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Foreign Correspondence

Oct. 26
Diagnosis: Critical
In the Remnants Of the USSR, Health Care Is In a Deadly State Of Shambles

Oct. 26
The Most Vulnerable?
Region's Children

Oct. 27
'Like a Genocide'
Underfunded ex-Soviets losing battle against soaring TB rates

Oct. 28
A Bacterial Breeding Ground

Oct. 28
Czechs devise a Stringent, Scientific System

Oct. 28
Coney Island, an Entry Into Western Medicine

Oct. 29
Shots in the Dark
Stunningly low vaccination rates behind surge in diseases

Oct. 29
The Dr. Spock of Russia

Oct. 30
Region's Culture of Abortion

Nov. 2
The Drug Explosion
An epidemic of abuse, disease is devastating region's youth

Nov. 3
Plague of Alcohol
Russians are drinking more than ever, with deadly results

Nov. 3
A Region's 'Lost Generation'

Nov. 4
'Elista' Incident Fosters Distrust in the System

Nov. 4
A Hotbed of HIV

Nov. 11
Fallout of Fear and Uncertainty

Nov. 18
Resuscitating Science

Nov. 18
A region in psychological turmoil

Nov. 18
An Oasis of Medical Privilege


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7. Foreign Correspondence
IN THE SERIES. Today, Newsday begins a series of stories by Pulitzer Prize-winning reporter Laurie Garrett and photographer Viorel Florescu on the collapse of public health in the former Soviet Union at a time of dramatic social upheaval. The stories will appear in the news section, in special reports in the Discovery section and online at http://www.newsday.com. Researching the story led Garrett and Florescu to Moscow, Kiev and St. Petersburg, as well as locations as far-flung as Tallinn, Estonia, in the Baltics; Ulan-Ude on the Russo-Mongolian border; Nor'ilsk, 175 miles above the Arctic Circle in Siberia; war-torn Ossetia, on the Georgian frontier; Chernobyl, Ukraine; and Bohemia in the Czech Republic.

Diagnosis: Critical
In the Remnants Of the USSR, Health Care Is In a Deadly State Of Shambles

published Sunday, October 26, 1997

By Laurie Garrett
staff correspondent

others making key contributions to the series were Newdsay's Moscow Bureau chief, Susan Sachs; former bureau chief Ken Fireman; research Tami Luhby; and staff writer Delthia Ricks.

TSKHINVALI, GEORGIA--Most of the patients have been sent home because the vast medical complex has no heat. The nurses are huddled around a burning log in a makeshift fireplace carved out of a cement floor. But up on the fourth floor of Republican Hospital, remarkably, medicine is still being practiced. Two surgeons are performing a hernia operation with uncommon skill -- and uncommon speed.

As a doctor anesthetizes the patient with an ether-soaked handkerchief and a nurse keeps him breathing with a hand-operated ventilator, the scrub nurse scoops up a pile of bloodied surgical instruments and carries them to a basin of pink water that has been standing uncovered for hours.

Working barehanded, she dunks the instruments in the water, swishes them about and returns them to the operating table with no further effort at sterilization. A moment later, one of those instruments is inside the patient, clamping off a section of intestines.

The operation is finished in less than 10 minutes. When the surgeons are complimented on their speed, one replies: "It's not a matter of choice. We must go fast. The generator only supplies 15 minutes of electricity for the lights."

This provincial hospital is far removed from Russia's great cities, and Georgia has fared far worse than most former Soviet republics since the union split apart in 1991. But while the problems here may be especially acute, they are not atypical. Throughout this vast ex-superpower, the health care system once touted by the Soviet leadership as an exemplar of "the human, caring face of socialism" is a shambles.

Life expectancy rates have plunged precipitously, driven downward by a deadly combination of spreading disease, alcohol and drug abuse, poor nutrition, chronic underfunding of medical facilities and isolation from Western scientific advances. In one year alone, 1993, the life expectancy at birth for Russian males dropped from 61 to 58, according to the World Health Organization. Russia's death rate in 1995 was 1.6 times greater than its birthrate, triggering a decline in its population unprecedented in post-war times, and the premature death rate for adults has more than doubled since 1960, according to government data.

The impact of this crisis is also falling heavily on those most vulnerable: the region's children. They suffer from high rates of birth defects, disease and mortality, bear the brunt of their parents' drug and alcohol abuse and are often denied medicines because of a belief that they are "weakened" and cannot handle certain antibiotics or vaccines.

As a consequence, they are far less likely to reach adulthood than their Western European counterparts, according to UNICEF. Children in Russia, the largest of the former Soviet republics, are 2 1/2 times more likely to die before age 5 than American children, global health experts say.

Some doctors find this unbearable. At the Leningrad Republican Infectious Disease Hospital, for instance, Dr. Paul Sergeyev tenderly strokes the blond head of 9-month-old Natalia, who was abandoned by her HIV-positive, opium-addicted mother as soon as she was born.

"We can't know for sure whether a child is infected [with HIV] until 3 years old," he says with a frustrated shake of his head as he gently places Natalia back in her crib. "We have no money for [genetic] testing. We have no money for anything."

Dr. Lev Mogilevsky, co-director of an infectious disease treatment facility in the Ukrainian city of Odessa, sums up the situation succinctly: "We can no longer control or manage disease," he said. "It manages us."

An eight-month examination by Newsday that ranged over 4,500 miles, visiting 20 cities in five formerly communist countries, has found that this once-proud health care system has become a casualty of the region's wrenching historic transition.

It's not clear how quickly this occurred, because past health care claims by the communist government were unreliable at best, fabricated at worst. But it is crystal clear the system today is collapsing, unable to adapt to a non-authoritarian society where individual choice reigns, power is decentralized and economic realities constrain choices. And while most experts are focused on the profound economic and political problems plaguing the region, it is also clear that the collapse of public health is potentially just as destabilizing.

Here's what Newsday found:

  • Infectious diseases long thought to be under control or largely extinct in the developed world have swept through former Soviet republics in a rolling series of epidemics, producing disease rates far exceeding those in Western countries. These diseases -- which include tuberculosis, hepatitis, cholera, typhoid and influenza -- have been spread by chronically poor medical hygiene and sanitation, as well as misuse of antibiotics. The tuberculosis rate, for instance, is 10 times the rate in the United States, and growing.
  • The long decades of government-enforced isolation from the rest of the world have bred a striking ignorance of many modern medical advances among health care professionals, and a widespread public belief in unscientific folk remedies. For example, only 60 percent of Russian children under age 5 have been fully immunized -- according to World Health Organization standards -- against the six most common vaccine-preventable diseases, in large part because of opposition from parents and doctors who believe children with the mildest health problems should not be vaccinated. The U.S. rate, meanwhile, is above 95 percent.
  • The former health-care delivery system -- inefficient, expensive and authoritarian, but widely accessible -- has all but collapsed in the wake of a massive funding crisis, and little has been done to replace it. The Russian government, for example, currently earmarks less than 2 percent of its annual budget for health services, compared with nearly 20 percent in the United States, resulting in chronic shortages of supplies, deteriorating physical facilities and late payment of wages to personnel. In most hospitals visited by Newsday, strapped officials had stopped ordering rubber gloves and paper towels to save money.
  • Long-term environmental problems are taking a growing toll on the public's health. In St. Petersburg, for instance, officials acknowledge they can no longer supply safe water to the city, a problem that resulted this summer in more than 500 cases of dysentery. In Russia as a whole, the Environment Ministry has concluded half the nation's drinking water supply is unsafe.
  • Hundreds of thousands of new patients are now entering the health system due to an unprecedented surge in drug abuse, which has fueled an explosion of HIV and hepatitis and compromised part of the region's blood supplies. There are few public education programs on the dangers of sharing needles, for instance, within a huge region in which two-thirds of AIDS patients are drug users.

"We broke old mechanisms which managed society and health care, and we didn't create new ones, we didn't know how to," Mogilevsky added. "Now health care is on the brink of complete ruin."

The crisis threatens to engulf not only the 280 million people who live in the republics that once composed the Soviet Union but, because of immigration patterns and political interdependence, large parts of the rest of the world as well. For as the incidence of infectious disease increases, neighboring nations in Europe and popular immigration destinations such as the United States and Canada become increasingly worried.

One World Health Organization official called a 1995 diphtheria epidemic in Russia "the biggest public health threat in Europe since World War II."

Just as ominously, there is concern that the health care crisis will provide potent new ammunition to ultra-nationalist politicians who argue that American-style democracy and cooperation with the West have failed and that only a revival of authoritarianism can solve Russia's problems.

"How can the society, the economy, the military bear such a burden?" asked Murray Feshbach, a Georgetown University demographer who has studied Russian trends for years. "Will it lead to social disarray? Can the economy survive? Will a conservative military-type leader decide to overthrow the government? Why are these not viable possibilities if one looks at Russia from the demographic and health prism, and not just the political and economic dimensions?"

There is some evidence that this concern is well-founded. A poll ranking the concerns of Russian citizens earlier this year found that declining public health had risen to fifth (from ninth in 1995) and was cited by 29 percent of those responding as their top concern (up from 16 percent two years ago).

Opponents of the present Russian government are seeking to exploit health care as a political issue. Communist leaders routinely blame Western-style capitalism for the surge in infectious diseases, alcoholism and drug abuse. They argue that the nation's strength and security have been compromised, citing government statistics that one in three army recruits are now rejected for health reasons, as opposed to 1 in 20 in 1985. And Russia's most prominent nationalist leader, Alexander Lebed, apparently has incorporated the issue into his standard stump speech.

"Tuberculosis has increased -- it's a rampant wave," Lebed barked in his gravelly baritone during a recent talk to a group of supporters in the Siberian city of Irkutsk. "We have to stop this rampant increase. We need to deal with AIDS too -- we cannot wait ... There are skyrocketing infectious diseases. We must stop that -- now."

But translating such stern rhetoric into reality may prove difficult for any politician, even one as accustomed to command as Lebed, a former army general. And if Lebed has any doubts of that, he might have a chat with a fellow Afghan war veteran named Konstantin.

In 1993, two years after Konstantin was discharged from the military, communist and ultra-nationalist rebels seized the Russian White House in defiance of President Boris Yeltsin's order disbanding the old Soviet-era parliament. Konstantin grabbed his old army rifle and manned the barricades.

The rebellion was crushed, and Konstantin wound up in Butirka Prison, charged with treason. When his case finally came up for judicial review last January, a judge dismissed the charges and ordered him freed.

But by that time Konstantin had contracted tuberculosis, a huge and growing risk in Russia's grossly overcrowded jails and prisons. The treatment he received was erratic and ineffective, and the disease eventually spread from his lungs to his liver, kidneys and heart.

Today, Konstantin, 39, who won't allow his last name to be used, lies dying in a bed at the Moscow Tuberculosis Research Center, his disease beyond the reach of any drug. "It's like a joke, a particularly Russian joke," he says. "In principle, I was given a death sentence."

The rampant growth of tuberculosis among Russia's huge prison population -- estimated to be as many as one million out of a total population of 140 million -- is one of the engines that have driven the country's overall TB rate to a level at least 10 times greater than that in the United States. And while Russian scientists debate how to cope with the epidemic, those who care for TB victims in provincial facilities across the far-flung nation often work in the face of heartbreaking shortages.

In one such facility, in the city of Ulan-Ude, capital of Buryatia, a region of Russia just north of Mongolia, Dr. Galina Dugarova cares for patients housed in three unheated log cabins. Patients must supply their own pajamas and bed linens; supplies of antibiotics and other medicines are erratic at best.

"They are all going to die," Dugarova says as she ministers to four patients in the facility's intensive care ward. "We cannot treat them ... We would like to give them four drugs and some protein, but we have no money and they have no money. They are sentenced."

As ominous as the TB epidemic is, it is just one of the infectious diseases that have swept through Russia and other former Soviet republics in recent years. While statistical comparisons over time are difficult because Soviet-era data were notoriously unreliable, both domestic and foreign experts agree that many diseases have registered alarming increases.

Diphtheria, for example, infected 200,000 people in the region and killed 5,000 before it finally slowed down last year, thanks in part to a major international effort spawned by fears that the contagion would spread to other parts of the world.

Polio rolled into Azerbaijan in 1991, Uzbekistan in 1993 and war-ravaged Chechnya in 1995. Hepatitis is now so common throughout the former Soviet Union that it is regarded as endemic rather than epidemic. Influenza hit the region so hard in 1995 that the entire Ukrainian government was forced to shut down for a week. Typhoid infected 20,000 in the central Asian republic of Tajikistan last year, much of it surfacing in drug-resistant forms. Russia's second largest city, St. Petersburg, is currently coping with dual epidemics of cholera and dysentery for the third time since 1993.

While there are many reasons for these contagions, one source is health care practitioners and medical facilities themselves, according to Western experts who have studied the problem.

"I can't tell you how surprised I was by their lack of infection control," said Howard Cohen, former executive director of Coney Island Hospital in Brooklyn, which serves as a "sister" institution to a hospital in Odessa. "In the operating room they had commonly used soap bars, commonly used towels. Surgeons were going from one patient to another without washing."

Sometimes, lack of funds is the culprit, as in a children's hospital in St. Petersburg that suffered several outbreaks of internally generated infections last year. Investigators discovered that the cash-strapped facility had ceased buying paper towels and rubber gloves.

But in other cases, simple lack of knowledge born of isolation from Western colleagues is at fault. Cohen and others say most Russian and Ukrainian doctors believe airborne bacterial spores are the major source of infection within hospitals, whereas Western practitioners learned years ago that unsterile hands and instruments were the main culprits.

"For seventy years, public health here was linked to ideology instead of science," said Regina Napolitano, chief of infection control for Coney Island Hospital. "Now they're paying the price."

In some parts of the region, these problems are exacerbated by the misuse of antibiotics, leading to the emergence of drug-resistant strains of bacteria. Dr. Ed O'Rourke of Boston's Children's Hospital, an expert in infectious diseases who has visited Russia and other ex-Soviet republics on many occasions, says physicians there often "simply add one [antibiotic] on top of another" without any particular rationale.

O'Rourke has been urging doctors in the region to revamp their system for controlling infectious diseases, but fears he's made little impact. "It's as if they have horses and carriages but want diesel trucks," he said. "And we're trying to tell them that what they need to do is forget about these diesels and use the horses and carriages properly."

Another key source of the epidemics is a plummeting rate of vaccination against infectious diseases that began in the 1980s and has continued unchecked into the current decade.

Part of the blame for this lies with Soviet-era health officials, who trained pediatricians to withhold vaccinations from children with minor ailments -- or merely a family history of a disease -- on the theory that such "weak" children would be harmed rather than helped by inoculation.

One scientist, Dr. Galena Chervonskaya, carried this theory to extreme lengths, arguing that domestically produced diphtheria and pertussis vaccines were contaminated with poisons. Her views were publicized in a mass-circulation newspaper, further depressing the vaccination rate -- and opening the door to the likes of Boris Nikitin.

Nikitin, 82, was trained in engineering, not pediatric medicine. But he has proclaimed himself an expert in child rearing, and his influence in Russia is often compared to that of Dr. Benjamin Spock in the United States. His "Nikitin Doctrine" holds that most clothing and medical treatment weaken children.

"Nature has designed a certain stage in child development when natural immunity is formed," Nikitin says as he plays with his naked 6-month-old granddaughter outdoors on a chilly afternoon. "This natural mechanism is called children's infections. So this immunization of society is a great medical mistake."

A similar attitude toward medical science can be found at an AIDS clinic in the Ukrainian capital of Kiev, where a patient named Viktor rejects the drug AZT in favor of another "treatment": a bullet-shaped piece of tin taped to his chest.

The 38-year-old postal worker explains he received the apparatus from a local healer who invented it "to measure biocurrents from my body. She charges the currents with a piece of tin, which we call a bullet. And the bullet counters my negative biocurrents."

Such unscientific credulity can, of course, have tragic consequences. But given their history, citizens of the former Soviet Union might be forgiven their willingness to trust street healers over certified scientists. For most of their lives, the health care system was run entirely by the state -- the same state that was systematically befouling their air, water and soil in its headlong race to create an industrial and military superpower regardless of human cost.

The grim results of these policies can be found throughout the former union -- from the ruined Reactor No. 4 at the infamous Chernobyl power station, to the 50 secret cities where nuclear weapons production has left a deadly legacy of contamination, to the toxic shroud that envelops scores of industrial cities like Angarsk.

Angarsk, a Siberian city of 280,000, is ringed with aging chemical factories, oil refineries and energy production plants. The forest around the city has been denuded by acid rain; the landscape is webbed with rusting petroleum ducts. The sky is perpetually gray. The air smells of sulfur and methane and leaves an acrid taste in the mouth. "It's my perfume," one woman says sourly as she waits for a bus.

Some Russian scientists believe that this rampant environmental degradation, when combined with the political disasters that have stalked their century, has permanently damaged the raw human material of the nation and damaged the population's health.

In the industrial regions of Siberia, for example, the incidence of adult leukemia and Hodgkin's disease is nearly twice that seen in Western Europe. Overall, Russians are 1.8 times more likely to die of cancer than are Americans.

"The Russian gene pool is destroyed," asserts Dr. Askold Maiboroda, dean of the Federal Medical University in the Siberian city of Irkutsk. "First, there were Stalin's slaughters of millions of people, the most creative and intelligent people. Then more good people perished in the gulags ... And now we suffer an environmental assault unlike anywhere else. We are weakened. Our genes are damaged. You cannot expect much from the Russian people; do not ask much of us."

This attitude of passive hopelessness helps fuel another scourge: widespread and growing alcohol and drug abuse.

Alcohol consumption, traditionally high among Russian men, has increased 600 percent in the nine years since the Soviet government called off an effective but highly unpopular anti-drinking campaign. During that time, deaths from alcohol poisoning and cirrhosis rose by 300 percent and 250 percent respectively. And many younger Russians, caught in the pyschic backwash of their society's unprecedented transition, have turned to hard drugs to relieve their angst.

"Look at that drunken idiot!" a teenager shouts to his laughing buddies as they watch a sodden man try to enter a Moscow subway through the exit turnstile. "Only fools drink bad vodka!"

The teenagers, it turns out, are high themselves -- but not on vodka, good or bad. They've been doing a popular opium-based drug called poppy straw.

Hundreds of miles east of Moscow, in the Siberian city of Novosibirsk, another group of young people has gathered in a nightspot called the 888 Club to drink, smoke and contemplate their uncertain futures.

"I'm just a human, rolling through life," says 20-year-old Sevi. "I'm totally against drugs. My choice is vodka. I'm an alcoholic!"

A bit later, the group is asked, "What is a Russian?" Alex, 18, has a ready answer: "Drinking. And loneliness. No one is lonelier than a Russian."

This existential glibness may sound hip and trendy in the mouths of young people. But when damaged, alienated people grow older and begin families, continued alcohol abuse can reap a harvest of misery, especially for the children of such parents.

Vanya's parents were such people -- chronic alcohol abusers who battled ferociously and sometimes violently when they drank. After one such bout, they separated. Vanya's mother brought him to Moscow's bustling Byelorussky train terminal when he was 9, let go of his hand, and disappeared into the crowd.

When the police finally picked Vanya up last year, he had survived two winters by begging and sleeping in phone booths. Now, the 11-year-old boy lives in a children's shelter, trying to master the involuntary blinking and bed-wetting that remains with him as a reminder of his life on the streets.

Similar stories can be found throughout the former Soviet Union. At least 700,000 children are homeless in Russia, according to government data, and a recent UNICEF report predicted the number is likely to mount. Alcoholism, the report said, "not only directly affects the child's well-being, it also tends to increase family conflicts, stress-related 'paternal mortality' and other types of breakdowns."

And children caught in the toils of these problems are likely to be the most vulnerable to infectious diseases. The rate of childhood tuberculosis in former Soviet republics, for example, is now at its highest level since antibiotics-based treatment was introduced in the 1950s. In Ukraine, the second largest republic, the incidence of diagnosed TB in those aged 14 and younger has doubled during the past six years.

At the Kiev Institute of Pulmonology, where many of these children are treated, staff members are up against familiar obstacles -- chronic shortages of money, drugs and diagnostic resources.

In a ward in the institute, a woman named Galina lies quietly next to her 5-year-old grandson, Janya, bundling against the sick boy to ward off the chill of the unheated room. The lights have also been turned off in daylight to save electricity costs, making it difficult for Galina to read to the child on this overcast afternoon.

"The situation is just dreadful," says Dr. Viktoria Kostromira, the institute's director of pediatric services. "The government should take drastic action immediately, or we will have a huge epidemic."

But such relief is unlikely, given the tight fiscal constraints that governments in Ukraine and every other former Soviet republic now face. And so the health care crisis deepens, statistical indices worsen -- and those responsible for coping with the problems issue increasingly pointed warnings.

"We want to make it clear to everybody that the national security of the country is threatened," said Dr. N.F. Gerasimenko of the Academy of Medical Sciences in a speech to the Russian parliament earlier this year. "The situation is catastrophic ... It's even worse than it was in Russia one hundred years ago."