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Russia: Analysis From Washington -- Promoting Federalism, Fighting Disease

Washington, 23 October 1998 (RFE/RL) -- A dramatic rise in the number of tuberculosis cases across the Russian Federation reflects a situation in which Moscow no longer has the administrative responsibility for fighting it but in which the regions do not yet have the resources to do so.

Speaking to journalists on Wednesday, Aleksandr Khomenko of Moscow's Tuberculosis Institute said that 2.5 million Russians now have the disease -- a number equal to one in every 60 residents of the country. And he pointed out that this figure is up by 8.5 percent since the beginning of 1998 alone.

One of the reasons for this development is the lack of money available to Russian hospitals and public health agencies. At present, Russia spends approximately one billion rubles -- some $62 million -- a year, an amount that works out to approximately $25 per patient.

That is far below the amount needed. For most strains of tuberculosis, treatment costs between $50 and $100, and for some new killer strains that have appeared in the Russian Federation in the last several years, treatment costs are estimated at $10,000 per person or even more.

As a result, many of those infected either remain untreated or at least uncured and thus continue to spread the highly infectious disease to those they come in contact with. That in turn means that the number of tuberculosis cases in Russia will continue to grow.

Indeed, Khomenko said: Russia "can no longer control" this situation.

The impact of Russia's declining economic fortunes and state revenues on the health of the population has already drawn a great deal of attention. But Khomenko suggested that this lack of resources had been seriously compounded by a change in the country's administrative arrangements.

During the Soviet period, he reminded his listeners, the central health ministry directed and paid for the fight against tuberculosis. But since 1991, this situation has changed: The regions are now responsible for combating the disease, and they lack both the personnel and the funding necessary to do the job.

Moreover, when one region fails in its efforts to combat tuberculosis, an outbreak there can rapidly spread elsewhere, further complicating the battle.

On Monday, for example, the government of the Altay region in southern Siberia reported that it no longer had any funds to deal with a rising number of tuberculosis cases among children, raising the specter that the disease there will quickly spread.

This human tragedy, one that international medical groups in August called on Russian President Boris Yeltsin to address, reflects an underlying and as yet unresolved political problem in the Russian Federation: a growing gap between those with responsibilities for doing something and those with the resources to do it.

In the field of public health, this gap is especially critical and obvious. But it is true in many other areas as well, including education, crime fighting, and economic development.

Both by decision and default, Moscow increasingly has left to the regions the responsibilities for taking action but has not been willing or able to devolve to the regional governments the resources that these regions need to do the job.

That situation helps to explain why many regional governors are pressing Moscow for more resources and why many in Moscow appear increasingly willing to argue that responsibility as well as resources should be returned to the center.

In the short term, a return to the more centralized pattern of the past might help to alleviate the human suffering that tuberculosis and other diseases have inflicted on the Russian people.

But in the longer term, matching resources with responsibilities at the local and regional level appears more likely to allow Russia to overcome the plague of tuberculosis as well as the other challenges of fiscal and political federalism.