TB spreads in Russia as government chops health funds
By Renfrey Clarke
MOSCOW — At about 2.5% of GDP, health spending in Russia last year compared poorly with western European levels of 7-8%. That was before the cost-cutters lopped another 4% from health care allocations in the 1998 budget.
Health care, the new Russian orthodoxy runs, should become a private responsibility. Unfortunately, no one has explained this to the country's bacteria.
The result is that infectious diseases have made a spectacular comeback. Cholera, typhus, diphtheria, malaria — all are to be had in the new, free-market society.
The big killer is tuberculosis, which killed around 25,000 Russians in 1997, even though it is regarded in the west as normally curable. In retreat during the final decades of the Soviet Union, the incidence of tuberculosis almost doubled in Russia between 1991 and 1996. More than 2 million people are believed to be infected now.
The classic neo-liberal disease, tuberculosis preys above all on the people who fall through the cracks of an uncaring society. In normal circumstances, people are protected against it by their immunological defences. But in individuals who are ill-fed or under high levels of stress, these defences can break down. In the west, efforts to wipe out tuberculosis have been thwarted by its return among the growing number of homeless people.
In Russia as well, the new legions of homeless — refugees from regional wars and victims of housing rackets, as well as women and children fleeing domestic violence — are a major pool of infection. The centre of the epidemic, however, is in the prisons.
Widespread crime and a primitive, get-tough response from the state have meant that around a million Russian citizens are now in custody. Prison conditions — heavy overcrowding, poor ventilation and inadequate food — allow tuberculosis to thrive. Between 20 and 30% of prison inmates are believed to have an active form of the disease.
Health care is rarely a priority for prison administrators, who are often short of money to buy food for inmates and to pay warders' wages. Prison hospitals have room for only a fraction of the number of seriously ill prisoners and often lack even the most common medicines. Consequently, when thousands of prisoners are released each year after serving their sentences, they take with them active cases of tuberculosis. Estimates of the proportion of former prisoners among tuberculosis sufferers in Russia range as high as 60%
On the outside, only a small minority of ex-prisoners with tuberculosis register with dispensaries and obtain treatment. This is partly because of the methods of treatment used. Though successful in Soviet times in reducing the number of sufferers, these techniques are old-fashioned by western standards, relying heavily on the isolation of patients in a network of sanatoriums. From one type of confinement, former prisoners are thus required to move on to another.
The practice of shutting patients away also deters other sufferers from seeking treatment; in post-Soviet society, the loss of a family breadwinner can mean near-starvation for his or her dependents.
In the west, tuberculosis is now usually treated on an out- patient basis, with good nutrition and a cocktail of antibiotics. Cures are typically achieved in six months, compared with two years for the Soviet-style methods, and cost far less.
While aid workers and some doctors have sought to introduce these methods to Russia, progress has been slow. As well as resistance from sanatorium staff who face redundancy, there is suspicion of the western practices among health officials, many of whom gained their posts on the basis of contacts rather than competence.
Meanwhile, cuts to health funding mean that the Soviet system of tuberculosis treatment is disintegrating, at the same time as the number of new sufferers is increasing at a rate of 10 to 15% a year. From being a disease of social outcasts, tuberculosis is beginning to spread into the broad working population.
Experience in Third World countries suggests that even the small funds now available in Russia for tuberculosis prevention and cure would be enough to contain the epidemic, if modern methods of treatment were consistently applied. But the problem is not simply prejudice or bureaucratism. The new state regime in Russia has transformed the whole basis on which society is organised; it would be quite capable of revamping the health system, and even of reforming the prisons, if it chose to do so.
The crucial problem is that Russia's "reformers", unlike even the Soviet apparatchiks of past decades, do not care enough about the general population to stop a public health disaster. Despite abundant publicity, and efforts within the health ministry to devise an urgent anti-tuberculosis program, the 1998 state budget makes no mention of funding for any specific program to combat the epidemic.
Tuberculosis is running wild in Russia for exactly the same reason it maintains a stubborn presence on the streets of New York: to the practitioners of capitalist "economic rationalism", the sufferings of the poor are a necessity, to be lamented but not seriously combated.