The tuberculosis hospital in Togliatti, Samara, in the distance.
Tuberculosis is still a very deadly disease – especially in the former Soviet Union.
The number of patients with very difficult to treat forms of tuberculosis is growing steadily in that part of the world. Officials from health organizations say it is an epidemic and it is not slowing down. More and more patients are found to have the non-treatable form of tuberculosis – XDR (extensively drug-resistant).
Though Ukraine, Russia and Central Asia are very different, they have one thing in common – people are not treated properly, and people are not aware that tuberculosis does not have to be so deadly, if only more time would be spent on educating the population, thus preventing the disease from spreading. Instead, those who become sick also become stigmatized, relatives turn away, neighbors stop speaking to them. They spend months in prison-like clinics, where equipment is outdated and medical and nursing staff are just as poor as their patients. Many leave without finishing their treatment and many come back again and again.
The tuberculosis hospital in Togliatti, Samara, in the distance.
Nurse organizing dead patients’ files.
A newly arrived patient stares at a hospital worker distributing fish soup while bickering with another patient
Polina, 37, has just been brought into the hospital severely malnourished and suffering from numerous diseases, including tuberculosis, hepatitis C and HIV.
A homeless man with a Swastika tattoo receiving free consultation in a Saint Petersburg Hospital.
A man waiting to exchange needles and to be tested for HIV in an outreach bus on the outskirts of the city. Intravenous drug users have a very high risk of contracting tuberculosis.
A seriously ill patient (left) sitting in a ward in Mariupol. He is living with HIV, has hepatitis and drug-resistant tuberculosis and uses intravenous drugs. Across the street from this tuberculosis clinic is a clinic for drug users, where patients get their daily doses of a synthetic opioid substitute drug.
A lab technician looking into a microscope. Tuberculosis clinic, Donetsk.
A group of tuberculosis patients with various degrees of drug resistance have a smoke just outside a tuberculosis clinic in Donetsk.
Man walking away from a tb hospital. Ukraine
At a tuberculosis clinic in a Donetsk suburb a doctor checks Andrei for signs of life and finds none. A drug user of many years, he died at the age of 46 from HIV-associated drug-resistant tuberculosis. He had checked himself into the hospital three days earlier.
In that part of the world, unemployment levels are high, most young people are left jobless and spend their time taking drugs, using the same needles and having unprotected sex. Many end up HIV positive. But they do not die from developing AIDS, they die much quicker – from tuberculosis. Most of them do not even know they are sick, till it is too late.
I have been working on this story since 2008. It first started as an assignment from Doctors Without Borders in Chechnya, and quickly grew into a much larger project, involving several countries, dozens of hospitals and clinics, and hundreds of doctors and patients. I have seen very little change in the past few years, but I hope that now, when my project is complete, any attention it receives will bring some change at least to the people involved.
A doctor is preparing her tuberculosis patient for an X-ray at a tuberculosis clinic in a Donetsk suburb.
34-years old, a mother of four children was beaten by her husband and her relatives for being sick with TB. Nukus, polyclinic No. 2 Uzbekistan 2011
MSF psychologist holding a group meditation session for MDR-TB patients. Nukus, TB hospital No. 2. Uzbekistan, 2010
A 19-years old, has XDR-TB. His younger/older brother has MDR-TB and is recovering. Doctors just found out Islambek can’t be treated. Their mother died from TB. Nukus, TB hospital No. 2 Uzbekistan 2010
A patient with advanced MDR-TB. She is too frail to play table tennis, as are most of her fellow patients at the hospital. Uzbekistan 2011
Many patients don’t want their faces photographed as there is still a lot of misperceptions and stigma attached to TB.Uzbekistan 2010
A doctor talking to a patient, Togliatti Russia 2011
Kolya, 31, who is living with HIV and has tuberculosis, has a poor prognosis for recovery. Tuberculosis clinic, Mariupol.
A woman undergoes X-ray at the tuberculosis clinic in Mariupol.
MSF psycho-social support counselor is waiting for her MDR-TB patients – those who live at home and come for daily checkups at the clinic. Nukus, polyclinic No. 2 Uzbekistan 2011
An empty hospital stretcher. Ingushetia Russia 2009
Bio
Misha Friedman is a documentary photographer who has worked for various NGOs, including Médecins Sans Frontières, documenting the humanitarian crisis in Northern Uganda, urban violence in Nigeria, Kala Azar in India, and civil war in Darfur.
Recent projects deal with the tuberculosis epidemic in the former Soviet Union, and corruption in Russia.
Related links
Misha Friedman
There are some strong photos, here. Too much of the grainy B&W thing for my taste.
The biggest challenge with photos of XDR patients is that Nachtwey has pretty much “done” this.
Nachtwey? You mean James Nachtwey? .. Oh yea the guy who’s stuff looks ike Friedman’s photos.
Great stuff until 16 peters out a bit from then on
“I threw my arms about those shoulders”
M.B.
I threw my arms about those shoulders, glancing
at what emerged behind that back,
and saw a chair pushed slightly forward,
merging now with the lighted wall.
The lamp glared too bright to show
the shabby furniture to some advantage,
and that is why sofa of brown leather
shone a sort of yellow in a corner.
The table looked bare, the parquet glossy,
the stove quite dark, and in a dusty frame
a landscape did not stir. Only the sideboard
seemed to me to have some animation.
But a moth flitted round the room,
causing my arrested glance to shift;
and if at any time a ghost had lived here,
he now was gone, abandoning this house.
–Joseph Brodsky
Unlike Nachtwey’s treatment of XDR, Misha’s story FEELS and LOOKS more real to me, for a number of reasons. First, the pictures are both haunting and haunted (and not simply by the devastation of the disease and these people’s lives) but by the ENVIRONMENT (both in the hospitals and within the frame itself) and the underlying social collisions that are so evident in this picture. The picture-taking strong and emotional (and not just because of all the grain, shadows, low-light, long exposures) but it is the treatment of the environment that is so dense and effective. While Jim’s work was properly lauded, I frankly never FELT the pictures, in other words, I respected them, but they seemed so much more effigies and so much statuary (am i being iconoclastic here?) than fully aware. Its impossible to dismiss the disease and the sufferer from their environment (social and remedial). Jim’s were certainly loving testament to human endurance and struggle, but MIsha’s story is as much about PLACE as XDR T itself. The loss and struggle and tragic circumstances are made fully real here (the people and their thinning lives) but so do is the environment.
This looks and feels very much as the reality of these TB clinics in russia, as well as the environment (especially outside the major cities) and that’s the accomplishment here, for me. An insight and evocation of not only the suffering, but maybe something arguably larger….had this essay been about ‘Russia’ only, i might have winced (yes, friends, there is color still in Russia) but the technique here and the emotion is married to the very specific conditions of life in these “houses of the dead”….
Where with Jim’s work, I was always left wanting more (of the places themselves, and maybe something exterior to the immediate suffering), I see and feel that here….take a look at that magnificent #4 for example….the juxtapositions in no. 18….the soul-crushing 19 (which, for me, is the most powerful image in the group and one of the best images, for all reasons, i’ve seen about institutional care and this disease, up there with Richard’s)….
powerful, heart-breaking, sensitive, fully aware and powerful work….
left bereft….
and what shall we do with this life, the lives loosening…
“Unlike Nachtwey’s treatment of XDR, Misha’s story FEELS and LOOKS more real to me, for a number of reasons.”
While it may “feel and look” more real, is it? I understand both this photographer and Nacthwey’s intent is to persuade. Both shoot in B&W, while this photographer adds in grain and motion to add to the drama. At least Nacthwey has huge name recognition to make the issue more visible through his work.
Few people, unfortunately, will look at this kind of photo. So perhaps it doesn’t matter. And people have grown progressively more suspicious of photography as truth. I think this would be more effective as persuasion if presented as clear, sharp, saturated color images. They would be much harder to look at, IMHO.
“…people are not aware that tuberculosis does not have to be so deadly, if only more time would be spent on educating the population, thus preventing the disease from spreading. Instead, those who become sick also become stigmatized, relatives turn away, neighbors stop speaking to them. They spend months in prison-like clinics, where equipment is outdated and medical and nursing staff are just as poor as their patients. Many leave without finishing their treatment and many come back again and again.”
That’s a great sentiment, but unfortunately MDR or XDR TB is going to be quite deadly, particularly combined with HIV. I think public health concerns for drug resistant TB would involve isolating patients and directly observed therapy that is completed as prescribed. If the disease is incurable, because it is so resistant, than the isolation and prevention of transmission becomes even more important. There is a reason that TB patient were kept in sanitoriums when the disease was rampant.
I am inclined to agree with Jim Powers on this one. Misha, your essay feels too film-like and “unreal” to me. Like a film noir that ultimately is left back in the cinema of place of viewing and not carried away with the viewer. There’s no doubt that they are powerful images but this feeling detracts from the reality of it.
Personally, I found Maxim Dondyuk’s images of TB in the Ukraine more powerful and more real. Those images were photographed in color and many of them have strikingly similar content to this essay by Misha, e.g. a tatooed man having his heart listened to. But the color and other technical choices made mean Maxim’s essay feels more real to me and makes me feel for the people more. I would go so far as to say more so than James Nachtwey’s work on the same subject also – the obvious touchstone for all following photoessays on TB. These are important points to consider when positioning this kind of story. Maybe that’s why Maxim won the BD Hope for a Healthy World competition this year? I’d be interested in others thoughts on the juxtaposition of the two.
Links:
Maxim Dondyuk TB Epidemic in Ukraine
http://maximdondyuk.com/album/thetbepidemicinukraine?p=1&s=UA-19603566-4#1
Maxim Dondyuk TB in the Faces
http://maximdondyuk.com/album/tuberculosis-in-the-faces?p=1&s=UA-19603566-4#4
Nevertheless, good luck Misha getting these images to the right people and using them to bring the healthcare required to the Ukraine. There’s clearly a lot of anguish and concern over this epidemic, given the number of people who seem to be covering it now. I hope that the care and attention the people need arrives soon. It’s been going on far too long.
Both Jim and Bob have good points…
I usually don’t understand what Bob writes about (no disrespect) but this time is crystal clear.
This is powerful work. Not because of anything technical but because the suffering is palpable.
Good strong work.As with a lot of similar work there is too much stick and not enough carrot. I would like to see the best cases, recovered people or vaccination programs or some sort of hope. Otherwise it’s just a lot of poor people dying. Is there any positive work being done that you could shine a light on?
I’m gonna have to come back to this; I’m tired.
Some shots are strong, others feel contrived – e.g. the excessive use of vignetting, presumably to add a vibe of darkness in a couple of shots. I agree with Bob, suffering is palpable, but then I wonder is it comparable to, say, Leros? Or other similar work looking at groups of very ill people? I’m not sure. The images, for the most part, aren’t giving me much idea of how this links to a bigger picture (i.e. why tuberculosis is particularly rife here), yet it doesn’t overly draw me in to any individual.
I’m just not convinced the approach best serves the intent.
And that’s nothing against the b&w or the grain, both of which I’m fine with.
Maybe on a second viewing I’ll see things differently.
ALL
except for the topic and b&w i don’t see anything here resembling the Nachtwey aesthetic imo…Jim is way more structured…Misha loose
What’s a Nachtwey?
Excellent.
However, weird that I have this impression that some of the photographs are almost “too good” as photographs to be about their contents as much as they are about being good photographs. I can, of course, also see how they ARE connected with the contents and the essay and am not suspicious of the photographer’s motives. Personally, I get lost in their visual excellence and have to remember that that isn’t the reason they exist or what I’m supposed to glean from them.
IMANTS – I think a Nachtwey is a type of fruit. Someone told me once you’re supposed to have at least 5 fresh Nachtweys a day.
Nope found out is was………… A North German topographic name, a reduced form of Nachtweide ‘night pasture’, for someone who owned land for grazing cattle or sheep at night.
hey Misha! nice work!