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The epidemic may have taken a long time to reach this region because of the strict controls once placed on the movement of people and contacts with foreigners. With the collapse of the Soviet Union in 1991, the barriers between its republics and the rest of the world tumbled down, facilitating the propagation of the virus. Today, this region has some of the fastest-growing rates of HIV infection in the world, according to the United Nations Development Program (UNDP).1
Because of the nature of the disease, measuring the extent and progression of the epidemic is a matter of educated estimates based on a variety of indexes and assumptions (see Figure). In 2003, the official Russian figure was 240,000 cases of HIV infection. The United Nations estimate was 750,000 to 1.2 million — somewhere around 1 percent of the adult population. Predictions vary widely, but some estimate that by 2020, the figure will be as high as 14.5 million.2 There is wide variation from region to region and from town to town, in other former Soviet republics and in Eastern Europe more generally, with the highest rates in the major cities. Most infected persons (about 80 percent) are younger than 30 years of age (as compared with about 30 percent in the United States).
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There have also been several iatrogenic cases resulting from the use of contaminated equipment in the vaccination of infants, as well as nosocomial infections among patients in Russia and Romania. The blood supply has often been contaminated owing to a lax testing system and a black market that arose in response to blood shortages.
The first "serious" reaction to the appearance of the disease was couched in moralistic and criminalizing terms, reflecting the Soviet culture's prudishness with regard to sexual matters. As in many other places, AIDS was seen by some as divine punishment for a sinful way of life, and its lethality was viewed as a blessing, since it would rid the world of deviants. In 1997, a group of Russian medical school graduates issued a statement proclaiming, "We are . . . categorically opposed to combating the `new disease' AIDS! We intend . . . to impede the search . . . to combat this `noble' epidemic. We are certain that . . . AIDS will destroy all drug addicts, homosexuals, and prostitutes. . . . Long live AIDS!"3
At the policy level, the initial response was characterized by indifference, as the spread of the virus was accorded the low priority that had commonly been given to health care in the Soviet Union and that remains prevalent in the region today. Then strict measures were enacted in the form of laws calling for mass testing and other drastic steps that were poorly implemented and ultimately largely abandoned. The major question was whether to focus on treatment or prevention, given grossly inadequate resources.
The medical system inherited from the Soviet Union was woefully underfinanced and poorly supplied and equipped. The medical establishment and clinicians were unaware of many Western medical advances. The collapse of the political system led to a further deterioration of health care. The UNDP estimates that in the Russian Federation, the current per capita annual expenditure for HIV infection and AIDS amounts to 5 rubles — the price of a pack of cheap cigarettes.4
Prevention is difficult: in most of the countries of the former Soviet Bloc, the medical community and the population at large know little about the nature of the disease or its transmission. Sex education was introduced in the late 1980s but has been strongly opposed by conservatives, who also see needle-exchange programs as encouraging the use of drugs.
According to the UNDP, when the prevalence of AIDS reaches about 1 percent of the adult population, it should be taken as a warning signal that a tipping point has been reached. If the epidemic is not addressed with drastic and effective measures, it becomes difficult to constrain or reverse.
The conditions that would permit such a change are multifactorial, involving many segments of society. Leadership, responsibility, transparency, democracy, and broad cooperation are required, as is the investment of a large amount of financial resources. On the most obvious practical level, well-equipped facilities and relatively expensive drugs are required. Efforts must be made to educate young people about high-risk behavior and the nature and transmissibility of HIV. But there are also cultural barriers to be overcome. The stigmatizing quasi-criminalization of the disease must be abandoned, and affected persons must be recognized and accepted as victims with human rights rather than perpetrators who are being punished.
In addition, such change requires the political will and full support of the governing bodies and the reform of "breeding" institutions such as the prison system. The public should be made aware not only of the social implications of the epidemic, but also of its consequences in contributing to the decline of the productive population and to an increase in the number of abandoned and orphaned children. Unless the epidemic is stopped or controlled, it will result in a sizable decrease in the gross domestic products (GDPs) of the former Soviet republics. It is estimated that the epidemic will cost these countries about 1 percent of their GDP in lost productivity annually and that health care for affected persons will cost between 1 and 3 percent of their GDP — funds that are difficult to raise in impoverished countries.1
The demographic projections are equally dismal. Since the early 1990s, the population has been decreasing steadily, and this trend is expected to continue. AIDS is expected to kill about 20 million Russians by 2025, and given the toll of tuberculosis, cardiovascular disease, and other sexually transmitted diseases such as syphilis, the population of Russia may be 100 million or lower by midcentury, as compared with 144 million in 2003, arousing concern about implications for Russian territorial integrity.5 Although the outlook is somewhat better in some other Eastern European countries, such as Poland, the legacy of the Soviet system, with its rigid authoritarianism, hinders the transparency and flexibility required for anti-AIDS efforts, as noted above.
The situation is not entirely bleak: in the face of a lack of serious engagement by the government, some steps have been taken by nongovernmental organizations, particularly foreign groups that have made some important inroads. Unfortunately, these organizations, as well as such burgeoning aspects of a civil society as free speech, have not met with great approval from Russia and other states.
The threats in the region from AIDS and other epidemics are potentially dire. Prophecies are always hazardous, but in the former Soviet Bloc, the outlook for the next few decades is perhaps best characterized by a Russian neologism invented to describe the adverse effects of the disintegration of the Soviet system: "katastroika."
Source Information
From the Davis Center of Russian and Eurasian Studies, Harvard University, Cambridge, Mass., and the Harvard School of Public Health, Boston.
References
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