alcoholism

TARTU, Estonia – Ave Peetsman grew up among horrible violence in her household. Her parents were alcoholics and their fights, she said, raged on and on. But their battles left more than emotional scars. Mother and father carried drug-resistant strains of tuberculosis, infecting both their children.

 “I saw terrible things as a child,” Peetsman said. “The violence was related to the drinking. What I didn’t know, or didn’t see, was that they also gave me TB.”

In interviews with several TB patients in Estonia, I heard versions of this story over and over: Alcoholics weren’t just passing TB to other alcoholics in homeless shelters or dingy quarters. This wasn’t a disease of just hard-core addicts. The alcoholics were infecting their own children, many of whom harbored the bacteria unknowingly until it began active years later, when they were adults. This time bomb was a cruel twist of a disease that has hung around for millennia.

This report is part of a three-country project by photographer Riccardo Venturi and me at the invitation of the Japanese company Otsuka Pharmaceutical. On these trips, during which we are acting independently, we are looking at the human impact of TB and the different innovations in treatment for patients. In Estonia, we also were joined by Dr. Lee Reichman, a global TB expert and founding executive director of the New Jersey Medical School’s Global Tuberculosis Institute.

“A lot of people think that TB is a disease of alcoholics and drug abusers, people who live alone in single room occupancy buildings,” Reichman said. “But here you see all these young women and men who get multi-drug resistant TB. Their alcoholic father or mother gave it to them.”

In Estonia, 41 percent of the country’s 330 new TB cases last year were patients who were considered alcoholics. Another 7 percent were drug abusers, according to the country’s tracking of TB cases.

“The profile of our cases is all over the place – some are drug users, some alcoholics, and some are young mothers,” said Piret Viiklepp, head of the Estonian Tuberculosis Registry in the National Institute for Health Department. “Many are getting TB from family contact.”

A paper published three years ago in the BMC Public Health journal did a systematic review of studies on whether there was a relationship between alcohol problems and TB and found that alcoholics had a “substantially elevated” risk of getting active TB. “This may be due to both increased risk of infection related to specific social mixing patterns associated with alcohol use, as well as influence on the immune system of alcohol itself and of alcohol related conditions,” the paper concluded.

We met four patients who said in interviews that one or both of their parents were alcoholics. Doctors said in each case that they were virtually certain that the parents infected their children.

Agnes Nikandrova, 31, who will finish her two years of treatment for multi-drug resistant TB at the end of this month, said her stepfather had tuberculosis. “My stepfather never told me that he had TB,” she said. “I guess he was afraid of the stigma.”

Dr. Manfred Danilovits, head of the Department of Tuberculosis at Tartu University Clinics and a coordinator of the National TB Program, listened to her and nodded knowingly. “In Estonia, this situation is not rare,” he said. “I’ve had patients who say, ‘Don’t tell my wife. Tell her I am being treated for pneumonia.’”

For Peetsman, whose father, mother, and brother all died from TB, her experience with the disease – including how she contracted it – made her even more determined to raise her four children well and in good health.

“I’m always taking care of my children very carefully,” she said. “My children know they have my support every minute and every day.”

Her experience with TB impacted all her children emotionally, she said, but none more than her youngest: her only girl, Karolees, who was three years old when Peetsman was diagnosed with MDR-TB in 2008.

Peetsman went to the hospital when she learned she had TB. Only a few months before, the family cat had been put to sleep by a veterinarian and she had told Karolees that the cat had “gone to see a doctor.” The child’s father told the girl that same thing when Peetsman was hospitalized, and the girl thought her mother would die as well.

“Almost every day she made a drawing for me,” Peetsman said. “Most of them had a girl holding hands with her mother and father next to a house. So we have a really emotional connection. I am actually surprised at how this child can have so many good feelings toward me. For me, she’s the most important person in my life.”

Peetsman finished her TB treatment a year ago. She is cured. “My childhood is very difficult,” she said. “But I feel very lucky right now.”