Russian Healthcare in Moscow

When I’m sick, I go to Finland!

As I am currently on injured reserve, with a bum knee, I am getting an
interesting tour of the healthcare system of Moscow. There are two
quasi-independent healthcare systems here, the collection of Western clinics,
and the underlying Russian healthcare system. My employer’s healthcare
contracts with two of the larger clinics, the International and the American
Medical Clinic (IMC & AMC). From rumors at work, I chose the IMC
to receive the physical therapy I need for my knee.

The IMC is located on the top floor of a Russian polyclinic, and is an odd
dose of Western style in an otherwise drab building. The staff is nice
and bi-lingual, but the service is the same as any Western clinic, disorganized
at best. They do fly in a Finnish orthopedic surgeon once a month to
check up on people like myself, but there is only one Western physiotherapist
in Moscow to treat us after he recommends physical therapy. She is
thinking about leaving in spring, and the entire sports community here is
in a panic. If you are, or know of someone who is a good physiotherapist,
and wants a change, please email me!
There is a waiting list for the current specialist, and we all are
willing to pay whatever it takes to walk again! Oops, got a little emotional
there.

Ok, so the Western clinic is just like the ones in the West, hence the name.
The Russian clinics are an odd bunch. Wandering around the different
floors of the polyclinic where I have my physical therapy, I see an odd
assortment of healing styles. Everything from high tech CAT scans,
to leaches. I know of a hospital somewhere near the Kremlin, where
an entire cardiac center was sent straight from Iowa for Yeltsin when he
had his heart trouble. I also know of people who have regular acupuncture
sessions to cure illnesses like cancer. The Russian healthcare system
is even more cash-strapped than the American system, so for a price, you
can have anything you want.

For Russians, without access to the international clinics, its a whole different
story:

Moscow Times, July 25, 1998

Young, Russian And Pregnant

By Anna Badkhen

When she waited too long and missed her chance to have an abortion,
St.Petersburg journalist Anna Badkhen entered Russia’s prenatal care system.
She still managed to have a healthy baby boy.

Gynecologist Tamara Rudenko glanced absently through her gold-rimmed glasses
at my name written on top of a medical file while I rested my belly on a
corner of her table. I had just told her my last menstrual period was six
months ago.

“Did you come to see me about the delay?” Rudenko asked with a bored look.

I told her I had come to register. In Russia, all pregnant women are required
to register their pregnancy with a zhenskaya konsultatsiya — a city
gynecological office that provides pre-natal care and the papers necessary
for acceptance to a maternity hospital. Rudenko was a doctor at St. Petersburg’s
Zhenskaya Konsultatsiya No. 30.

“What are you, pregnant?” she asked, finally looking at me. And so went my
introduction to free prenatal care in Russia.

Elsewhere in St. Petersburg during the months I was visibly pregnant, it
was an entirely different story. I was the object of great care and concern
from almost everybody I met. People allowed me to go to the head of the line
in department stores and at currency exchange windows. Cabdrivers gave me
free rides. Soviet-bred waitresses became paragons of politeness. Crippled,
90-year-old babushki, who ordinarily seem to derive unspeakable pleasure
from scolding everyone in sight, eagerly yielded their seats in trams and
buses. One elderly woman who insisted that I take her seat explained to the
other babushki: “We have to take care of pregnant women. There are so few
of them nowadays.”

Pregnancy would have felt like an extended bubble bath had it not been for
my sobering encounters with the medical personnel who were in charge of my
prenatal care. When I first learned that I was pregnant at the age of 21,
I panicked. Having a baby would put an end to my youth and to my career as
a journalist, I thought. After a brief discussion with my boyfriend of two
years, Andrei, I decided to have an abortion — the most popular form of
birth control in Russia.

In St. Petersburg alone, doctors performed last yea over 60,700 abortions
— versus 32,900 births, according to the city health committee. Compared
with other industrialized countries, Russia has an extraordinarily high abortion
rate, according to the most recent figures from the nonprofit, New York-based
Alan Guttmacher Institute, which researches reproductive health. In 1994,
for example, there were 80.8 abortions per 1,000 Russian women between ages
15 and 44. In the United States, by comparison, the number of abortions in
1992 was 25.9 per 1,000 women in that age group, and in Finland, 9.4 in 1994.

At the time, I knew nothing of this. My expectations of what the abortion
would be like were colored by an experience I had in 1994, when I volunteered
to assist as a translator at an abortion in a Planned Parenthood clinic in
the small city of Utica, New York. Larissa, a Russian woman in her 30s who
was getting an abortion, arrived at the clinic and was taken to a private
room. There she was asked to sign documents saying that she was making the
decision of her own free will.

A counselor duly gave Larissa a detailed — and terrifying — description
of the negative consequences of an abortion: the possibility she might never
get pregnant again, the increased likelihood of future miscarriages. Larissa
was then taken to an operating room, where a doctor, a nurse, and two volunteers
explained to her what the procedure would be like. I held Larissa’s hand
during the operation — to keep her from feeling “alone,” the nurse explained.
When the abortion was over, nurses brought her cookies and tea in a private
room. She ended up spending about two hours at the clinic before returning
home.

Two years later in St. Petersburg, I learned that abortions in Russia are
a much different affair. When I told the doctor at Konsultatsiya No. 26 that
I wanted to have an abortion, she told me to have a blood test for AIDS and
syphilis, and set the operation date as soon as possible. “In a week, it
won’t be safe for you to have an abortion,” she said. So much for the warnings.

When I returned two days later for the procedure, I found seven other women
who had also come to terminate their pregnancies. We sat together in the
main hallway near the door that led to the operating room, watching other
women visiting their gynecologists come and go. When I returned from a brief
visit to the toilet, my seatmates had all disappeared. I sat in the hallway
for about 90 minutes before they started to emerge from the operating room
one by one. I knocked at the door. A doctor came out and asked me why I didn’t
come to the operating room when everybody else did. I said I thought they
were assisting one woman at a time.

“We have eight beds in here,” the doctor replied. “We operate on you all
simultaneously.”

She then told me that I could not have an abortion that day because her shift
was over. The konsultatsiya, indeed, seemed abandoned. When I told her about
my deadline, she took me to an examination room, where I saw a row of washed
one-time-use-only medical rubber gloves drying on a radiator, so they could
be used again the next day. She examined me and told me that the period when
it was safe for me to have an abortion had passed three weeks ago.

“The doctor who examined you must have been mistaken,” she said in a
matter-of-fact tone. “It’s a good thing you didn’t have an abortion. It could
have only done you harm.”

I took the metro home, and over the next day, Andrei and I wrestled with
the prospect of bringing the baby to term. Although I knew that having a
baby would complicate my life a lot, I also had a confusing feeling that
to terminate a pregnancy means to murder a living being. While I was getting
ready to have an abortion, I had a sense that I was doing something wrong,
and I was surprised to feel a relief when I learned that I had no other choice
but to have the baby. The attempt at abortion behind me, I began to prepare
for motherhood.

The first step was to visit the konsultatsiya in the neighborhood for which
I have a residence permit, or propiska. Other options were limited. With
a monthly salary of $500, the $210 charged by one Western clinic for each
prenatal care visit was certainly out of the question, as was even the $20
per visit charged by a private Russian clinic. I had to be especially frugal
since I was spending more and more on necessities like food. I remember eating
seven cans of canned peaches and then immediately consuming a kilogram of
smoked sausage. I could eat two kilograms of blue cheese in 20 minutes. It
was easy to spend $20 a day on french fries.

So I turned to Tamara Rudenko, the stout, middle-aged — and above all, free
— doctor at the district konsultatsiya who was to register my pregnancy
and, in theory, take care of me. Rudenko — just like any other doctor at
any other konsultatsiya in St. Petersburg — earned a monthly salary of 300
rubles ($49).

Having timed my first appointment with her at the end of her shift at 7:30
p.m., I might well have been her 30th visitor that day. As soon as I entered
Rudenko’s office, I was introduced to the trademark of the konsultatsiya:
The client is always humiliated.

“Leave your dirty bag there! No, there!” Rudenko’s nurse ordered as soon
as I stepped inside the office with a backpack slung over my shoulder. Later,
after I had dismounted from the gynecological chair and accidentally stumbled
over a couch, Rudenko said, “I see 90-year-old women here, and yet they are
not as clumsy as you!”

During another visit, I had trouble understanding something Rudenko was saying,
and she commented, “All pregnant women have something wrong with their heads.”
Whenever I came to see Rudenko, she addressed me as “beremennaya,” or “the
pregnant one”; her nurse, who never introduced herself, did not address me
at all. But even more humiliating than Rudenko’s rudeness was the lack of
intimacy that her konsultatsiya provided.

Although she and her nurse shared a separate office, Rudenko shared the
examination room with another doctor. The examination room had two examination
chairs and one short sofa where the clients of both doctors were to leave
their pants, socks, and underwear. Sometimes, both Rudenko and the doctor
from the adjacent office examined their clients at the same time: an intimidating
striptease, if you will. As if to underscore the fact that there is no privacy
in her office, Rudenko often saw two patients at a time, and the women had
to share their intimate problems not only with their doctor, but also with
other women who happened to be in the room. During one of my visits, Rudenko
scolded a pregnant 19-year-old patient in front of me. “Are you serious about
keeping the baby? But you are too immature to take good care of him! Are
you married?” Rudenko screamed at the crying girl.

I endured all this for months, never once having Rudenko ask how I felt or
if I had any questions. I needed medical advice badly, so I called a friend
who knew someone at Snegiryovsky Maternity hospital, popularly known as
Snegiryovka. Ida Vanovskaya, a doctor at Snegiryovka’s intensive care ward,
examined me three times. I called her for advice four times more. She took
me to have ultrasound tests. She was not authorized to fill out the papers
that would get me into a maternity hospital — and, therefore, could not
substitute for Rudenko — but she gave me advice on what to eat, what to
drink, what vitamins to take and even what kind of washing machine to buy
when the baby is born. She never charged me a kopeck.

Once I complained to Vanovskaya about my humiliating visits to the konsultatsiya.
“I know, dear,” she said. “All konsultatsii have the same terrible way of
treating people. It is free health care. Deal with it.”

Free health care means a St. Petersburg woman in labor is entitled to one
of four to six beds in a delivery room. It also provides her with one of
up to 12 beds in the postnatal ward. It pays for the nurses to take care
of the infant for the first three days after birth: The hospital staff only
brings the newborns to their mothers for short periods of time to nurse,
five to seven times a day.

One of the best indicators of the quality of prenatal care and maternity
wards is a country’s infant mortality rate. According to the World Health
Organization, the rise in Russian infant mortality rates following the breakup
of the Soviet Union stopped in recent years. Still, the figures from WHO’s
division of health statistics in Geneva are telling. In Russia, there were
18 infant deaths for every 1,000 live births in 1995, the most recent year
for which statistics are available. In the U.S. in 1994, there were eight
infant deaths for every 1,000 births, and in Finland, the figure was four
per 1,000 in 1995.

Free health care in St. Petersburg comes at a definite price. Mida Samarskaya,
an inspector at the city’s health committee, said that in 1997, four women
died from infections contracted while giving birth in maternity wards with
unsterile conditions. Another woman died last year because of an infection
that was contracted during an abortion. In some cases, Samarskaya said, doctors
and midwives are to blame, but she cannot remember an instance of someone
losing their job over a death. By the time I was ready to have a baby, I
had had enough of free health care.

Four hundred dollars bought me a separate room at a special “family confinement”
ward in Maternity Hospital No. 16. When I arrived at the hospital in June
1997, the private ward was a local innovation. It allowed my boyfriend to
be present at the childbirth. It provided a separate room and private bath
for my baby, my boyfriend, and me. Our room was furnished with two beds,
a crib, a refrigerator, and a television. (“Wow! A fridge! A shower!” my
mother exclaimed when she came to see me at the hospital. She said that when
she was in labor before giving birth to me in 1975, she was offered a bed
in the hallway, because there was no free space in the hospital.)

Later, the ward’s personnel told us that we were the fourth couple to ever
use the new facilities since they opened a month earlier. In the four days
we stayed at the hospital, two more women arrived to give birth there. The
ward had a doctor, a midwife, a pediatrician, and a pediatric nurse. Galina,
the midwife, told my boyfriend that in the regular maternity ward downstairs,
there were 32 women, 4 to a room, all served by three nurses and one doctor.

On June 5 last year at about 10 a.m., the contractions started. Some nine
hours later, Andrei and I took a cab across town to the hospital. We arrived
at 8 p.m., after the private ward’s doctor was gone. By the time we had come,
I was in labor, and Galina had to call a doctor from the maternity ward
downstairs.

“What a stupid novelty,” the doctor said, regarding the private department.
“Why not have a baby the way everyone else does?” There was something about
her that immediately reminded me of my experience with Rudenko.

The doctor, who failed to introduce herself, examined me and said my cervix
was not adequately dilated. She gave me shots. Then more shots. The cervix
still wouldn’t dilate. At 8 a.m. the next day, the doctor told my teary-eyed
boyfriend that she would have to perform a Caesarian section. She kept coming
and going from our room, shaking her head at my stubborn uterus.

At 9 a.m., Olga Kordunskaya, the head doctor of the ward, arrived on duty.
“Why have a C-section?” she asked. “In order to open the neck, just turn
it to the side, like this.”

Two and a half hours later, my boyfriend rushed across the delivery room
to count the wrinkled toes of our newborn son, Fyodor.

After Fyodor was born, my boyfriend met the doctor who had advised a C-section
in the hallway.

“So, did Anna have the baby?” the doctor asked. My boyfriend said, “Yes.”

“And she had no ruptures?”

“No,” he said.

“And is the baby O.K.?” she asked.

“Yes,” he said.

“Very strange,” she said with a puzzled look.

(The next day, when my mother came to meet her grandson, the same doctor
stopped by. She looked at Fyodor and said to my mother with surprise: “Bizarre.
I thought they would both die.”)

Four days later, we left the hospital. Rudenkos, Caesarian sections, and
washed one-time-use-only medical gloves drying on a radiator were left behind.

Moscow, Sept 15 (Reuters)

Russia’s Crisis Stuns Expectant Mother

By Adam Tanner

Life seemed pretty stable in Russia eight months ago when Lena Golubeva decided
to have a baby as a single mother. She had a good job with a firm importing
foreign goods, inflation was low and the situation in the Russian capital
appeared to be getting better as economic reform seemed to be bearing some
fruit at last. Then four weeks ago the government devalued the rouble, shrinking
the value of her 5,000 roubles savings threefold to about $300. Her company
took a major hit, and she says it is unlikely she still has any future there
after maternity leave.

‘If I had to think today whether I would have a child or not, I’d probably
decide against it,’ she said in her Moscow apartment where she has abandoned
a planned sprucing up midway though the job. ‘Everything seems so terrible
now.’ ‘I think that those in the first three months who are not well off
will do something about it,’ she added, referring to abortion which is common
in Russia.

Golubeva, 36, who is due in early October, is only one of millions facing
hardship after severe economic changes in recent weeks have led to empty
store shelves and have made some medicines hard to find. But as Lev Tolstoy
wrote in Anna Karenina, every unhappy family suffers unhappiness in its own
way. For Russia’s expectant parents the twist of fate that left the economy
reeling is particularly bitter.

‘Stability then played a role in my decision. It was all thought out,’
she said of her decision to have a baby outside of marriage. ‘But I’m afraid
that I cannot survive in this Russian economy, or won’t be able to find a
job, or won’t find a social safety net in case of need.’

ECONOMIC CALM BRINGS MORE BABIES

For years instability in Russia after the 1991 collapse of the Soviet Union
deterred would-be parents from having children. The birth rate plummeted
from about 17 births per 1,000 people in 1985 to nine per 1,000 last year.
But as some families began to see light at the end of the transition period
from communism, the trend began to show a reversal. Russian women gave birth
to 645,000 children in the first six months of 1998, up from 639,000 during
the same period a year before, during a time that the overall population
fell slightly.

‘From about 1996 or 1997, people began to feel that they could raise children
again,’ said Zinaida Kanasyova, head of the newborn section of the Birth
House 32 maternity hospital where she has worked since 1952. ‘We have seen
more births in 1997 and 1998.’ Kanasyova said a better economy played a
role in the rise, and some experts say the latest wave of economic setbacks
are likely to send the numbers shrinking again.

The chaos in Moscow markets outside seems far away for the new mothers in
Birth House 32 overwhelmed by the joy of their new babies. ‘We have forgotten
about everything that’s happening out there,’ said Layla Mukhameta, 25,
a beauty salon administrator who had just given birth to a daughter. ‘We
don’t care at all about the course of the dollar, that one prime minister
was rejected and another chosen.’ ‘We are just waiting for the moment when
they bring us our babies and it’s then that we are happiest.’

As in Soviet times, mothers usually spend about a week in maternity hospitals,
and the infants are kept away except at regular feeding intervals. The husbands
are also barred. Mukhameta’s husband is a hockey player who earns a salary
designated in dollars so she is not worried about finances.

‘Of course everything that’s happening (in the economy) is terrible but
we wanted children anyway,’ she said. Another new mother in the ward, Maryam
Mogamedova, 26, does not have a husband, but maintains a cheery, upbeat outlook.
‘My mother had six children and she, an uneducated woman, raised us practically
by herself,’ she said, wearing the hospital’s standard-issue loose robe.
‘So why shouldn’t I be able to raise one?’ Mogamedova said she does not
plan to use imported disposable nappies which have become scarce in Moscow
in recent days, and she will supplement her food through her mother’s garden
plot outside the city. ‘Of course it will be hard,’ she said with a smile.
‘We are already used to the fact that things will always be unstable.’

PARENTS BUY NAPPIES IN PANIC

On the streets of Moscow where panic buying over the past weeks has sucked
goods off stores shelves, Golubeva feels a more glum apprehension only amplified
by a visit to one of the city’s baby supply stores. Disposable nappies —
called pampersy in Russian after the Pampers brand that became widespread
after the fall of the Soviet Union — have again become rare as during Soviet
times, and even new cribs have sold out in some stores.

‘It’s not that I’m afraid that I won’t find imported nappies or food,’
she said before spotting nappies for more than $30 a pack of about 40. ‘The
problem is what happens if he falls ill or I fall ill? The other day I had
to wait 40 minutes in line at a pharmacy.’ Golubeva’s only significant asset
is her apartment which she could either rent — she said a neighbour rents
a similar apartment for $1,000 a month — or sell and move to the periphery
of the city. She wants to stay put of course.

But Golubeva and millions of other Russians now have to cope with the reality
of less in life after years of rising expectations. ‘Of course ultimately
I’m not sorry to be pregnant, I want the baby,’ she said. ‘But things are
so grim now. I’ve never been in such a situation before.’

Johnson’s Russia List, November 30, 1998

Russia Carried out 2.5 Million Abortions in 1997

Agence France Presse

Some 2.5 million abortions were performed in Russia in 1997, with seven
pregnancies in 10 ending in terminations, Interfax news agency reported Sunday,
citing Health Ministry figures. The agency said the figures were published
to coincide with Russian Mothers Day, which was being marked for the first
time on Sunday.

According to the ministry’s statistics, every tenth abortion is performed
on women under 19 and more than 2,000 on girls under 14. Two women in three
suffer from health complications as a result of the terminated pregnancies,
the statistics indicated.

Abortion has long remained the leading method of birth control in Russia,
though the 1997 figures indicated that the number of abortions has fallen
by 25 percent in the past four years. The abortion statistics take on even
more significance in light of Russia’s overall population figures. The Russian
population has declined by well over 1.5 million people since 1992.

Johnson’s Russia List, Monday, 12 October 1998

Financial Crisis Deals Health Service a Death Blow

Reuters News Service

Russia’s financial crisis has dealt a deadly blow to the country’s faltering
health service, leaving doctors and nurses without wages and medicine and
equipment in short supply, the health minister said on Friday.

“The socioeconomic crisis has hit all aspects of the health system, stopping
us from doing our job,” the newly appointed minister, Vladimir Starodubov,
told a news conference. “People cannot get medical help when they need it…and
the crisis is making people ill.” He said the rate of illness in Russia had
grown in the first eight months of this year, with 21.5 million registered
cases in a population of 150 million.

Cash earmarked for the sector in the government budget fell by 26 percent.
He gave no further figures. “We want to support our employees, but we are
not in a position to support them,” Starodubov said. “They want do their
job and they’ve got hands and brains, but not the necessary materials.”

Some doctors, nurses and other public health employees have not been paid
for between three and eight months and, according to official figures, were
owed some 3 billion rubles ($187 million), he said. Trade unions say the
backlog stands at 5 billion to 10 billion rubles.

Millions of Russians in both the public and private sectors are owed wages
stretching back many months, prompting some to attend rallies calling for
President Boris Yeltsin’s resignation on Wednesday.

The government blames the delays on a complex web of debt that has built
up between companies and between firms and cash-strapped state bodies including
the armed forces. Starodubov called for some additional capital to encourage
a greater domestic involvement in the pharmaceuticals market, which is swamped
with Western tablets and syrups. The supply of imported medicine has declined
sharply in the past two months as the ruble has lost two-thirds of its value.

“We have worked on far-reaching reforms for the health system despite living
through this country’s crisis,” he said.

He said he hoped to introduce standardized training for doctors, new equipment
for hospitals and guarantee people an effective health service. Many Russians
lost faith in public medicine after the collapse of communism and alternative
medicines have thrived as the average life expectancy for men has plunged
by some six years to 58 over the past decade due to a combination of poor
health care and diet and heavy drinking.

Some Westerners have begun to campaign for a higher level of public health
awareness in Russia. Bob Swan, president of the Corporation for Russia-American
enterprise, has set up a campaign called “Heart-to-Heart” to fight heart
disease and set up an AIDS awareness program. “Russia’s health care crisis
can only be solved if the private sector steps forward in this hour of need,”
Swan said.

He said he has called on foreign firms to give one percent of their sales
in Russia to support the public health education drive. Cough and cold remedy
maker Quigley Corp. has agreed, he said. “What is at stake is the very future
of Russia and her magnificent, although presently quite unhealthy, people.”

Financial Times November 28, 1998

MEDICINE: Russian doctors left to face empty cabinet

By John Lloyd

City Hospital No 2 is buried in a suburb of St Petersburg composed of row
after row of massive, already-sagging apartment blocks. Although the hospital
opened in the early 1990s, it too is scruffy looking; its entrance hall is
echoing and empty, with an air of indifference where some attempt at warmth
might be expected.

But its operating theatres and intensive care units are sparkling, high-tech
and carefully tended. Racks of medicines stand in whitewood cabinets. In
the ophthalmic department – the treatment of cataracts in the disproportionately
elderly population of St Petersburg is a specialty – state-of-the art machines
jostle for space in the crowded examination rooms. City Hospital No 2 is
a show hospital, well funded and generously staffed. Yet it illustrates,
better than the dank, stench-ridden barracks which are often the norm for
hospitals in the Russian provinces, the crisis in Russian healthcare.

The state now supplies no more than 20 per cent of City Hospital No 2’s budget
– the rest comes from paying patients. The doctors and administrators give
a clear impression that those who can afford it buy treatment while those
who cannot are treated as and when they can be fitted in. To repeated questions
of “How do you actually manage?” the answer is most often something like:
“We do it with patience,” the response of Vitaly Khilko, a senior surgeon.

This obfuscation springs largely from wounded pride. Professor Khilko is
an innovative neuro-surgeon who claims to have pioneered new forms of surgery
in the 1970s. He and his colleagues, especially the more senior ones, find
the present state of Russian medicine hard to bear. And to face the certainty
that it will deteriorate is hideous. But it will. “We have spent a lot of
money and energy bringing our practices up to the highest levels,” says Yuri
Shulev, another neuro-surgeon. “But now there are no funds to renew the
medicines, and no funds to service and maintain the equipment. Strokes are
one of the most common causes of death – and if we can get the patient to
hospital in time we can often save him. But the ambulance service is not
geared up to this, and we have no funds to reform it.”

No funds. It underlies all of the conversations in the hospital, as the shock
of what happened in August – when the rouble crashed and the scale of the
fiscal crisis was revealed – sinks in. The crash came on top of already exiguous
funding. The state pays the equivalent of ú5 to buy food for one patient
for two weeks, with a further ú4 for medicines over the same period.
Now the doctors fear they will soon be looking at an empty budget.

Private medical insurance companies, both Russian and foreign, have started
up in the past few years but, says Oleg Vasiliev, dean of the Academy of
Military Medicine who practises at the hospital, they represent a tiny fraction
of the hospital’s income. “Our psychology is against it. They really only
exist for foreigners. Russians have the psychology of fatalism, which is
mixed with the feeling that the state will take care of it. If they have
money, they buy vodka. You can avoid strokes if you lead a healthy life and
don’t drink heavily. But who listens?”

When poverty and fatalism meet, it seems hopeless. Worse, the unbalanced
age structure of St Petersburg, a legacy of the second world war when men
were slaughtered, means there are 1.2m pensioners in the city, mostly women,
and a birth rate which is dropping fast. The population fell by 600,000 last
year. Russian men are dying in their late fifties and Russian women are not
reproducing.

It had been getting better here and there. Christopher Davis, a fellow of
Wolfson College, Oxford, and an expert on Soviet and Russian health, says
that many infectious diseases were on the decline and the infant mortality
rate, high by international standards, was falling slightly. But cancer,
heart problems and tuberculosis have all worsened; and the brutal fact that
Russians live on average 10 years less than western Europeans has not changed.
Now, says Dr Davis, further decline is inevitable. “The cuts in the budget
only mean they can’t afford western medicines – which make up 70 per cent
of the total.

“And the fact that western drugs replaced Russian ones has severely damaged
the pharmaceuticals industry here, so it can’t respond. The same with the
medical equipment industry. It is a serious, a very serious situation.” The
doctors of City Hospital No 2 – who earn $125-$360 (ú75-ú220)
a month on their state salaries – see colleagues leave the profession to
go abroad or seek more lucrative work.

They see their equipment rendered inoperative and their medicines run short
and struggle with patients aged and fearful, who often refuse to leave their
hospital beds to go back to the isolation of bleak rooms.

“We will manage with patience,” says Prof Khilko, but patience is becoming
a much abused commodity in Russia.

21 January 1999, The Moscow Times

Dying Souls of Russia

By Murray Feshbach

Health in Russia is even worse than most Russians and foreign commentary
would indicate, and the consequences for Russian society, the Russian economy,
and the Russian military will be enormous.

Environmental issues lurk behind much of the public-health problem. Radioactive
contamination is rife. Chemical contamination, such as dioxin, is largely
to blame for the fact that life expectancy for both men and women in the
town of Dzerzhinsk, in the Nizhny Novgorod region, is no better than 50 years.
At least until 1995, DDT continued to he used, despite an announcement by
the Soviet government almost three decades ago of a ban on its production
and use.

Bad water nationwide has led to high rates not only of bacterial dysentery
but also of hepatitis and cholera. The air in Omsk is polluted: Authorities
two years ago distributed some 60,000 gas masks to residents. And thermal-power
plants throughout the country are spewing forth carcinogens, owing to incomplete
combustion. Lead emissions in Russia are about 50 times those in all of the
European Union. I have seen a Russian government report indicating that as
a result of lead pollution in one locale, “76.5 percent of the children in
the town are mentally retarded.”

But even absent of these environmental problems, public health in Russia
would be appalling. I anticipate that an unprecedented surge in the incidence
of infectious and parasitic diseases, combined with existing high levels
of alcohol poisoning and violent death, will contribute to a continued lowering
of life expectancy. The Russian population is likely to decline as well,
by about 800,000 to a million people a year until 2010, when the total may
well he no more than 138 million. Alcoholism, drug abuse, sexually transmitted
diseases, malnutrition and various chronic and infections diseases already
mean, among other things, that a third of the adult population is incapable
of reproduction.

The incidence of tuberculosis in Russia has skyrocketed. The number of deaths
ascribed to tuberculosis in Russia in 1996 (24,877) was almost 15 percent
greater than the number of new infections (usually nonfatal) that year in
the United States. The Russian mortality rate for tuberculosis is 16.9 per
100,000; the U.S. rate is 0.5.

According to the State Statistics Committee, the number of new cases of
tuberculosis that occurred in Russia in 1996 is 99,000 -an official number
that is in fact too low. It is known that at least a tenth of prison inmates
in Russia have tuberculosis, and that some 850,000 to 1 million Russians
are in prison. Are these infected prisoners in the official data? For that
matter, do the agency figures include the homeless, forced migrants, refugees,
people living in railroad stations, people who avoid the medical establishment
and so on? I believe that the number of new cases is actually closer to 150,000
each year. And given that everyday ordinary pharmaceuticals are pathetically
scarce, are not most of these people going to die of the disease?

If a memorandum titled “Epidemic Tuberculosis in Russia,” prepared by the
Interior Ministry and described in a Newsday article by Laurie Garrett, is
even close to being correct, then the Russians face a bleaker future than
they (or we) could have thought possible. To quote: “By the year 2000 the
incidence of [tuberculosis] will increase ’50 times compared with now’; mortality
will increase seventy-fold; and deaths in children are expected to rise
ninety-fold.”

If these predictions prove true, then Russian deaths attributable to tuberculosis
will be more numerous than the total reported for heart disease and cancer,
In 2000, according to these numbers, tuberculosis deaths in Russia will reach
approximately 1,75 million, whereas 1 estimate that heart-disease and cancer
deaths will number about 1.5 million. This says something extraordinary about
the state of public health.

HIV and AIDS cases in Russia and deaths from AIDS are also on the verge of
exploding. The former health minister, Tatyana Dmitriyeva, has forecast that
a million Russians will be infected with H IV by 2000. Assuming that only
half that many are infected and that it costs “only” $15,000 per patient
per year to administer protease inhibitors, AZT and 3TC, where is the $7.5
billion a year for these drug cocktails to be found? The answer is nowhere.
AIDS patients in Russia will die.

The growing number of Russian AIDS cases reflects a sharp rise in sexual
promiscuity and hard drug use. In the past five years, syphilis cases among
girls who are 14 or younger have increased thirty-fold. Chlamydia rates are
said to be very high in the same age group, though very few, and likely
unreliable, data are available. How sick will these children he in subsequent
years? Will they he able to have children themselves’? Will their children
also be sick? Will they become part of Russia’s growing army of drug abusers,
now thought to number 4 million to 6 million? Many of them, of course, will
simply die young.

Here is another way of viewing the overall situation: How many of today’s
16-year-old males will survive to age 60? In the United States, the figure
is about 83 percent. In Russia it is only 54 percent; 1 00 years ago in the
European part of Russia the figure was about 56 percent. Of course, many
of tile Russian men who survive to age 60 will be very sick.

Analysts specialized in geopolitics, economics, or the military who ignore
these issues do so at the risk of overlooking Russia’s most fundamental
realities. So much of the shrinking Russian population may soon be so ill
that long-term solutions to the country’s political, economic and military,
problems will be inconceivable.

Murray Feshbach is a research professor at Georgetown University. He
contributed this comment to The Moscow Times