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
In the Remnants
Of the USSR, Health Care Is In a Deadly State Of
published Sunday, October 26,
By Laurie Garrett
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
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
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
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
- 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
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
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
"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
"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 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
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
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
"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
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
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
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, 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
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
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
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
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
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
"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
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