Russia: The Sickness of a Nation

BY CHANEY KALINICH

The probability that a 15-year-old boy in Russia will die before he reaches the age of 60 is greater than 40%.1 The ongoing health crisis in Russia presents a frightening picture of a nation’s leaders undermining its own citizens’ lives through neglect, corruption, and a quest for power. Russia is a wealthy country with vast resources at its disposal—an estimated 40% of the world’s natural resources—but these riches have limited benefit for its citizens’ health.1 Typically, a country’s overall health improves with industrialization and increased wealth, but male life expectancy in Russia is 13 years shorter than that of its counterparts around the world.2 Russia is widely regarded as one of the world’s superpowers, yet it suffers from HIV infection rates higher than most developing countries, and one of the highest rates of alcoholism in the world. Russia’s massive public health problems result from complex and deep-seated societal norms paired with a government that has demonstrated inadequate interest in fixing them.

During the Soviet era, healthcare was labeled a basic human right and was available and free for all citizens.3,4 The state owned healthcare facilities and employed all doctors and healthcare workers.5 Doctors were severely overworked, lacked resources and training, and received the same compensation as common laborers.5 Hospitals lacked basic equipment, sufficient beds, plumbing, and proper hygiene.3 The payment of bribes to obtain faster or higher quality treatment became necessary, and therefore commonplace.3 Obsessed with compartmentalization, Soviet hospitals were inexplicably divided by specialty area, resulting in disjointed treatment for patients with multiple health issues, and troublesome compartmentalization of essential medical information.5 The Soviet system was wasteful and inefficient, but it was free.3

Following the collapse of the Soviet Union, the new Russian Federation promised universal healthcare in its constitution. In 1996, this promise was put into effect through a mandatory health insurance mechanism.5 Unfortunately, the new system retains many problems of the old Soviet model.6 Doctors remain undertrained, usually with no more than two years of post-undergraduate medical training, and hospitals continue to lack the funding necessary to purchase critical resources.3 Russia’s annual healthcare expenditure reaches just 158 USD per capita, as opposed to 4,187 USD in the US.5 Under-the-table medication deals persist and patients continue to pay substantial bribes to obtain better care as underpaid doctors seek additional sources of income.6 Patients generally cannot afford many of the medications prescribed for them, and hospitals lack the facilities to carry out necessary procedures.3 Different specializations are still divided between clinics, and this “stovepiped” system represents a serious barrier to treatment for people with comorbidities.7 Health programs are chronically underfunded, while corrupt public officials often skim sizeable portions of the medical budget.6 Ultimately, due to poor government planning and corruption, the Russian healthcare system remains poorly equipped to manage public health crises.

 

ALCOHOLISM

To accompany their struggles with chronic disease and viral epidemics, Russians—especially working age men—have for some time been drinking themselves to death. Russians’ alcohol consumption is among the highest in the world, and the rate of alcohol-related deaths is estimated to be 10 times higher than in other countries.8,9,10,11 It is estimated that half a million people in Russia die each year from illness directly related to alcohol consumption, including cirrhosis of the liver and alcohol poisoning.1,8 When other alcohol-related deaths are taken into account, such as accidents, homicides, suicides, and poisoning from bootleg or non-beverage alcohol, this number more than doubles to 1.2 million, making alcohol the second leading cause of death in Russia after cardiovascular disease.12

Throughout history, Russian rulers from the tsars to President Putin, have used the tactic of reducing vodka prices to control the population and gain popularity, despite the direct effect on the nation's mortality rate.

Throughout history, Russian rulers from the tsars to President Putin, have used the tactic of reducing vodka prices to control the population and gain popularity, despite the direct effect on the nation’s mortality rate. Source: Th1234, Wikimedia Commons.

Alcoholism presents a curious problem, because the deeply-ingrained drinking culture in Russia is characterized by a few key differences from other developed countries.13 Russia’s consumption of spirits is unique; elsewhere, softer drinks such as beer and wine prevail.9,14,15 Wine, for example, was largely reserved for the aristocracy during the tsarist era, and beer was not widespread.10 Now, drinking has ingrained itself into every kind of social gathering, and drinking distilled alcohol to intoxication is commonplace.9 It is considered normal to binge drink for days, and solitary drinking, a particularly troublesome phenomenon from a health perspective, is common among Russian men.9,15,16 This drinking culture is not a new development. In fact, it has been noted for centuries.9 From the 16th through the 20th centuries, state policies failed to discourage excessive drinking and, when politically expedient, actually encouraged alcohol consumption.10 A huge proportion of state revenue has historically come from vodka sales, and the series of authoritarian states have actually created policies to encourage drinking in order to keep the population docile.10,17

Excessive drinking in Russia has historically been correlated to the stability of the country, with changes in alcohol consumption leading to huge fluctuations in the death rates.17,18 Russian men born between 1950 and 1970 maintained a relatively stable quality of life, with education, housing, and employment guaranteed by the government. During the decline of the Soviet regime, when stability decreased and resources grew scarce, alcoholism increased.9 To respond to this phenomenon, then-President Gorbachev instituted an anti-alcoholism campaign from 1985 to 1988, during which he closed numerous distilleries across the country and limited the sale of alcohol.10 Gorbachev’s campaign actually succeeded, to an extent, and appreciably increased the life expectancy in Russia for a short period.9,18,19 By the early 1990s, however, deregulation of the market, which resulted in cheaper vodka and greater instability, led to increasing alcohol consumption and related illnesses.10 This trend continued until the early 2000s, when the rise of Vladimir Putin, increased oil prices, and greater stability caused alcohol consumption to mostly level off.9 In 2005, progressive regulation was introduced to limit alcohol production, which had a noted, albeit limited, benefit.8,9,14 Plummeting oil prices and economic sanctions have been accompanied by an increase in alcohol consumption since 2013, especially among young people.20,21

Despite the modest but apparent positive effects of the 2005 alcohol policies, in early 2015, President Putin made the critical—and questionable—decision to cut the minimum price of vodka.22,23 Russian rulers, all the way back to the tsars, have used the tactic of reducing alcohol prices as a method of controlling the population and gaining popularity.17 Cynical measures, such as lowering vodka prices to placate the masses, helped leaders maintain power despite the decrease in the overall mortality rate that accompanies increases in vodka prices.18 In August 2015, less than a year after Putin slashed vodka prices, Russia’s Health Minister reported that mortality rates had already risen among young people, ages 30 to 45, and that 70% of autopsies revealed alcohol in the decedents’ blood.20

 

HIV, DRUG USE & TUBERCULOSIS

Russia also faces additional public health crises. Around 1 million people in Russia have been diagnosed as HIV positive.24 The WHO estimates another million HIV-positive Russians remain undiagnosed. Even more disturbing is the fact that 80% of those who are HIV-positive are under age 30, indicating that, unlike alcoholism, HIV/AIDS is a modern epidemic.12 According to a 2013 United Nations estimate, HIV diagnoses rose 30% during each of the three previous years.25 It was also estimated that, in 2013, 98% of new infections occurred in intravenous drug users.12 Further complicating the dismal health outlook of the epidemic is the fact that enormous numbers of Russians suffer from opioid addiction, a problem deeply intertwined with HIV. Indeed, the HIV epidemic was jump-started by infections among opioid users. In 2008, 80% of all HIV infections were associated with injection drug use, and in 2010, the World Drug Report suggested that approximately 1.6 million Russians regularly use opioids.26 This problem is exacerbated by the fact that opioids remain cheap in Russia, since the country is the preferred route for heroin trafficked from central Asia to Europe.7 Recently, the HIV epidemic has spread beyond traditional risk groups into the general population. Since 2013, the proportion infected by IV drug use has fallen to 50%, and 42% of new infections occur as a result of heterosexual contact.27

In some ways, the emerging HIV and opioid “dual epidemic” perfectly represents the failure of Russia’s healthcare system. First, the combined epidemic demonstrates the grave lack of education among healthcare workers: many healthcare workers report fearing that the casual contact involved in the treatment of people with HIV/AIDS would infect them with the disease and one in four nursing students in their last year of training believe that all homosexuals have AIDS.28,29 These misconceptions go hand-in-hand with deep-seated social stigma surrounding HIV and the LGBT community in Russia. In a healthcare context, stigma leads to confidentiality breaches, refusal of care, and humiliating practices, among other issues.28,29,30 This stigma also leads people to avoid seeking treatment for fear of themselves or their family being ostracized.28

russia_tb_wiki

A patient receives MDR-TB care in Russia. Source: Cjmadson, Wikimedia Commons.

The rising prevalence of HIV has also resulted in the recent resurgence of tuberculosis (TB) in Russia. Russia has historically struggled with high rates of TB, as evidenced by the government policy enacted after the October Revolution of 1917 that mandated TB screening and access to treatment.31 This program achieved some success throughout the Soviet era, and by the collapse of the Soviet Union in 1991, Russia had achieved a steady rate of just under 50 cases per 100,000 people per year.32 Unfortunately, with the fall of the Soviet Union, these programs fell into chaos, and TB returned with a vengeance.31 By 2005, the number of TB cases had tripled to almost 150 per 100,000 people per year, largely resulting from an ongoing epidemic in Russia’s notorious prisons. A policy enacted in 2005 helped initiate a decline in TB incidence, but a new and even more daunting problem emerged: multidrug-resistant tuberculosis (MDR-TB). Although overall TB incidence has diminished to 75 cases per 100,000 people, MDR-TB is becoming more prominent, representing 21.4% of new cases in 2013.32 Furthermore, a HIV-positive patient is more likely to develop MDR-TB than a patient without HIV, so the increase in prevalence is likely tied to the emerging HIV epidemic.33 Thus, as the HIV epidemic continues to worsen, MDR-TB will likely grow, as well.

 

RUSSIA IN PERSPECTIVE

Even chronic health problems typically shared by all developed countries are substantially more prevalent and deadly in Russia. The most common cause of death in Russia, for instance, is cardiovascular disease, which accounts for 57% of all deaths. The main driver of cardiovascular disease is high blood pressure and an estimated 39.7% of Russian adults suffer from hypertension, as compared to 29% of American adults.34 Institutional failure contributes significantly to this disparity. The Russian healthcare system tends to allocate most of its attention and resources to acute issues, rather than to effective long-term treatment of chronic disease.18 Hypertension is difficult to treat due to poor adherence to medication, comorbidities such as obesity and smoking, and failure to execute recommended lifestyle changes. Instead of providing long-term treatment after a severe cardiovascular event or allowing people to die, it would be more effective to divert funds to programs such as smoking cessation interventions and nutritional counseling. It is estimated that improved hypertension treatment alone could increase life expectancy in Russia by 0.93 years.34

President Vladimir Putin

President Vladimir Putin. shown here with other world leaders at the Global Fund to Fight AIDS, Tuberculosis and Malaria. Since this July 2001 photo, Russia’s AIDS and MDR-TB crises have continued to worsen. Source: http://www.kremlin.ru.

Russia also leads the world in tobacco use. At 60% of the male adult population, and 39% of the entire adult population, Russia has the highest prevalence of smokers in the world.35 Approximately a third of all cancers worldwide result from tobacco use, and that number grows even higher in Russia.36 Smoking causes an estimated 332,000 deaths in Russia each year, accounting for up to 30% of all male deaths. Not only does smoking cost Russian lives, but smoking also demands more than 125 billion rubles (1.9 billion USD) from Russia’s health system each year. The World Health Organization (WHO) recommends higher taxes, smoke-free laws to reduce the risk of secondhand smoke, a ban on advertising, and provision of cessation programs to reduce smoking in Eastern Europe. Until 2010, no law to limit smoking had been proposed. As late as 2008, the Duma actually acted to prevent the WHO from providing its own programs to reduce tobacco use. Finally, in 2010, Putin mandated that the Duma pass regulation to limit public smoking, but due to industry opposition, including that of members of the Duma who represent key figures in the tobacco industry, this effort met significant resistance.35 It took three years for any regulation to pass, and even then, the legislation was minimal: smoking was banned in schools, hospitals, government institutions, train stations, and airports.36 Even more discouraging is the fact that an estimated quarter of all Russian youths smoke. Another obstacle to an effective anti-tobacco policy is the popular view, even among healthcare workers, that smoking is a psychiatric disorder, with no physiological component. The main treatments offered to assist people in quitting rely on hypnosis, acupuncture, and cognitive behavioral therapies. Additionally, most addiction treatment centers are inundated with alcoholics and IV drug users, so treating smokers remains a low priority.35

The government under Putin has done little to address the failings in its health care system and, in many ways, has made matters worse. Putin himself has exacerbated the stigma surrounding HIV with his support for Russia’s “anti-propaganda” bill in 2013, which banned teaching minors about “non-traditional relationships” or ever communicating about homosexual relations in a positive context.37,38 Laws such as these effectively prevent the education necessary to reduce transmission, and increase the stigma among healthcare workers and the general population.38

Additionally, the health of marginalized groups remains a very low priority for government funding. It is difficult to know exact numbers because historically, Russia’s Health Services Ministry has misrepresented health data, but, as of 2011, only an estimated 5% of people with HIV were receiving lifesaving antiretroviral therapy (ART).25 In large part, this small percentage resulted from the high cost of ART in Russia as compared to other countries and, because of the chronic underfunding of hospitals, the full cost of treatment often falls upon those with the disease.39

The insufficiency of policies to combat opioid addiction further demonstrates Russia’s shortsightedness. Most doctors worldwide classify opioid addiction as a chronic, relapsing mental disorder. The Russian medical system, however, focuses on the acute symptoms of drug use, and largely ignores the rest. The most effective treatment centers are largely funded by international donors, and state-funded hospitals and clinics tend to fall short in comparison. Furthermore, Russia’s stovepiped system of treatment promotes the comorbidity of opioid addiction and HIV.7 Opioid addiction is treated in one specialized medical center, and HIV in another, so it can be nearly impossible to receive treatment for both at the same time.

Worse still is that, in spite of the rampant health issues facing the population, Putin has enacted policies that reward downsizing the healthcare system. This “optimization” officially began in 2013, but the effort to cut healthcare costs began well before that. Between 2005 and 2013, the number of healthcare providers was cut from 8,249 to 2,085, and in rural areas fell from 2,631 to 124.40 As a result, mortality rates continue to climb. In 2014, overall mortality increased 2.6% from the 2013 rate. In the first two months of 2015 alone, mortality climbed 2.2% above that of the same period in 2014.41 These mortality increases likely result directly from downsizing. Health care workers are being laid off in droves, despite a severe shortage.5,41 There are now 64,900 doctors in Russia, and, if the plan is followed, there will be only 50,800 by 2018.42 With the system already struggling and ineffective, it is hard to imagine a justification for further reductions in care.

Given plunging oil prices and economic sanctions against Russia, the government claims that cutbacks in healthcare spending are necessary. Indeed, the Russian economy is predicted to contract by 4% this year.43 Another driver for these cuts, however, is the dramatic increase in military spending and intervention.44 The government’s military spending has reached record high levels, at 3.1 trillion rubles per year, or about 50 billion USD.45 Military spending makes up 4.4% of Russia’s GDP, an increase from 2.6% in 2012, when Putin assumed the presidency, and now drains 34% of Russia’s total federal budget.40,46 Meanwhile, since the beginning of 2015 alone, the number of people below the poverty line has increased 3.1 million to 22.9 million, meaning that one in five Russian adults is now considered officially “poor.”47

The average man in Russia dies before he reaches the age of 65, whereas the average American man lives to the age of 76 or above. If Russia wants to bridge this gap, it must adopt effective policies to prevent chronic disease and improve patient care. Vodka and tobacco sales need increased regulation and higher prices. Homophobia and the resulting HIV stigma must be addressed, or HIV will become Russia’s most significant health issue. Russia needs to reduce corruption within its medical system, and policies must be enacted to ensure higher standards for both doctors and nurses. Hospitals should be streamlined, rather than compartmentalized.  And, most important, funding to the hospitals needs to be increased.

Russia is in the midst of a massive, largely ignored public health crisis. Although considered a superpower due to its vast natural resources and military spending, Russia stands out for its overwhelmingly poor health as well. Many preexisting societal circumstances have contributed to the emergence of disease, but negligent and corrupt government actions have exacerbated problems, allowing them to become endemic. These missteps have already caused life expectancy in Russia to fall thirteen years below that of any other developed nation, and the consequences will only increase if Russia’s leaders continue to enact policies that ignore the best interests of its populace.
Chaney Kalinich is a sophomore in Davenport College planning to major in Molecular Biophysics & Biochemistry. She can be contacted at chaney.kalinich@yale.edu.

__________

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