December 26, 1997
Since the breakup of the USSR in 1991, Russia's public health care system has fallen into disarray with horrific results.
MARGARET WARNER: Now, a look at health care problems in the former Soviet Union. The breakup of the USSR in 1991 shattered the public health system in Russia and the other former republics with dramatic results. The life expectancy for a Russian male, which used to be in the mid 60's, has dropped to 58. The life expectancy for an American male is 74. In 1995, Russia's death rate was one and a half times greater than its birthrate, triggering an unprecedented declined in population for a peacetime era, and a Russian child is two and a half times more likely to die before age five than an American child. To find out why all this is happening Elizabeth Farnsworth recently interviewed Newsday Correspondent Laurie Garrett. She traveled to Russia earlier this year and completed a major series about the problems there.
ELIZABETH FARNSWORTH: Thanks for being with us, Laurie. Why did you do this? What did you see? What kind of figures were you seeing that made you devote eight months of your life to this?
LAURIE GARRETT, Newsday: Starting in 1991 and ‘92, UNICEF started releasing these reports, calling this the most dramatic shift in peacetime history, comparing what was going to what happened in the United States during the Great Depression in terms of all your basic health markers, life expectancy, infant mortality, child mortality, birthrates. The numbers were so astonishing I said we have to find out what's going on here. It's too easy to just say it's because of social change.
ELIZABETH FARNSWORTH: Why? Why did the break-up of the Soviet Union lead to this?
LAURIE GARRETT: Well, first of all, we now know some of this preceded the break-up. Some of it's because of policies going back to the Soviet period. But we also can see that there have been severe economic transformations and the collapse of the essential infrastructure, which used to be very centralized, very Moscow, dictated down to all the little republics all over the system, now those are all independent nations, and pieces of the system don't work anymore.
ELIZABETH FARNSWORTH: Let's begin with the hospitals and clinics. You tell really--to me, it was very surprising stories about the lack of infection control, even in hospitals and clinics in the big cities. Tell us about that.
LAURIE GARRETT: It's fairly startling. Under the Stalinist system any larger infrastructure, which medicine certainly qualified as, had to have a parallel policing infrastructure that would keep eyes on the other guys, make sure they didn't deviate from the party line. Parallel infrastructure in the case of medicine was something called sanitation and epidemiology. And SANAP would basically function like cops. So there was tremendous contention between the very people you would want to be spotting infectious disease problems and alerting them, alerting the physicians to make the appropriate changes. Instead, these people were viewed as cops. They would come marching in, and they would take samples off the walls of the hospital, on the floors, and the ceilings, and go back to the lab and culture them, and if they found streptococcus, for example, some doctor got in big trouble. So the result is that tremendous amount of energy is spent even now scrubbing the walls. You can walk into a hospital that will reek of chlorine and yet, when you see the procedures, the physicians will wash their hands, if they wash them, with a commonly-shared bar of soap, a commonly-shared towel. You will see bare-handed nurses changing IV drips, changing catheters, and changing shunts--bare-handed. There's just not a sense that this is your most likely mode of transmission of disease within a hospital.
ELIZABETH FARNSWORTH: And in some cases you wrote that there's no money for gloves, no money for towels.
LAURIE GARRETT: No money for anything. I mean, many physicians have gone unpaid for six months to a year across the region. We're not just talking here about Russia--the whole region. And--
ELIZABETH FARNSWORTH: And we have a picture of this in Georgia, some of the--ways of washing. Tell us about that.
LAURIE GARRETT: This was a particularly horrendous episode. I came into a hospital in Central Georgia, the nation of Georgia. And there was a hernial re-sectioning procedure going on. In the middle of it the scrub nurse, who you see in the foreground in this picture, picked up a bunch of surgical instruments that were bloodied, walked over to this standing pot of water, dipped them in the cold water, sort of air-dried them, and came back, and they went right back into the patient.
ELIZABETH FARNSWORTH: And as a result of this, drug-resistant staph, for example, is killing people. Tell us about that.
LAURIE GARRETT: Well, when you combine the lack of appropriate infection control with widespread misuse of antibiotics, and, in fact, just massive antibiotic underground. What you end up getting is the breeding of drug-resistant strains of streptococcus, staphylococcus, every garden variety infection you can think of.
ELIZABETH FARNSWORTH: Let me interrupt you just one second. By misuse of antibiotics, you mean using them for not the prescribed time, or using three or four, or what do you mean?
LAURIE GARRETT: Well, you may not even have prescriptions. It's simply--(coughing)--I don't feel well, what should I take--well, here, try these third-generation Sulfalasporin antibiotics. Any physician listening to this will cringe at the idea that someone who simply is running a mild fever and coughing should be given what we consider, you know, top-of-the-line antibiotics, final stage treatment. And any time you misuse antibiotics you run the risk of creating a resistant strain.
ELIZABETH FARNSWORTH: And we have a picture of this to a drug-resistant--somebody who's suffering from staph. Tell us about this.
LAURIE GARRETT: This is little Irakli. He's so malnourished that it's hard to believe he's 15 years old, again, in Georgia. He got a streptococcus infection, probably just a standard garden variety cut, but he was given one round of antibiotics after another, and eventually, because of the poverty of his family and their inability to purchase adequate antibiotic treatment, the streptococcus mutated or developed resistance, and, as you can see, ate through the skin, into his bones, into his heart, and eventually, I'm quite certain by now he is deceased.
ELIZABETH FARNSWORTH: And you write about an epidemic of tuberculosis. Tell us about that.
LAURIE GARRETT: TB is out of control, positively, completely out of control. To put this in perspective in 1991 we decided we had an out of control TB epidemic in the United States when the incidence reached 9.2 per 100,000 in New York City, with a total nationwide of 26,000 active cases. There's 145,000 active cases of tuberculosis in Russia alone. You go across the region and TB is simply raging. In the Buryatia Republic, which you see pictured now, where the ethnic Buryatis of Mongolian blood for one reason or another--
ELIZABETH FARNSWORTH: It's just North of Mongolia.
LAURIE GARRETT: Just North of Mongolia on the East side of Lake Vaykal in Siberia. They are especially vulnerable. And right now the incidence of TB in that population is approaching being the highest in the world, beating out South Africa.
ELIZABETH FARNSWORTH: Why is this happening? Why is TB so much worse than it was before?
LAURIE GARRETT: Well, first, it was climbing, we now know, at a rate of about 5 percent a year throughout the 1980's. So the system was already beginning to fail to deal with TB then. It's an old-fashioned system based on sanatoriums. If I identified as a Russian physician that you, Elizabeth Farnsworth, had TB, you would no longer be able to work; you would be removed from your family; you'd spend a couple of years in a sanatorium until I could prove you're absolutely disease free, and then you might be allowed back on the job. Well, obviously, once you no longer have a totalitarian state, it's pretty hard to enforce such a system and make people say, oh, test me for TB because I'd like you to throw me away for two years. So you have more and more untreated TB that goes to very advanced stages, highly contagious stages, before getting treatment. You have massive drug shortages and inappropriate use, so they're breeding drug-resistant strains. And the final piece of that is about 30 percent of all the tuberculosis is in the jails, and the jail system is just woefully overcrowded because they're also trying to transform a criminal justice system, but they don't have a lot of people who know how to be defense attorneys, who know how to do trials and know how to sit in court, so at any given time 20 to 40 percent of people in prison have never had a trial. And so the jails are just packed with tuberculosis spreading inside.
ELIZABETH FARNSWORTH: You said some jails have--50 percent of the people have TB, is that right?
LAURIE GARRETT: Yes. In fact, there is at least one jail I can identify in Siberia that has 70 percent of the jail population had had TB.
ELIZABETH FARNSWORTH: And you write a lot about AIDS and how the incidence of AIDS is increasing. Tell us about that.
LAURIE GARRETT: The United Nations AIDS program has labeled the explosion of AIDS in the region to be at this time the most dangerous in the world, and the Ukrainian AIDS people referred to their explosion as an A bomb, it's growing so rapidly, so dramatically.
ELIZABETH FARNSWORTH: Mostly because of IV drug use?
LAURIE GARRETT: Yes. IV drug use is the driving force, though, there is also a huge prostitution component, and the terror of it is that when you look at the IV drug use, it's fourteen to twenty-two year olds; it's kids. You see horrible things. This picture shows you in Odessa, where I saw the highest rate of drug use I've ever seen anywhere in the world as a reporter, there in one hour I counted 500 kids walking past me buying opiate derivatives and shooting them up right in front of me in an open field.
ELIZABETH FARNSWORTH: And using the same needles over and over again?
LAURIE GARRETT: Using the same needles; sharing needles; and the hepatitis rates are astronomical. HIV is soaring in this population group, and they're kids.
ELIZABETH FARNSWORTH: What do people there say about this? Is this something that a myth--this must be something that Russians or Georgians or people in the other republics are very aware of? What did they say to you about what's happening?
LAURIE GARRETT: Well, it depends on their politics. If they come from the old Communist line of thinking, they say, you see, this just shows, we never should have allowed the West in; look what they brought us. We never had this drug abuse problem under Communism. If they come from a more--shall we say future thinking--21st century way of looking at the world--they say, it's a tragedy that we have no idea how to deal with this because our old system was you rounded up drug addicts; you locked them up; and that's the last they ever saw of the world. We don't know how to do outreach programs. We've never tried to do programs related to public health that reached out to teenagers and convinced them to change their behavior; and we need to learn how to do these things. It's an altogether new science for them.
ELIZABETH FARNSWORTH: Is some of that happening? Are people learning? Is there any good news?
LAURIE GARRETT: Well, there's a difficult point that we're at right at this moment because the key professional age group that's most enlightened, most interested, are those who grew up during perestroika and are now in their mid 30's roughly. Professionally, they are more likely to have had exposure to western medical literature, but they're also far more likely to have decided to leave the region and emigrate here or to Europe. They've lost thousands and thousands and thousands of physicians and scientists, a massive brain drain. And you can see that the time is short, very, very short for intervention in assistance because soon all that generation will have left if they can find work elsewhere.
ELIZABETH FARNSWORTH: Laurie Garrett, thanks very much for being with us.
LAURIE GARRETT: Thank you.