Russia is confronting one of its most serious public health threats since the collapse of the Soviet Union. The threat is tuberculosis, but with a dangerous twist: Strains of the bacteria are widely circulating that are resistant to ordinary anti-TB drugs, and far harder to cure.
In parts of Siberia, nearly 30 percent of all tuberculosis cases aren't treatable by two of the most potent medications, the World Health Organization reported last year.
One Siberian city is tackling the problem with an innovative health program, called Sputnik, affectionately named after the first man-made satellite launched by the Soviet Union in 1957. The new Sputnik is a mobile clinic; teams of nurses orbit like satellites around the sprawling city of Tomsk, finding and treating patients with drug-resistant TB.
The program is a joint effort between Russia's Health Ministry and the American nonprofit Partners in Health. It's the first mobile TB clinic of its kind, and it allows health workers to fight the disease among the people who are the hardest to reach — the homeless, the mentally ill and drug addicts.
It's a job that's often uncomfortable and, sometimes, not completely safe.
"My parents worry about me in this job," says Yulia Safronova, a nurse affiliated with Sputnik, "not so much because I might catch tuberculosis. But I tell them what sort of patients I have to work with. Maybe that worries them more:"
Safronova's patients all have one thing in common: They can't or won't go to the hospital.
"Have you actually seen a hospital?" Olesia Tarazanova asks. "They've got drunks, dope addicts, ex-cons, crooks. I don't even drink. Why should I stay in a hospital with people like that?"
Tarazanova, 24, is a wisp of a woman with bleached-blond hair, holding her nearly 2-year-old son by the hand.
She meets the health team in their car on the street near her apartment, gets into the back seat, and takes a handful of pills that Safronova doles out from a black gym bag on her lap.
Tarazanova has been in treatment for TB for almost two years, she says. If all goes as planned, she'll complete it in a couple of months.
Safronova rides with driver Sergei Goryunov, who left a safer job seven years ago to work for the Sputnik program. Goryunov is a big man and capable of acting as a bodyguard for the nurses when he needs to.
"I like talking with the patients," he says, grinning. "I like to play tricks on them, joke with them. It's interesting for me, hanging out with alcoholics and drug addicts."
Members of the Sputnik crew spend a lot of their time bumping along rutted roads on the edges of this industrial town, with its oil companies and petrochemical plant.
Drug-resistant tuberculosis is a growing problem in Tomsk. People with the infection often have to take as many as 18 pills daily — including some to relieve the side effects of TB medications, which include psychosis, severe nausea and hearing loss.
Some patients get fed up with their treatment before it is complete. They resist, they hide, they lock their doors to avoid the Sputnik team.
But if the treatment is interrupted, it can give the tuberculosis bacteria a chance to recover and develop more resistance. Safronova and Goryunov often have to cajole people into taking the medication.
The next patient, Sergei Gaptenko, lives with his father in a weathered, run-down house. He's a sometime electrician in his mid-40s, and an alcoholic. He wants to know when scientists will invent something that will cure his multiple-drug-resistant TB in one go.
The nurse Safronova sets out a plateful of pills — just half of Gaptenko's daily dose. Another nurse will come by in the afternoon with the rest.
Gaptenko says he has to stay home to take care of his father, also an alcoholic. That's the main reason he's not in a TB hospital, although he too insists that most patients in the state hospitals are criminals.
Both men are on pensions, Safronova says. When they get their money, they "drink it up," and then Gaptenko becomes a difficult patient, hard to find and uncooperative.
But because of Sputnik, both Gaptenko and his father are getting treatment.
Sputnik is only one of many ways that the city is fighting drug-resistant TB, but it's a crucial one, says Alexander Barnashov, a head physician at the Tomsk Health Department. "If this program didn't exist, there would be a lot more people in Tomsk, in Russia and even in America who could be walking around and infecting others with one of the most dangerous forms of tuberculosis."
The success of Sputnik has prompted other Russian cities to start programs of their own, Barnashov says. Delegations visit from other parts of the country and abroad to learn how it works.
But Sputnik could be in danger, he says.
The Russian government recently imposed a law that requires nonprofits that receive funding from outside Russia to register as "foreign agents." That label is practically equivalent to the word "spy" in Russia. Thousands of charities and other groups around the country have been raided by investigators, demanding to see their records.
So far, Partners in Health hasn't been affected. And the Sputnik team continues rounds its throughout the city.
Safronova admits she might even like her job, although it doesn't pay well. "You know what to expect from the patients, what sort of people they are, and you see them differently, not the way an outsider would," she explains.
And that's what Sputnik seems to be — an irregular orbit for patients who can be treated only by someone who takes the time to really see them.