|
|
|
|
|
|
08.02.08
|
Russia Profile Weekly Experts Panel: Fighting For Russia’s Health
|
|
|
Introduced by Vladimir Frolov
|
Contributors: Stephen Blank, Eugene Kolesnikov, Ira Straus, Gerhard Symons
Dmitry Medvedev, as Russia’s most likely third President, will soon have his hands full dealing with Russia’s serious social problems – from reforming the outdated pension system, now headed for inevitable bankruptcy, to refurbishing the country’s dilapidated health care system.
Russia’s government-funded health care system is in shambles. Each year, 1.3 million Russians die from cardiovascular disease and another 300,000 die of cancer. The average life expectancy for a Russian man – 59 years – is almost 20 years shorter than men in Western Europe or the United States, where life expectancy averages 75 to 76 years. Life expectancy for Russian women is 10 years less than in Western Europe or the United States – 72 years, compared with 82 to 83.
Russia is the only developed country in the world that has seen a decline in its population’s lifespan over the last 40 years, while death rates in certain working age groups have doubled. Russia’s population fell from 149 million in 1992 to 141 million in 2007.
The Russian healthcare system is seriously underfunded. Current public health care expenditure in Russia is 3.7 percent of GDP, compared with the EU average of 7.1 percent of GDP.
Only with the introduction of the National Projects in 2005 did Russia begin addressing its mortality problem. The Russian government has spent over $2 billion dollars on different health care improvements, including construction of 15 regional high-tech hospitals for innovative treatment of the most serious diseases.
During 2006 and the first half of 2007, the population decline began to slow down. From 2003, when the number of deaths exceeded the number of births by almost 800,000, population decline dropped significantly to 532,600 in 2006 and around 500,000 in 2007. The number of deaths in 2006 decreased by 138,000. It was the first year in a long time in which death rates actually fell, not rose; the death rate decreased from 15.3 per 1,000 people in 2006 to 14.7 in 2007.
Birth rates also increased, due to greater economic stability and rising incomes, as well as a special federal benefits program that allocates a $10,000 “mother’s capital” for all women giving birth to a second child. According to the latest Russian Health Ministry report, the number of births in 2007 – 1.6 million – was the highest since 1991, almost 123,000 more than in 2006.
The Health Ministry estimates that by 2011, birth rates will balance out death rates at 12 to 13 per 1,000 people and the demographic decline will stop.
But the Russian healthcare system continues to be inefficient and rundown by Western standards. The quality of care is substandard and unworthy of a great nation. Russians face daily humiliations in getting access to needed treatments. Drug insurance programs, administered by the government, do not provide universal coverage, and their underfunding has led to deficits of the most expensive innovative drugs, which are mostly imported. Many people cannot afford quality medical care and medicines. Private health insurance programs usually provide for only basic treatment.
There are serious political and national security implications of Russia’s demographic situation. Whether it will improve or continue to decline will largely depend on whether the improvements in health care and drug coverage will decrease mortality rates from preventable and treatable diseases.
Will Russia be able to overcome its demographic crisis? Or will death rates rise again if the health care system is not reformed and effective healthcare and drug insurance programs are not introduced? How will Russia’s demographics influence the country’s economic growth and regional development (particularly the stark disparity in population levels between Russian regions)? How will the country’s health problems affect Russia’s ability to field a viable military force? How will the AIDS epidemic play out in Russia? What about drug resistant TB? Will Medvedev and Putin be able to cope with Russia’s health problems? What can the West do to help Russia modernize its healthcare system and solve the most urgent health care problems?
--------------------------------------------------------------------------------
Gerhard Symons, Doctoral Researcher, Centre for Health Management, Tanaka Business School, Imperial College London:
It is widely acknowledged that Russia has the highest prevalence of AIDS in Europe, with approximately 940,000 people living with HIV in Russia at the end of 2005. Furthermore, Russia shoulders the 12th highest global burden of tuberculosis (TB). As an opportunistic infection disproportionately affecting an immuno-compromised population, TB is the leading cause of death in people with AIDS, with both communicable diseases considered a dual epidemic in Russia.
To combat TB and HIV, the government financially supports a heavily-staffed, extensive, yet ineffective, secondary care network for TB, with $513 million committed to TB programs, which is by far the highest disbursement of public funds for TB globally. Donors such as the World Health Organization (WHO), the World Bank, and the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM) spend tens of millions each year in Russia in the fight against TB and HIV. In addition, AIDS programs alone consumed 0.5 percent of Russia’s one trillion ruble ($40.7 billion) health care budget in 2007.
To date, this investment has had mixed success; in terms of HIV/AIDS, newly-reported annual HIV cases have stabilized since 2002. With continued vigilance and the scaling-up of harm reduction programs amongst intravenous drug users, the “South Africa scenario” (12 percent of the total population living with HIV) is less likely to develop in Russia. In terms of TB, the adoption of WHO-approved TB treatment protocols is still diffusing through Russian medical practice. Physician resistance to this perceived Western method has led to the increasing rate of multi-drug resistance to the two best forms of TB pharmacological treatment (MDR-TB) in Russia. Although we may be on the verge of an inexorable rise of extensively drug-resistant TB (XDR-TB) in certain populations in Russia and a concomitant increase in the death rate in people with AIDS, a quarantine scenario described by the Washington CSIS is not currently recommended by the WHO for tuberculosis control.
Considering the vast economic and political capital expended on TB and HIV by the Russian government and Western donors, it may be surprising that more people actually die in Russia due to homicides (30,000 in 1999) and fatal road traffic accidents combined (34,000 in 2004), than of AIDS (56,000 in 2005). Indeed, non-communicable diseases and injuries comprise the top ten leading causes of mortality in Russia with poisoning (no.3), liver cirrhosis (no.10), self-inflicted injuries (no.4), violence (no.6), road traffic accidents (no.7) and respiratory, stomach and colon cancers (no.5,8,9 respectively) included in the top 10.
Yet, a significant barrier to Russia’s economic growth is the combination of ischaemic heart disease (no.1) and cerebrovascular disease (no.2) – heart attacks and strokes – comprising 51.8 percent of all deaths in 2002. It was estimated that death from cardiovascular disease (and diabetes) cost Russia $11 billion in national income in 2005, and that from 2005 to 2015, the cumulative losses will amount to more than $300 billion.
With Russia, the problem is easier to define than a solution. However, one place to start is by identifying the risk factors that increase the probability of preventable death. It has been estimated that three risk factors - smoking, high blood pressure, and high cholesterol - contribute to more than 75 percent of Russia’s annual mortality. However Russia’s health system, inherited from the Soviet Union, and comprising 609,000 physicians staffing 29,000 hospitals, polyclinics, and emergency care stations, is focused on curative rather than preventative medicine.
Russia’s population is slowly sinking at the intersection between communicable diseases of the developing world (TB/HIV), non-communicable diseases of the developed world (cardiovascular disease, cancer), and symptoms of social decay - suicide, alcohol abuse, homicide.
--------------------------------------------------------------------------------
Professor Stephen Blank, the US Army War College, Carslile Barracks, PA :
I noticed that in his introduction, Vladimir Frolov did not mention drug use and sexually transmitted disease, which are also wreaking havoc among the Russian population and affecting mortality and natality rates. These figures, if anything, add to the dimensions of the overall health crisis and cannot be overlooked in any attempt to come to terms with this scourge. Global warming, if unchecked, also feeds into this problem. The same holds true for the environmental pollution of Russia through misguided industrial and nuclear policies. Thus this problem is even larger than Frolov suggests and certainly much more multidimensional, even though every remedy he suggests is very much to the point.
The impact of this scourge will be felt across the country and will affect national security issues. A rational defense policy would see that this decline in population spells the end for good of the mass conscription army. Nonetheless, and for all the talk of professionalism starting this year, a professional army does not mean in Russia what it does in the West, and there is overwhelming evidence that the Russian military still thinks in terms of wars where it will have to mobilize the entire country, and also still wants the benefits of what Herzen called baptized property or serf labor for its own material benefit. Medvedev needs to break this resistance once and for all if Russia is to have a 21st century military that can effectively defend against real threats to security rather than a lead-footed colossus that is rearming itself with nuclear missiles, as is now the case. Secondly, the labor shortage will drive up the price of labor, which is already not very productive, and further handicap Russia in global economic competition. Given Russia's technological backwardness, it must find a way to catch up and substitute high-tech work for the missing labor, because immigration from Central Asia will not produce high-quality labor even if it comes en masse. Most probably, the population disparities on a regional basis will cause a further decline in the ability of the Russian Far East to compete in the global economy on a non-criminalized basis, and this has significant long-term and negative implications for Russia's entire "Ostpolitik" towards Asian countries.
At home, the Medvedev regime will have to invest even more money in creating an effective pension system for the elderly, which will soon grow very large given the birth rate boom after World War II. Moreover, it must build hospitals and free up the acquisition of medicines and adequate medical care for the population. This also means more money for research and for investment in contemporary medical technology. The pent-up demand for such investment will undoubtedly generate inflationary pressures in the economy, especially if energy prices fall or if Russia cannot use the current structure to satisfy rising domestic and foreign demand for its energy, and must pay ever-higher prices for Central Asian energy as increasingly appears to be the case. And these investments must occur as Medvedev and company try to diversify the economy. This is only a snapshot of the problems pointed to by Frolov, but it reveals just how extensive domestic reconstruction must be in the next few years if the country is to move forward socially and economically, as well as militarily.
--------------------------------------------------------------------------------
Ira Straus, US Coordinator, Committee on Russia in NATO, Washington, DC :
The main problem with Russia's demographic decline is not the high death rate, but the low birth rate. This is something it shares with the entire West and the entire developed world as a whole. The falling birth rate dates back several decades in all developed countries. It reflects deep cultural trends that have permeated Russia together with the West, and its continuity across the Cold War divide illuminates an interconnection between Russian and Western society on the most intimate level, that of sexual conduct and fertility, despite a literal iron curtain between the societies.
No separate Russian national policies can have much impact on this, nor can Russian nationalistic policies, imitating the Islamist and fundamentalist practice of promoting population growth as an instrument of collective power and struggle against enemies, which would put Russia "in bed,” so to speak, with the very sources of its demographic fears. Rather, it can be overcome only by an equally deep alteration of a cultural trend, permeating all Western and developed countries.
The counter-trend, or the adaptation of modern society to the new experience of a deficit of births, has already begun. However, it will require decades for it to have much impact on birth rates; it had originally required many decades for the fear of excessive population growth – which began with Thomas Malthus' essay on population – to translate into Victorian morality, a re-direction of societal approval from large to small families, birth control, family planning and, finally, plummeting birth rates. A revised modern moral doctrine is emerging, favoring a somewhat higher stabilizing birth rate. However, it will be able to solidify only if Western society recovers its general doctrinal morale and only if the environmental dangers concomitant to population are ameliorated and set on a path to being overcome.
Broadly, the sources of the "birth dearth" are threefold: modernization (education and jobs for women, general extended education, extended childhood, urbanization, secularism, individualism), the fear of overpopulation, and the recent loss of morale of the modern societies about their role in the world.
What can be changed in this triad?
Modernization is here to stay; only in secondary aspects can it be amended. People are not about to give up their education and women are not about to give up their rights.
The fear of overpopulation can be altered greatly. It is already in the process of changing in developed societies as the birth deficit grows. However, its thorough, sustainable alteration requires a more adequate dealing with the related environmental problems.
The general loss of morale of the Western and modern societies can in principle also be overcome, and some of the processes of overcoming it have already begun. The loss of morale began with the internecine World Wars of the West and the subsequent Cold War, with nuclear weapons leading to the realization that the growth of modern human power was leading to a growing danger of annihilation of humanity. Demoralization became prevalent in the 1960s in the West, and even more deeply in the East where it fit together with the slow general breakdown of the totalitarian order. The basis for recovering morale lies in the fact of the ending of these three global conflicts on Western democratic terms, coupled with the formation of a Euro-Atlantic institutional order in which all but one of the great power conflicts of the classical European world have been transcended. The ending of the last of the three conflicts in 1991 opened the door for transcending also the last of those great power conflicts, for consolidating a wider pan-Western unity, and for rebuilding morale more thoroughly; but it has not happened. This displacement or demoralization was never overcome, not even in the 1990s when the end of the Cold War made nonsense of the 1960s left-neutralist arguments against the Euro-Atlantic system. The Euro-Atlantic doctrine was left in cold storage, rarely updated even among the elites that worked the collective Western institutions, and unknown to wider public of new generations. Its revival would require something more than a PR offensive by ideological workers; it would require further steps in deepening the unity of the Western world, extending its competences to new relevant spheres and making it more visible and comprehensible (as in the "Union of the West" proposed in the latest book of former French Gaullist Prime Minister Edouard Balladur), and incorporating Russia more fully into it. In sum, recovery of Western morale will come in a sustainable way only if there is more deeply united West with an updated doctrine of global responsibility.
How long it will take to change from Malthusian to post-Malthusian fears and doctrines, to set environmental problems onto a course of being dealt with adequately, to deepen and update Western unity, and to bring Russia into the Western system? There are trends toward all these changes, but not adequate, much less nearing to full consummation. Evidently the recovery of birthrates will go slowly and unsurely. Which means temptations will persist, particularly in Russia, for trying to revive morale in the opposite, quick, but ultimately self-defeating way of nationalist sentiment.
--------------------------------------------------------------------------------
Eugene Kolesnikov, Private Consultant, the Netherlands:
Many people believe that demography is Russia's Achilles' heel. It certainly looks this way when comparing the UN estimate of Russia's population decline from the current 141 million to 107 million by 2050 with the projected U.S. population growth from 300 million to 402 million during the same period. This projected decline is exacerbated by a population that is aging and the looming, if not already acute, shortage of workers that threatens to stymie economic growth. The two fundamental demographic issues thus facing Russia are whether the decline can be reversed in the long term and how to deal with the shortage of the working age population in the short-to medium-term.
Coping with these two issues is a matter of national survival. This is fully recognized by the government, as is evident from President Vladimir Putin's state of the nation addresses, the adoption of the Strategy for Demographic Development, the inclusion of demography and health care into the National Projects and recent changes in migration policies.
It is too early to judge how well the state is managing these existential threats and whether it can be successful. The pre-election fanfare about the growth in the number of births and decline in number of deaths cannot mask the fact that the measures undertaken so far have just scratched the surface of the problem. Nearly all Western – and a large number of Russian – analysts hold a pessimistic view. Only a real optimist can see a light at the end of the tunnel. I belong to the optimists' camp and believe that Russia has a real fighting chance to overcome its demographic challenge.
Let's start with the population dynamics. In simple terms, it is a factor of birth rates, life expectancy and migration. Polls show that majority of young Russians want a family with several children. Improved economic wellbeing, pro-family policies, such as the mother’s capital and accessible kindergartens, along with a family-friendly moral atmosphere in society may relatively quickly results in higher birth rates. History provides many examples of this – the Western baby boom of the 1960s is a case in point.
Life expectancy largely depends on economic well-being and the state of health care. In Russia, economic well-being is on the rise. Health care, unfortunately, is in the state of complete disrepair. Injections of cash through the national projects cannot radically change the situation. Extreme underfinancing for 20 years and foolish, if not outright destructive, experimentation with insurance models have to be replaced by a sound, centralized healthcare strategy and steep increase in investment. This is within the capability of the state. Qualitative improvement in economic well-being and healthcare will solve the problems of AIDS, TB and non-communicable diseases.
Migration trends are on Russia's side. Currently, Russia's population is not 141 million; it is probably 150 million if you count both legal and illegal immigrants. It is quite reasonable to expect that, over time, 8 to10 million immigrants will settle in Russia, giving it a population boost. Russia can absorb this number of immigrants, even if the majority of them are from Muslim countries. In fact, this process is well under way. Repatriation from the CIS countries can add another million or two.
The problem of the short- and medium- term shortage of the working age population is also solvable. All too many demographers and economists see no alternative to massive immigration far beyond the 10 to 15 million that Russia can absorb. This would be a cultural catastrophe for Russia. Fortunately there are other alternatives.
The Center for Strategic Studies estimates that up to 4 to 5 million working age people can be released into the economy over the next 10 to 5 years from decreasing the bloated bureaucracy, easing internal migration and including the currently idle disabled population. Several million can come to the job market as a result of increased productivity in the industrial and agricultural sectors. Russia can also follow the example of the United Arab Emirates in sourcing a construction work force for large projects. The UAE extensively uses an inexpensive workforce from India, the Philippines, Pakistan and Bangladesh, but imports these workers on a strictly temporary basis. Russia, as a centralized state, can do the same. We don’t have to look too far for a working example: over 6,000 foreign workers have been imported for the construction of the LNG plant in the Sakhalin-2 project. They live in a large town at the construction site and will be gone when the job is over.
Despite its overwhelming challenges and complexities, the Russian demographic problem can be solved. Russia is quite resilient. It lost more than 30 million in World War I, during collectivization and in World War II and recovered. It can recover again. In my view, the glass is half full. I will stick with this assessment for a couple of years until Mr. Medvedev's policies become clear enough to either reward or frustrate my optimism. |
| The source |
|
|
|
|
|
|
The virtual community for English-speaking expats and Russians
