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East: Taking The Pulse Of Post-Soviet Health Care (Part 1)

In the decade following the fall of the Soviet Union, many postcommunist countries have faced sharp declines in the quality of their health care systems. No longer protected by a centralized health sector that serviced urban centers and provincial regions alike, large segments of the post-Soviet population today find themselves denied even the most basic medical services. The picture, while generally grim, differs dramatically across the region -- from Central Europe, where nations are striving to catch up to their Western neighbors, to countries like Russia, which are seeing the resurgence of communicable diseases like tuberculosis. In the first of a five-part series on the state of health care in the former Soviet bloc, RFE/RL correspondent Alexandra Poolos speaks with an expert from the World Health Organization (WHO) about larger trends across the region.

Prague, 22 March 2002 (RFE/RL) -- The economic and social upheaval that has characterized the years following Communism's collapse in the former Soviet bloc is evident in nearly every aspect of life. Perhaps most notably, it is reflected in declining health care across the post-Soviet spectrum.

From Bulgaria to Turkmenistan, mortality rates are rising and birth rates are falling. Hospitals are understocked; doctors are underpaid. In Russia, life expectancy for men has dropped 10 years in a single decade, from 68 to 58 years. Health professionals in Moldova earn the equivalent of $12 a month. A recent survey in Ukraine showed that more than 80 percent of the population finds it difficult or impossible to obtain health care.

It's a trend, says Martin McKee of the WHO, that is closely tied to government spending cuts and the breakdown of centralized care that have accompanied the collapse of the Soviet system.

McKee says that in periods of transition when countries are engaged in building new states -- as in the case of the Soviet Union, from which 15 new nations emerged -- health is often low on the list of priorities. He adds that many of these countries also are undergoing major economic crises, which have a negative impact on health care:

"The health care system that existed in the past had many weaknesses. It's easy to look back and think everything was fine. It certainly wasn't. But it often provided a high degree of health care to people in remote areas. I think we see this especially in places like Siberia, where some degree of care was provided in a way that is much more difficult now that the system is tending to come apart," McKee says.

McKee, who has been studying the effects of post-Soviet transition on health care across the region, says that while medical care overall has declined, individual regions in the former communist bloc are suffering from their own particular problems. In Central Asia, for example, infant and maternal mortality rates, always poor by Soviet standards, have shot up even further. In Turkmenistan, mortality rates among women living in rural areas has also seen a dramatic increase.

McKee says the breakdown in health care in postcommunist countries can be seen in the rising death rate from diseases that were once easily managed during Soviet times: "We do see a breakdown of the health-care system. [The] most striking example of this is the increase in death rate of people with diabetes. We looked at the death rate among people under 50 who had diabetes and found that it had increased about eight times in Russia and Ukraine. We looked at this in more detail in Ukraine, in Lviv, and we found that although people with diabetes were able to get insulin, they were not able to get the same strength or the same type of insulin from one week to another."

Furthermore, McKee says, the collapse of medical care has been compounded by new health concerns across the region -- especially increases in alcoholism and smoking. McKee says alcoholism is contributing to a rising rate of death by injury, as well as long-term illnesses like cardiovascular disease. Smoking, he says, has increased in almost every part of the postcommunist population, including among young women.

But even more troubling, McKee says, is the rise in communicable illnesses such as tuberculosis and HIV: "There has been a significant increase in a number of communicable diseases. This is almost what one might expect in any case of major social and economic transition. It was what we saw in the Industrial Revolution in Western Europe in the 19th century. And there are lots of reasons for this. We can look at different diseases, because they each have particular risk factors. But underlying them all is the case of transition. In the case of tuberculosis, we know that we have very high rates of transmission of the disease in the prison population. And the prison population has been increasing markedly in many former Soviet countries. In the case of HIV, clearly the risk factor is the increase in commercial sex workers. But linked with that is the marked increase in injecting-drug use. The two, of course, are coming together in many cases."

Russia is dealing with a tuberculosis (TB) epidemic. Since 1991, the number of Russians with the disease has nearly tripled, with the country averaging 150,000 new cases annually. McKee says a growing proportion of TB cases in countries like Russia are proving resistant to the standard drug treatment used in the West. Although the former Soviet Union does have access to some TB drugs, poor supervision of the long-term treatment often means that new, drug-resistant strains of the disease are generated.

Central Europe, however, is the one bright spot. Health care in this region has actually progressed. McKee attributes the advances in the Czech Republic, Poland, and Hungary to these countries' proximity to the West, which has given them access to better training and working models of professional health care systems: "When we look at Central and Eastern Europe, the picture is quite different, and particularly as we go further toward the West. Largely, [health care there is much better] because of the accessibility to international literature due to the much wider use of English, which is actually very important to find out what's going on. But it's also because there were always much stronger links with the West [in this region]. So, for example, in a country like Hungary, you will find that many of the senior people in the health industry would have been able to have spent some time in the West even during the 1970s and the 1980s. That clearly was not the case for the Central Asian republics."

The loosening of borders in the former Soviet bloc, McKee says, does leave room for hope. The ability to travel freely and improved access to information is allowing many citizens in the postcommunist region to be better informed about their health options.

For now, however, it is mainly the wealthy elite who can afford to explore medical options in the West or pay for private health care at home, McKee says. The general public has yet to reap the benefits of access to Western medical care and information. And the general decline in health standards, he adds, is only likely to get worse when the cumulative effects of higher alcoholism and smoking rates begin to add up.

"It's only been a decade," McKee says. "I don't think we've even seen the worst of it yet."