Russia has an entrenched, albeit underfunded, system of socialized medicine. Basic medical care is available to most of the population free of cost, but its quality is extremely low by Western standards, and in the mid-1990s the efficiency of the system continued the decline that had begun before the collapse of the Soviet system. In the first four post-Soviet years, that decline was typified by significant increases in infant and maternal mortality and contagious diseases and by decreases in fertility and life expectancy.
The decline in health is attributable in part to such environmental and social factors as air and water pollution, contamination (largely from nuclear accidents or improper disposal of radioactive materials), overcrowded living conditions, inadequate nutrition, alcoholism, and smoking, and in part to a lack of modern medical equipment and technology. In 1991 life expectancy in Russia was 74.3 years for females and 63.5 years for males. By 1994 the figure for males was 57.3 years. The male-to-female ratio in the population reflects the higher male mortality rate and the enduring impact of losing millions more males than females in World War II. (In all age-groups below thirty-five, there are more males than females.) In 1993 the overall ratio was 884 males per 1,000 females, and experts predicted that the figure for males would decline to around 875 by the year 2005 (see Demographic Conditions, ch. 3).
By the mid-1990s, Russia's death rate had reached its highest peacetime level in the twentieth century. Curable infectious diseases such as diphtheria and measles have reached epidemic levels unseen since the Bolshevik Revolution, and the rates of tuberculosis, cancer, and heart disease are the highest of any industrialized country.
In 1993 the incidence of a number of infectious diseases increased significantly over the previous year: tuberculosis by 1.25 times, brucellosis by 1.9 times, diphtheria by 3.9 times, and syphilis by 2.6 times (see table 14, Appendix). In 1995 the Russian health system was overwhelmed by the return of epidemic diseases such as cholera and typhoid fever, even as it faced chronic staff and equipment shortages. In the winter of 1995-96, Russia suffered its most severe epidemic of influenza in decades. An estimated 1 million people were infected in Moscow alone, and numerous schools and public institutions were closed to prevent the spread of the disease. Experts attributed the virulence of the epidemic to the generally low level of resistance of much of the Russian population, the result of poor overall health care and stressful economic conditions. Other causes were the uneven availability of influenza shots and the population's general belief that injections enhance rather than decrease an individual's chances of becoming ill.
Between 1980 and 1989, cancer and its complications increased from 15 percent to 18 percent among causes of death. In 1990 the most common types of cancer were breast cancer, cancer of the stomach and liver, and skin cancer. In the last years of the Soviet Union, about 680,000 new cases were diagnosed annually. The causes of cancer are varied and complex, but contributing factors in Russia are heavy smoking, radiation exposure, and contact with pervasive toxic emissions and chemicals in soil, food, and water. According to the deputy minister of environmental protection and natural resources, about 50 percent of all cancer-related illnesses can be attributed to environmental factors. Heavy-manufacturing regions show especially high rates; in Noril'sk, the metallurgical center located above the Arctic Circle, the incidence of lung cancer among males is the highest in the world (see Environmental Conditions, ch. 3).
Russia's birthrate has shown an increasingly steep decline in the 1990s, amounting to what one commentator calls "the quiet suicide of a nation." For example, the annual birthrate for the first six months of 1992 was 11.2 per 1,000 population--a 12 percent decline from the same period in the previous year. In some areas, the rate was even lower, for instance, 9.2 in St. Petersburg and 8.2 in the Moscow region.
Russia's Ministry of Health reported in June 1991 that the country had a negative rate of population change for the first time since records have been kept. The declining number of births is attributed in part to a drop in fertility, which presumably stems from a combination of physiological and environmental factors, and in part to women's reluctance to bear children in a time of economic uncertainty.
Maternity, Infant Care, and Birth Control
Some of the same factors shortening the lives of adults cause needless premature deaths of newborns in Russia. Poor overall health care and lack of medicines, especially in rural areas, reduce infants' survival chances. In Russia an estimated 40 to 50 percent of infant deaths are caused by respiratory failure, infectious and parasitic diseases, accidents, injuries, and trauma. For developed countries, this share ranges between 4 and 17 percent.
Infant mortality rates vary considerably by region. Central and northern European Russia's rates have been more in line with West European rates. In the intermediate category are the Urals, western Siberia, and the Volga Basin. The highest rates are found in the North Caucasus, eastern Siberia, and the Far East. Several autonomous republics, including Kalmykia, Chechnya, Ingushetia, Dagestan, and Tyva, consistently record the highest rates in the Russian Federation. In these areas, social and economic underdevelopment, poor health care, and environmental degradation have had an impact on the health of mothers and newborns.
Unwanted pregnancies are common because of the limited availability and substandard quality of contraceptives and a reluctance to discuss sexual issues openly at home or to provide sex education at school. No social stigma is attached to children born out of wedlock, and unmarried mothers receive maternity benefits. Medical care for expectant mothers is among the least adequate aspects of the country's generally substandard system of health care. A high percentage of pregnant women suffer from anemia and poor diets--factors that have a negative effect on their babies' birth weight and general health.
In the mid-1990s, modern forms of contraception are unavailable or unknown to most Russian women. The Soviet Union legalized abortion for medical reasons in 1955 and overall in 1968. But information about Western advances in birth control--and all modern means of birth control--was systematically kept from the public throughout the remaining Soviet decades. As a result of that policy, today's Russian gynecologists lack the training to advise women on contraception, and public knowledge of the subject remains incomplete or simply mistaken. Even in Moscow in the mid-1990s, most contraceptives were paid for by voluntary funds and international charities. In the early 1990s, an estimated 22 percent of women of childbearing age were using contraceptives; the percentage was much lower in rural areas.
Abortion remains the most widely practiced form of birth control in Russia. In 1995 some 225 abortions were performed for every 100 live births, up from a rate of 196 per 100 in 1991. According to one study, 14 percent of the women in Russia with sixteen or more years of school had undergone eight to ten abortions. The conditions under which abortions are performed often are primitive. Moreover, it is estimated that nearly three-quarters of abortions take place after the first trimester of pregnancy, involving substantially greater maternal risk than those performed earlier. The number of abortions is much higher among Russian women than among Muslims and other minority groups, however. Statistically, the higher her social status and the extent of her Russification, the more likely a Muslim woman is to seek an abortion.
Infant and child health in Russia is significantly worse than in other industrialized countries. According to official statistics, only one child in five is born healthy. The inability of more than half of all new mothers to breast-feed, mainly because of poor diet, further undermines infants' health in a country where diets generally are unbalanced. Another problem is that most women of childbearing age are employed and thus must place their young children in day care centers, where they often contract contagious diseases. Illnesses such as cholera, typhoid fever, diphtheria, pertussis, and poliomyelitis, which have been virtually eradicated in other advanced industrial societies, are widespread among Russia's children. Vaccines are scarce. Even when immunizations are available, parents often refuse them for their children because they fear infection from dirty needles.
Alcohol, Narcotics, and Tobacco
Russia's rate of alcohol consumption, traditionally among the highest in the world and rising significantly in the 1990s, is a major contributor to the country's health crisis, as well as to low job productivity. Rated as Russia's third most critical health problem after cardiovascular diseases and cancer, alcoholism has reached epidemic proportions, particularly among males. In the twentieth century, periodic government campaigns against alcohol consumption have resulted in thousands of deaths from the consumption of alcohol surrogates. The latest such campaign was undertaken from 1985 to 1988, during the regime of Mikhail S. Gorbachev (in office 1985-91). Although some authorities credited reduced alcohol consumption with a concurrent drop in Russia's mortality rate, by 1987 the production of samogon (home-brewed liquor) had become a large-scale industry that provided alcohol to Russians while depriving the state of tax revenue. When restrictions were eased in 1988, alcohol consumption exceeded the pre-1985 level. According to one study, between 1987 and 1992 annual per capita consumption rose from about eleven liters of pure alcohol to fourteen liters in 1992; current consumption is estimated at about fifteen liters. (According to World Health Organization standards, consumption of eight liters per year is likely to cause major medical problems.)
A 1995 Russian study found that regular drunkenness affected between 25 and 60 percent of blue-collar workers and 21 percent of white-collar workers, with the highest incidence found in rural areas. Because alcohol remains cheap relative to food and other items, and because it is available in most places day and night, unemployed people are especially prone to drunkenness and alcohol poisoning. In 1994 some 53,000 people died of alcohol poisoning, an increase of about 36,000 since 1991. If vodka is unavailable or unaffordable, Russians sometimes imbibe various combinations of dangerous substances. The Russian media often report poisonings that result from consumption of homemade alcohol substitutes. Production of often-substandard alcohol has become a widespread criminal activity in the 1990s, further endangering consumers. Alcohol consumption among pregnant women is partly responsible for Russia's rise in infant mortality, birth defects, and childhood disease and abnormalities.
Smoking, a widespread habit, especially among women and teenagers, compounds Russia's health crisis. Chain-smoking is endemic in Russia; in 1996 an estimated 55 percent of Russians were regular smokers, and health authorities believed that the figure was rising. However, rather than urge patients to quit, doctors often recommend the purchase of American cigarettes, which are more expensive but have less tar and nicotine than Russian brands. When import restrictions ended in the early 1990s, the American cigarette industry found a large new market in Russia. A modest government antismoking campaign paralleling Gorbachev's anti-alcohol campaign in the late 1980s had little effect. In January 1996, cigarette advertising in the print media was prohibited, and smoking in theaters and workplaces generally was restricted to designated locations.
The increasing incidence of drug abuse was belatedly acknowledged by the Russian government as a public health problem. In 1995 an estimated 2 million Russians used narcotics, more than twenty times the total recorded ten years earlier in the entire Soviet Union, with the number of users increasing 50 percent every year in the mid-1990s. In the Soviet era, drugs were viewed officially as a capitalist vice, but that attitude disappeared soon after the Soviet Union dissolved. Russia legalized drug use (but not possession or sale) in 1991. According to experts, laws against possession are not dissuasive. Narcotics use has spread to new elements of society in recent years, including alcoholics seeking a new means of escape. Russian experts rate the new class of Russian businesspeople as the group with the highest percentage of drug users; for them, success often includes the ability to purchase the most expensive narcotic. The drug scene, once dominated by students and intellectuals, now includes large numbers of housewives and workers. Synthetic drugs now are manufactured in small laboratories by professional chemists; some are easily fabricated by amateurs as well. Legally produced drugs often are stolen and move into the black market (see The Crime Wave of the 1990s, ch. 10).
Medical treatment and educational programs now include hot lines in major cities and walk-in clinics that provide advice and treatment on an anonymous basis. Some schoolteachers have begun class discussions of drug-related issues and have distributed antidrug literature to students. Nevertheless, Russia's drug problem remains largely intractable. Many addicts overdose, and some who cannot afford heroin inject themselves with other substances that cause illness or death.
Acquired immune deficiency syndrome (AIDS) likely was brought to the Soviet Union by students from countries with high levels of incidence of the disease. In 1987, after the first case of AIDS was confirmed in Russia, the Supreme Soviet of the Soviet Union passed the strictest anti-AIDS law in the world, making the knowing transmittal of the infection a criminal offense punishable by up to eight years in jail. A 1995 law, which has been criticized vehemently for its human rights implications and the cost of its administration, stipulates that all visitors remaining more than three months must prove that they are not infected with the AIDS-causing human immunodeficiency virus (HIV).
The government has established a diagnostic and screening infrastructure for AIDS prevention and control at the central and subnational levels. This system has been criticized heavily, however, because it tests only populations with little chance of infection, and because it fails to allocate scarce funds to root causes of AIDS transmittal such as infection from hospital procedures and reuse of hypodermic needles. The release of statistics on the incidence of AIDS and other sexually transmitted diseases has been extremely slow. In late 1995, the Ministry of Health reported that 1,023 Russians, including 278 children, had been registered as having HIV, and that to that point 160 Russians, of whom seventy-three were children, had died of AIDS. Before 1992 several mass infections of children occurred in medical facilities.
Official diagnoses of HIV increased 50 percent from 1993 to 1994. However, according to an official of the Imena AIDS support group, which is devoted to rehabilitation of HIV victims, the official statistics are understated at least tenfold because Russians in the groups most at risk--prostitutes, homosexuals, and drug users--have reason to fear that results will not remain confidential and so refuse AIDS testing. Although the 1990 Law on Prevention of AIDS mandates confidentiality of medical records, in practice jobs often are lost and social services denied after a positive diagnosis. The highest incidence of HIV is in Moscow, St. Petersburg, Rostov-na-Donu, Volgograd, and the Republic of Kalmykia, the last three of which have medical facilities where unsanitary procedures have resulted in mass transmission of the virus. The majority of reported HIV-positive individuals are drug users.
As in the Soviet period, the public receives little information about precautions against AIDS or the identity of the high-risk categories in society, and AIDS sufferers meet much intolerance in Russian society. Because the disease has been associated with foreigners, government officials and the public have ignored the need for preventive measures among Russians. AIDS transmittal is increased by a chronic shortage of condoms (which Soviet medical officials euphemistically called "Article Number 2") and by the lack of disposable hypodermic syringes in hospitals and clinics, which results in the repeated use of unsterilized needles.
The Health System
The glasnost period of the late 1980s first revealed the decay of the Soviet system of socialized medicine, which nominally guaranteed full health protection to all citizens without charge. That system had been installed under Joseph V. Stalin (in office 1927-53) with an emphasis on preserving a healthy work force as a matter of national economic policy. In the 1980s, Russia had a huge network of neighborhood and work-site clinics and first-aid facilities to provide readily accessible primary care, together with large hospitals and polyclinics to diagnose and treat more complex illnesses and to perform surgery. In 1986 the Soviet Union had 23,500 hospitals with more than 3.6 million beds. Such facilities included about 28,000 women's consultation centers and pediatric clinics, together with emergency ambulance services and sanatoriums.
In the 1980s, the Soviet Union was first in the world in the ratio of hospital beds to population. Behind this system was a huge, multilevel bureaucracy directed from Moscow in consultation with organs of the CPSU. All aspects of health service had nationwide annual programs with complex statistical accounting and goals. Physicians devoted an estimated 50 percent of their time to filling out forms, and every year a large part of the national health care budget went to construction of new facilities.
The structure of the Soviet system, which specified the length of treatment for every disease, often caused people suffering from relatively minor ailments such as influenza to be hospitalized. The result was a serious overcrowding problem in hospitals despite the large number of beds available. Patients preferred hospital treatment because hospitals were better equipped than clinics and because crowded living conditions made recuperation at home difficult. Many large enterprises operated clinics that provided workers health care without requiring them to leave the work site. Such clinics aimed at reducing the incidence of sick leave, which averaged 3 percent of the workforce per day in the 1980s.
The most outdated and abuse-ridden aspect of Soviet health care was psychiatric treatment. That system never advanced from the methodology of the 1950s, which included Pavlovian conditioned-response treatment, heavy reliance on drug therapy, and little practice of individual or group counseling. Therefore, most citizens preferred to suffer rather than submit themselves to treatment. In addition, Soviet psychiatry was at the service of the government to declare dissenters "insane," commit them to psychiatric hospital-prisons, and administer powerful psychotropic drugs. In the mid-1980s, estimates of the number of political prisoners in such institutions ranged from 1,000 to several thousand, and in 1983 the Soviet Union withdrew from the World Psychiatric Association to avoid censure for its abuses of the profession. In 1988 the special psychiatric hospitals to which political dissidents had been committed were transferred from the jurisdiction of the Ministry of Internal Affairs to that of the Ministry of Health.
In 1986 the Soviet Union had about 1.2 million doctors and about 3.2 million paramedical and nursing personnel. Medical training emphasized practical work over basic research and pure science; only nine medical institutes were attached to universities. In the late 1980s, the average doctor's salary was roughly comparable to that of the average industrial worker. In 1996 the average Moscow specialist made about US$75 per month, and senior doctors made about US$150 per month. Paramedics and nurses needed only two years of training and no scientific background; however, in rural areas, which suffered a shortage of doctors, such individuals often were the only medical personnel available.
Despite the nominally equitable nature of Soviet socialized medicine, the actual system was highly stratified according to location, with far inferior care and facilities available in rural areas, and especially according to political status. The Ministry of Health maintained a completely separate, vastly superior system of clinics, hospitals, and sanatoriums for top party and government officials and other elite groups such as writers, actors, musicians, and artists.
The outline of the Soviet system did not change appreciably in the first half of the 1990s, but quality declined in nearly every aspect except the facilities designated for the elite. In 1992 Russia had 662,700 doctors, a drop of about 32,000 since 1990, and 131 hospital beds per 10,000 population, a drop of 97,000 beds (about 5 percent) since 1990. Among the doctors, 78,600 were surgeons, 77,600 pediatricians, 39,600 gynecologists, 20,300 psychiatrists, and 18,500 neurologists.
In the early 1990s, the public health delivery system in Russia was in crisis. Although the number of doctors and paramedics has remained sufficiently high to ensure the provision of adequate treatment, most such personnel are poorly trained, lack modern equipment, and are badly paid. In 1995 Russia had one doctor for every 275 citizens (compared with one for every 450 in the United States), but about half of medical school graduates cannot diagnose simple ailments or read an electrocardiogram when they enter practice. In 1993 about forty institutions offered medical training, but the quality of training varied considerably. Many medical schools suffer from shortages of instructors, textbooks, current medical journals, contacts with Western experts, and equipment.
Low salaries have made corruption common among medical personnel, who often extract bribes for both materials and services. Thus, although health care is free in principle, the chances of receiving adequate treatment may depend on the patient's wealth. The combination of bribes and authorized charges puts many types of medical treatment beyond the reach of all but the wealthy. Elderly people are hit especially hard by this situation. Meanwhile, a sharp decline in state funding has affected all aspects of medical care, from prevention to emergency treatment. Between 1990 and 1994, state funding declined from 3.4 percent of the national budget to 1.8 percent.
Although Russia pioneered in some specialized fields of medicine such as laser eye surgery and heart surgery, the country's medical establishment is generally deficient in hospital equipment, technology, and pharmaceuticals. For example, preventable infant deaths result from an absence of fetal heart monitors, ultrasound units, and various other equipment for monitoring labor and delivery; needless deaths from heart disease occur because hospitals lack the equipment needed to perform bypass surgery and angioplasty.
Facilities for the disabled, of whom about 6 million reside in Russia, also fall far below Western standards. Wheelchairs and artificial limbs are in very short supply, rehabilitation centers are few, and wheelchair ramps are virtually nonexistent. A 1995 law, On the Social Protection of Disabled Persons in the Russian Federation, provides for a wide range of benefits and services, including equal access to education, employment, transportation, and services. The law requires businesses to set aside at least 3 percent of their jobs for the disabled. However, no funding was available for any of the law's programs in 1996.
The shortage of medicines in Russia is chronic and catastrophic. Soviet-era supplies of materials and drugs have been depleted and are not being adequately replenished. Domestic production has plummeted because of the obsolescence of pharmaceutical factories and shortages of requisite raw materials and supplies. Many of the items produced are ineffective. Russia relies increasingly on imports from former Soviet-bloc nations in Central Europe, which formerly accepted barter transactions and payment in rubles but now demand hard currency (see Glossary), a scarce item in Russia, for their products. The nonconvertibility of the ruble also has hindered Russia's ability to purchase medicines abroad. Even when pharmaceuticals are available in Russia, they often are priced beyond the reach of doctors and patients.
Russia's hospitals and polyclinics are generally old (about 15 percent were built before 1940), and they lack basic amenities. Roughly 42 percent of the country's hospitals and 30 percent of its clinics lack hot water, and 12 percent and 7 percent, respectively, have no running water at all. About 18 percent of hospitals and 15 percent of clinics are not connected to a sewerage system, and only 12 percent in both categories have central heating. Even in the best hospitals, medical personnel do not regularly wash their hands, surgical instruments are not always properly sterilized, and rates of infection are abnormally high.
Aside from shortfalls in Russia's health facilities and the quality of medical personnel, much of the country's public health crisis stems from poor personal hygiene and diet and lack of exercise. Preventive medicine and wellness programs are virtually nonexistent, as are programs to educate the public about personal sanitation, proper diet, and vitamins. The average Russian does not consume a balanced diet. Vegetables often are scarce in Russia, except in rural areas where they are homegrown, and fruits never have constituted an important element of the Russian diet. Per capita meat consumption also has fallen in the 1990s (see table 6, Appendix).
Russia's government is attempting to equalize the distribution of health care by fragmenting the Soviet-era network of top-level medical facilities for exclusive use of the elite. In the spring of 1993, President Yeltsin signed a decree entitled On Immediate Measures to Provide Health Care for the People of the Russian Federation. The proclaimed goal, which already had been established in the 1980s, was the creation by 2000 of a "unified system of health care" for the entire population. However, economic constraints are likely to stymie achievement of that goal in the near future. In 1995 less than 1 percent of Russia's budget was earmarked for public health, compared with 6 percent in Britain and more than 12 percent in the United States. Experts forecast that such a meager outlay will not address the major shortfalls in Russia's health care system, not to mention the air, water, and soil pollution that continue to contribute insidiously to worsening public health.
The impersonality and inaccessibility of national health system facilities, with patients often standing in line at clinics for an entire day before receiving brief diagnoses and prescriptions for drugs they cannot afford, has encouraged many Russians to turn to unorthodox alternatives such as faith healing, herbal medicine, and mysticism. By the mid-1990s, private medical clinics were serving a growing number of Russians able to afford their care.
In the Soviet era, the state discouraged alternative medicine by arresting practitioners. By 1995, however, the number of such individuals was estimated at 300,000, and as many as 80 percent of Russians needing medical assistance have turned to them, according to a Yeltsin adviser on social policy. Traditional folk healers constitute the largest group of nontraditional practitioners. They offer personalized attention and affordable cures such as birch bark and cranberries to cure a variety of complaints. Russians with access to a plot of land often grow their own herbs, and books describing home cures have become popular. Long-practiced cures such as wrapping oneself in a vinegar-soaked blanket and drinking one's own urine have become more widespread in the 1990s.
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