Photo Anatomy

A Blog by David Rochkind

People’s Choice Award

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It’s been a while since I posted a blog and I am back with a bit of shameless self promotion.  In the weeks to come I will post more interesting things about my ongoing work dealing with the drug war in Mexico as well as more technical stuff about the equipment I use to produce multi-media pieces.  But for now . . .

The above picture is entered in the BD Hope for a Healthy World Photo Competition.  As you know, I have dedicated quite a bit of time to working on health related issues, especially TB.  The competition includes a grant that would allow me to continue the project.  Part of the competition is a People’s Choice award.  If you have a spare minute to vote for my photo at the link below it would help give the project more visibility and put me on the path to being able to continue working on the issue.  Please do vote and pass on the link to anyone else you think would be willing.  Thanks in advance and, as promised, more meaty posts will come soon.

Written by rochkind

November 19, 2010 at 1:02 PM

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Press about current show in El Paso, TX

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I am currently in a show called “Border 2010: Photographs by Alejandro Cartagena and David Rochkind” at the Rubin Center for the Visual Arts in El Paso, TX.  It is the first time I have participated in a museum exhibit and I am thrilled to share the space with Alejandro, a photographer whose work I admire, as it is, at once, breathtaking, thoughtful and thought provoking.

Here is a link to a bit of nice press about the show(scroll down to the bottom):

Press About Show

And a link to the museum’s page on the show:

Border 2010 at the Rubin Center

Written by rochkind

September 10, 2010 at 12:44 PM

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A funeral exposes the complexity of TB

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Dumitru Stupalov lies in a casket during a wake. His mother, Evgenia, and daughter, Maria, stand over him.

Dumitru Stupalov’s body arrived to the morgue on a Thursday, the same day he died.  His autopsy was performed on Friday morning. He had spent several months at the TB Hospital in Balti battling MDR-TB under the supervision of Dr. Pablo Cioabnu.  Ciobanu was on hand during the autopsy and explained that in Moldova practically every death results in at least a cursory autopsy and, that in the case of TB patients, the attending doctor is asked to come to inspect the infected organs and confirm the diagnosis and cause of death. Dumitru was also living with HIV, which Ciobanu said significantly complicated his MDR-TB treatment.  The autopsy confirmed that the TB had not only damaged his lungs, but had spread to other organs as well.
 
Dumitru Stupalov had spent time in prison for a drug offense.  Vladimir Stupalov, Dumitru’s  father and a former prisoner himself, is sure that his son was infected with TB while in jail.  According to statistics kept by Moldova’s Department of Penetentiary Institutions, and confirmed by a local NGO that works in the prisons, the TB rate in Moldova’s jails is currently at about the rate that the World Health Organization(WHO) defines as an epidemic.  Still, the prisons have seen a drastic reduction, as much as 700%, in their TB rate over the past 10 years.  This drop is the result of the implementation of various measures, including isolating infectious prisoners and following the DOTS treatment strategy, which is endorsed by the WHO.  It is entirely possible, in fact likely, that Dumitru got TB while in prison, thoughTB is so prevalent in Moldova that it is impossible to know for sure.
 

A nurse stands in the city morgue just before the autopsy of Dumitru Stupalov.

After Dumitru’s autopsy, his father picked up his body and took it to the apartment that the family lived in together.  Typically in Moldova, the body would be laid out inside the apartment, like a wake, giving friends and family an opporuntity to visit and say goodbye.  The Stupalov family shared a very small apartment,- five of them slept in a 8×12 foot room with 3 beds- that was too small to fit the coffin, so they laid the coffin on two chairs in front of the apartment building’s porch. A few dozen friends and neighbors came to support the family, while others who lived in the nearby building simply walked through the wake on their way home.  For a family with a member who was infected with MDR-TB, their living situation was potentially a very dangerous one.  Living and sleeping in such tight quarters is a set up that allows for the possibility of other family members catching the disease.  Unfortunately, this is the reality for many families in Moldova because of the dire economic limitations that they face.
 
After the wake, the family took Dumitru’s body to his grandmother’s home in Maiskoe, a small village where he grew up, about 30 kilometers from the city of Balti.  The funeral would be the next day, and until then they would hold a wake for the residents of Maisoke that wanted to pay their respects. When I arrived on Saturday morning for the funeral, Valdimir, Dumitru’s father, told me that the body, which was not embalmed, had already begun to turn color.  You could smell the body upon entering the house and, once the funeral began, his mother tirelessly swatted flies away from her son’s face with a few wilted, yellow roses.
 
Dumitru’s life was filled with many of the risk factors that can make it much more likely for a person to develop active TB, and then much more difficult to treat it: he lived in poverty, used drugs, was co-infected with HIV and spent time in prison.  His life, and death, are not only examples of the human tragedies that TB causes, but also of the complex set of social situations that make TB an incredibly difficult disease to prevent and treat.

Written by rochkind

August 31, 2010 at 1:06 AM

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Without community health organizations, MDR-TB runs rampant

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Angela, an MDR-TB patient who is normally too weak to get out of bed, at her home in Balti.

Angela Orlov has multidrug-resistant TB and HIV and is so weak that she is often unable to get out of bed. She is thin and tired, and her health is rapidly deteriorating. She is trying to get admitted to the local TB hospital, but so far has been unable to do so. Every day Galina Zaporojan, a volunteer health worker with a local NGO, brings Angela her TB medicine to make sure that she is able to adhere to her treatment. Speranta Terrei, the NGO that Galina works with, is the only organization working in Balti, the town with Moldova’s highest TB rate.

One of the biggest obstacles in the struggle to contain tuberculosis is finding ways that make it easy for patients to adhere to the often long and arduous treatment process. Even the mildest cases of TB require months of daily medication that can have uncomfortable side effects, and it is common for patients to skip days or stop the treatment altogether if they begin to feel better. This is a result of little awareness or education about the disease and its treatment, sub-par health care systems, and the fact that many of the patients live in difficult economic situations and sometimes must decide between getting to the hospital to take their medicine or getting to work to feed their family. Multidrug-resistant TB (MDR-TB) can arise when patients incorrectly take their treatment, or default altogether. These strains of the disease are deadlier than traditional TB and require longer and more difficult treatment regiments,making it even harder to ensure that patients adhere to the treatment for MDR-TB.

Dr. Valeriu Crudu, Program Director at the Center for Health Policies and Studies in Chisinau, says “in Moldova we have access to all the drugs, but we have a very low rate of success of treatment.” It is estimated that 10 percent of all patients default on their treatment. Crudu attributes this mainly to little education about the disease and Moldova’s huge migrant labor population, many of whom leave the country before they finish treatment.

A homeless man with TB sits on the mattress where he sleeps. He relies on a community health worker to bring him his daily medicine.

But there is also very little patient support in Moldova. There are only three or four organizations, including Speranta Terrei, in the entire country that work on TB. Patients are almost always forced to make daily trips to the nearest hospital to take their medication. If a patient does not show up, doctors and nurses are tasked with finding the patient, but this is often a dififcult proposition for already overworked staff. Moldova’s MDR-TB rate is one of the highest in the world, and this is a direct result of poor adherence to treatment.  

Among other activities, Speranta Terrei sends health workers like Galina to patients’ homes to bring them their TB medicine and ensure that they take it. This is part of the DOTS Strategy (Directly Observed Treatment, Short Course) endorsed by the World Health Organization that is meant to have community or health care workers actually observe a patient take their medicine every day. It is thought to be highly successful.

The DOTS program does exist for out-patient treatment in the TB hopsitals in Moldova, but limiting the program to the hospitals limits it to those patients who are willing or able to get to the hospital.  There are a variety of reasons, many listed above, that make it difficult for people in Balti to get to a hospital, and there are no small clinics closer to their homes that offer the service.

Speranta Terrei relies on a handful of workers who basically donate their time to visit patients and bring them their medicine, but they are unable to meet the great need that Balti has. They focus on the patients that come from particularly vulnerable populations who find it difficult to get to a hospital.  In addition to Angela, Galina visits a homeless patient, a patient who is an alcoholic and lives in an apartment with no electricity and filled with trash, and a paraplegic man who lives alone. These are all patients who need assistance to successfully complete their treatment; the consequences for not doing so not only affect the specific patient, but also the community at large, who are put at risk of catching a deadly disease.

The TB rate in Moldova has been slowly decreasing or holding steady the past few years, but the rate of MDR-TB has been rising.  It seems that without more support for organizations like Speranta Terrei, this trend will continue.

Written by rochkind

August 25, 2010 at 10:21 PM

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In one family, a heavy TB burden

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A table is set with flowers and candy before the funeral of a man who died of MDR-TB.

Mariana Bernofsky lives with her husband in Balti, a small town in Northern Moldova, in a house that has been passed through the family for generations.  She stays at home with their young child while he works as a trash collector, earning less than $200 each month.  Mariana is pregnant and is infected with TB. She expects to successfully complete her treatment in a few months and, after her child is born, will be able to get a final X-Ray that she hopes will show she has been cured of TB.

A few years ago her father died of TB. It was the second time he had contracted the disease and the last time occurred while he was a migrant worker in Moscow.  In this video, Mariana discusses her fathers illness.  She touches on a few themes that are very important when discussing TB: how migration can influence TB incidence and how lack of education can complicate the treatment of TB patients.
 
Walking through the streets of Balti you wonder where all of the young people are.  It seems like everyone between the ages of 20 and 40 are gone. In fact, they just might be.  It is estimated that as much as 25% of the population leaves Moldova to work in neighboring countries, where they can earn more and send money back to their families. There are many interwoven ways that this huge migration affects TB.  The most direct, perhaps, is that migrant workers typically live in poor conditions, work long hours and send most of their earnings home, meaning they have little money for food and shelter.  This lifestyle contains many of the risk factors that can make it easier for people to develop active TB.  In addition, the workers are usually in the country illegally and have little or no access to healthcare.  Because of this, they may wait to see a doctor until their sickness is very serious and, in the case of TB, this can greatly complicate treatment.  Some of the migrant workers travel to countries that also have high rates of TB, like Russia, increasing the changes that they will get sick while away.
 
Mariana also mentions that the fist time her father had TB, he choose not to get an operation that was recommended by his doctors out of fear that he would lose his entire lung.  While it is theoretically possible that his doctor recommended the removal of his entire lung, it is very unlikely.  What is more likely is that her father had heard rumors that this was a possibility, and he was too scared, or did not trust his doctor enough, to get the operation.  Instead, he choose to take the recommended medication as well as some traditional remedies, like badger lard and honey.  It is impossible to know if the operation would have made a difference, but this example does show the lack of education and information that patients have about TB and its treatment. 
 
These are two of the biggest issues with TB:  how to best educate the population about TB and how to treat people who are always on the move and have little or no access to health care.

To see the video, please click over to the Pulitzer Center’s website :  http://pulitzercenter.org/blog/untold-stories/treatments-obstacles-education-and-migration

Written by rochkind

August 23, 2010 at 9:27 AM

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As Health System Declined, TB Increased

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Patients take their daily medicine at the TB hospital in Balti, Moldova

The former TB hospital in Balti sits on the outskirts of town, unused and surrounded by overgrown foliage, far from the city’s everyday activities. Local health specialists say that it used to be  a very good hospital, with a large garden on the grounds where patients and their families could walk, and different wings to house patients depending on the  severity of their disease. The day I visited there were two drunk locals passed out in the trees in font of the wing that used to hold the sickest patients.
 
The hospital has been closed since 1999 when authorities, low on cash after the breakup of the Soviet Union,  decided that they could no longer afford such a large hospital and, moreoever, a city the size of Balti didn’t need one.  The hospital is now empty with crumbling and decaying walls.  The rooms are vacant, and only cobwebs, broken windows and dangling electrical wires remain ; there are old, glass bottles clustered on the floor of a few rooms.  It is an eerie experience to walk the halls of the defunct hospital, seeing total decay alongside remnats of a past. productive life:  beautiful, decorative tiling in the nurses’ offices and large dining halls on every floor with natural light, views of the city and colorful, educational paintings about Tuberculosis on the glass doors. The view becomes even sadder when you consider that this huge, 4 story building lies in ruins while the new, smaller TB hospital struggles to keep up with the demand of the region’s current TB patients..

Dr. Pablo Ciobanu used to work at the old hospital and is currently the head of in-patient treatment at the new TB hospital, which has nearly 60% fewer beds than its predecessor.  According to Ciobanu, when closing the larger hospital the government failed to consider that Balti has an extraordinarily high TB incidence rate, and a smaller hospital would never be able to meet the city’s needs.  Moreover, patients from other districts often come to Balti to receive treatment, transforming the hospital, by necessity, from a city service into a regional one. 
 
There are only beds for 190 patients, but the TB ward regularly operates ten to twenty percent above capacity. The first day I visited the hospital. there were 209 patients; a few days later the number had grown to 220.

“I have no choice”,  says Dr. Ciobanu.  “There are very sick patients that I can’t refuse, so I try to make space where I can”.    Each room is meant to hold five patients, already a tight fit that allows for the possibility of cross contamination, and Ciobanu is forced to turn patients away instead of exceeding an uypper limit of 6 patients per room.  One of the worst outcomes of the change, according to doctors and nurses, is that the hospital is now near the center of town, putting contagious patients in close proximity to the general public.

Only a shell remains of the old, larger TB hospital in Balti, Moldova. This was a structure that housed all of the heating systems for the hospital.

The reduction of TB services in Balti mirrors the deterioration of the health infrastrucutre throughout Moldova after the breakup of the Societ Union. The country faced a huge reduction of economic investment, resulting in fewer health and social services.  As poverty rose the conditions that can lead to people developing active TB, such as poor hygiene or nutrition, also rose, resulting in a spike in TB rates.  In addition, many Mol,dovans left the country to look for work opportunities, where they often lived in terrible conditions and returned to Moldova with TB.  Just as the TB rates were rising, Moldova’s ability to deal with the disease was decreasing.  Dr. Valeriu Crudu, program director at the Center for Health Policis and Studies in Chisinau, estimates that between 1995-2000 the country only had enough resources for 20%-30% of its TB patients.
 
There was a steady rise in TB rates in the country until the past few years when, thanks to a concerted effort by the government and devleopment organizations, there has been a slight decline.  But the decade of neglect took its tool and, at 22%, the country currently has one of the highest rates of MDR-TB in the world.  Moreover, while total TB cases have decreased over the past few years, TB mortality has remained constant, meaning that a higher percentage of TB patients are dying.  This is a direct result of the higher percentage of MDR-TB, which is more deadly and difficult to treat than traditional TB.

Written by rochkind

August 18, 2010 at 1:21 AM

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The Project Begins . . . TB in Moldova

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This is Moldova.

Tuberculosis(TB) is a disease that kills nearly 2 million people every year, yet most people outside of the developing world know very little about it. It is a lung disease. It is contagious. It can be deadly. But, it is also completely treatable. TB can be treated with a dose of daily pills for a period of months, sometimes up to a year. In the developed world, the story of a patient with TB often ends at that. In the developing world, however, the story often ends with the patient in a coffin. It is a shame that a disease that can be treated and cured is debilitating communities, destroying families and causing so much pain, damage and death. 

I began working on this project in South Africa, where I documented the work and life of the country’s gold miners. By many estimates, South Africa’s gold miners have a TB incidence rate that is three times what it is considered to be an epidemic. The miners’ small, cramped living and work conditions make it easy to pass the disease from one person to another, and their high rates of HIV and silicosis (an occupational lung disease) makes them more susceptible to developing active TB. To make matters worse, the disease can lie dormant in a person’s body causing no harm, only to become active when the person’s immune system becomes weakened. For these miners, that often happens once they have left work and returned to their rural homes, where it can be difficult, sometimes impossible, to access suitable healthcare. 

In February of this year I traveled to India to look at how TB can manifest in urban settings, as opposed to the largely rural areas I visited in South Africa. I specifically looked at communities in the slums in Mumbai, India. In order for TB treatment to be effective, patients must follow a strict plan that requires daily doses of medication; the slums in Mumbai are like circuit boards, dense and interwoven, making it difficult, despite incredible efforts by many local NGOs, to find and treat the city’s numerous TB patients. 

I am now on my way to Moldova, a country that is often overlooked and is dealing with this almost forgotten disease.  This trip is supported by a grant from the Pulitzer Center on Crisis Reporting ( You can find this blog post, and all future blog posts, here and on the Untold Stories Blog hosted by the Pulitzer Center) 

One of the most pressing threats surrounding the fight against Tuberculosis is the emergence of Multi Drug Resistant TB (MDR-TB), a deadly strain of the disease that is the result of poor health care systems, lack of effective prevention measures, poor quality drugs and lack of availability and/or accessibility to treatment; it also arises when a patient intermittently takes his medicine or fails to complete his treatment. This strain of the disease is difficult and expensive to treat, sometimes requiring a two-year course of drugs and chemotherapy that can cost upwards of $20,000. Nearly 500,000 new cases of MDR-TB are diagnosed each year, with the majority of the cases found in China and the former Soviet Union. Moldova has been hit particularly hard by this development, largely due to the deterioration of the country’s health infrastructure following the breakup of the Soviet Union. It’s estimated that one out of every ten patients in the country defaults on his TB treatment and that nearly 30% of all cases of TB in Moldova are Multi Drug Resistant. My project in Moldova will focus on MDR-TB;I will visit and photograph patients and their families, and will produce multimedia work that includes photography, video and recorded interviews. Please continue to check here for updates on the project, and posts that will include photos and short interviews. 

And, don’t forget to check out the project page on the Pulitzer Center’s website, as well as all of the other great work they are supporting.  In addition to the highlighted links above, you can find their homepage link on the list at the right.

Written by rochkind

August 11, 2010 at 8:13 AM

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