Current indicia of public health in Russia, combined with substantial declines in fertility, are unprecedented in time of peace. Since the mid-1980s, a combination of plunging birthrates and excess mortality has produced a striking net decrease in population. Males born in the Philippines or Indonesia now live longer than those born in Russia.

US efforts to help Russia deal with this crisis should properly be driven by humanitarian and foreign policy goals, but these efforts are hampered by the lack of effective leadership and coherent strategy. The humanitarian rationale clearly relates to those opportunities for reducing the burden of disease and minimizing the contributors to excess or premature mortality. The foreign policy issue centers on the need to maintain a civil society by shoring up the country’s social safety net. The US interest, ultimately, is in a stable Russia—and a secure world.

This was precisely the thinking of Otto von Bismarck who, in the 1880s, introduced a program of social insurance in Germany, including health insurance. Germany, recently recovered from a war with Napoleon, was struggling with a drive toward state unification and faced a series of social changes that threatened social stability. Bismarck envisaged social welfare as a way to preserve civil order and political stability. As he observed:

A century later, US (and Western) contributions to global health and welfare have been scattered, in a highly uneven and, at times, counterproductive, fashion. Yet, there are effective contributions to be made. Successful examples of foreign assistance in the health realm in the past can provide useful evidence of how humanitarian and security interests were addressed. Above all, what is most needed is a coherent strategy and leadership.

THE HUMANITARIAN IMPERATIVE

In the case of modern-day Russia, the humanitarian argument is compelling. Until the early 1960s, the Soviet Union (along with the Warsaw Pact countries) had been showing striking improvements in mortality rates and in what is known as the epidemiologic transition, that is, the shift away from infectious diseases as major contributors to morbidity and mortality. By the mid-1960s, life expectancy at birth in Russia (and, indeed, in the USSR) trailed that in the United States by only a year. Yet, by the late 1960s, these trends had markedly and abruptly reversed. By the end of the 1980s, for the region as a whole, mortality rates were higher than they had been in the mid- to late-1960s. Further, particularly for males, those trends have continued and even accelerated downward in the past decade.

Most affected are adult males in their most productive years. One-half of this “excess” or premature mortality is due to cardiovascular disease—strokes and heart attacks—attributable, in turn, to a combination of inappropriate social habits or risk factors (smoking, alcohol, diet, obesity) and inadequate medical intervention. In this latter category, for example, is an enormous amount of unrecognized and untreated hypertension (whose sequelae are strokes and myocardial infarcts) and diabetes (whose principal complications include cardiovascular disease).

Tuberculosis is an exceptional problem. There is, at present, an epidemic of tuberculosis and, in particular, of multi-drug resistant tuberculosis, among both civilian and prison populations in Russia. An estimated 150,000 Russian civilians have active TB, of whom perhaps 6,000 (or 4%) have active multi-drug resistant TB. There are approximately 1,400,000 people in prison in Russia and the other former Soviet republics. Of these, an estimated 140,000 (10%) have TB and 20,000 have multi-drug resistant TB.

The record of excess or premature mortality in Russia has combined with a second important trend—a sharply reduced birthrate—resulting in a striking net decrease (a negative natural increase, as it is termed by demographers) in population. Since the mid-1980s, when life expectancy for Russian males showed a dramatic decline, birthrates fell by as much as two-thirds. Thus, a nation, in transition to a market economy, cannot replace itself, but is losing population at the rate of 0.4% per year. Because of the implications for an adequate labor force or the ability to field an effective army, circumstances such as these provoke national anxieties and enhance the environment for extremists.

US FOREIGN ASSISTANCE IN RUSSIAN HEALTH CARE

In 1991, the US foreign policy community suddenly faced a series of challenges (and opportunities) triggered by the dissolution of the Soviet empire. At the same time, the international financial institutions, such as the World Bank, were handed a new set of members, the former constituent nations of the Soviet bloc. The principal focus initially was serving humanitarian goals in the face of the threat of severe economic crisis in 1991.

Some of the earliest health and social assistance programs for Russia, following the dissolution of the Soviet system, were humanitarian and food assistance projects and donation of decommissioned military hospital equipment in 1992-1993. A more significant initiative began in 1992, when Secretary of State James Baker convened the Washington Coordinating Conference on Assistance to the Newly Independent States (NIS) to determine appropriate humanitarian assistance for the former Soviet states. In conjunction with this inquiry, a Medical Working Group dispatched a delegation of 30 health care professionals from 13 countries to visit medical institutions in 10 of the former Soviet republics. The Russian hosts strongly admonished the delegation to limit humanitarian assistance. A common plea from the Russian quarter was “help us to help ourselves.” The delegates foresaw a loosening of the authority of the centralized federal Ministry of Health, a further decline in the financial resources available to the health care system, and a growing number of citizens without access to care.

One of the principal outcomes of the Medical Working Group’s work was one of the more productive health initiatives in Russia supported by the US Agency for International Development (AID). This program, known as the Hospital Partnership Program, set up 26 partnership linkages between pairs of hospitals in the United States and the former Soviet republics, involving educational activities and professional exchanges concentrating on selected clinical areas.

A second successful example is the American College of Physicians program of continuing medical education for Russian physicians. Again, the currency of this program is knowledge and experience shared among professionals in a partnership arrangement. American internists, expert in hyper-tension, tuberculosis, and diabetes, share their experience on a voluntary basis with Russian counterparts in each of a series of centers in Russia, all of which are located outside of Moscow. In turn, the Russian doctors share what they have learned with a much larger group of Russian practitioners drawn from the polyclinics during the regular medical post-graduate education cycles in Russia. The clinical focus is on diseases that are major contributors to excess morbidity and mortality, and where basic, not high-technology, medical intervention would contribute to better health.

These two programs are good examples of what academic and practicing physicians can do best— impart a body of knowledge and experience to their professional counterparts. The programs confirm again that professional exchanges bring with them the highest degree of leverage. Those trained, in time, train others. On the scale of foreign assistance, these programs have been relatively inexpensive, and can be set up without intermediary assistance from AID contractors.

By far the most ambitious (and most expensive) AID-sponsored health program for the NIS (including Russia) was the Health Care Finance and Service Delivery Reform Project, ultimately known as the Health Reform Project. This project aspired to reshape the organization and financing of medical care in several regions of Russia. The reshaping was to hew to the fashions currently of interest in the United States, that is, competition, market forces, and privatization. The orientation was entirely an economic and organizational one. Clinical medicine and its practitioners were actively excluded. As the original Request for Proposal stated:

The AID contract for the Health Reform Project was awarded to an AID contractor who, in turn, enlisted a series of additional subcontractors. The principal contractor, ABT Associates, proceeded to “reform” the organization and financing of health care with an initial budget of $44 million and a proposed ultimate expenditure of $75 million. Ultimately, the entire Health Reform Project was truncated, partly at the insistence of the Russian hosts, with no little embarrassment to the American operatives.

HEALTH AS A FOREIGN POLICY ISSUE

The principal foreign policy issue here is preservation of political stability and social order in the former Soviet republics during the difficult period of economic and political transition. One may well ask whether the striking demographic record of high and increasing mortality and sharply lower birthrates is a result of the current social and economic transition, or is itself a cause of, or contributor to, social instability. The best answer is that both may be true. The demographic record is a function of social, economic, and other forces, and the resultant record may have profound consequences for the social well being of the country.

Continued mortality increases and declines in fertility make individuals increasingly aware of their poor standard of living and make societies anxious over the state of their national prowess. By now, a number of commentators have warned that a continuation of these trends could translate into unfavorable populist and political pressures.

Beginning in 1991, American economists serving as advisors to the Russian federation government proposed a large, $27 billion foreign assistance fund for Russia, to be derived, it was urged, in part from national governments, and in part from international financial institutions. Nearly a third of the total financial assistance program was to be devoted to a “social fund,” a substantial portion of which was earmarked for health.

The proposal for a stabilizing fund was not embraced. As a result, in 1994, the advisors advocating this strategy predicted possible, serious instability, either through hyperinflation or catastrophic unemployment, not cushioned by an adequate safety net. They heralded a “contagion of antisocial behavior,” such as tax evasion, flight from domestic currency, and criminality.

Absent an overarching program of economic stabilization together with political reform, there was no corresponding social safety net component and no coherent strategy toward health. Assistance in the social safety net sector, including health, has been piecemeal and without the type of political long-term support needed for a truly successful effort. In the absence of a coherent strategy and clear direction, proffered contributions to health and medicine from many sources emerged, including from private and religious groups, individual professionals, and well-meaning citizens, without benefit of oversight or direction.

PRECEDENTS FROM THE PAST

There are some highly successful examples from the past in which health has been used explicitly as an instrument of foreign policy, with security as the overarching goal. And past US initiatives in which health care has been used as an instrument of foreign policy may suggest ways to ensure a more coherent and effective program in Russia.

In Latin America and, later, in Greece, the US government sought to meet security goals through large-scale health care programs. In Latin America, the evolving European war brought a new urgency to the task of strengthening relationships with Latin American neighbors in 1940. As the probability of war increased, many believed that the stationing of US troops and equipment at strategic locations in Latin America would become necessary. This, in turn, made it necessary to reduce threats of malaria and other hazards of endemic disease of the tropics. In addition, the US government was interested in certain natural resources, such as rubber; securing Ecuador and protecting the Panama Canal; and luring away from the Axis camp the nations of Argentina and Paraguay. The good will of the Latin nations and avoidance of political opposition were vital.

Nelson Rockefeller, then a dollar-a-year man in the Roosevelt Administration and with the strong support of the President, established an Institute for Inter-American Affairs as a quasi-governmental corporation devoted to health and medical assistance for 18 Latin American nations. Rockefeller Foundation staff members were heavily involved in this project, providing advice and talent. Those advisors impressed upon Rockefeller the importance of health as a vital element in Latin American social and economic development. Physicians and sanitary engineers were seconded from the Public Health Service and the military, and many of them remained in residence in Latin America for years. The primary objective was security and this was the manner it was presented to Congress each year.

The Institute for Inter-American Affairs and its health and medical program were extremely successful. The program, which came to a close only in 1958, was a closely collaborative one with the host governments. The program, in collaboration with the Rockefeller Foundation, built hospitals, nursing schools, and health clinics; and supported training programs for visiting nurses and health education programs for the general public. It included service, expert advice, and training of over 1,500 Latin American physicians. By 1945, 300 Latin Americans had received scholarships and travel grants to the United States.

In the second case, in Greece in 1947, the security threat was civil war and the spread of Communism. The country had barely begun to rebuild after the ravages of World War II. The nation was heavily in debt, facing the twin threats of economic collapse and possible famine.

The strong and unequivocal articulation of the Truman Doctrine led to the dispatching, in July 1947, of a combined military and civilian mission to Greece. By November, the American Mission strategy included a combination of military and physical security, and a series of thrusts designed to improve health and social welfare. Again, health was used to advance foreign policy goals, and, principally, the reestablishment of social order. All of this eventually became the last point of Truman’s Point IV foreign policy program—based in part on the pattern and success of the earlier efforts of the Institute for Inter-American Affairs.

The effort in Greece was enormously successful, lasting seven years. Specialists developed rural, potable water supplies, put in place programs to reduce malaria, and helped modernize hospitals and clinics. Physicians were once again seconded from the public and private sectors. The civil war ended and stabilization was achieved.

THE COMPONENTS OF A COHERENT STRATEGY

The successes of these two programs can help highlight the route that needs to be taken in Russia today. First of all, there needs to be a defined commitment to this matter, and a clear devotion to a strategy with defined goals. Those goals should incorporate both humanitarian as well as traditional foreign policy elements, including US security interests. A coherent strategy should take systematic account of both private and public interests that contribute to health and medicine matters in Russia. Further, as was the case of the Institute for Inter-American Affairs, a systematic effort should be made to seek out and incorporate advice and professional contributions from key, extra-governmental institutions with knowledge and long-standing experience in medicine and health in the former Soviet republics. Some of the components of a coherent strategy include:

Continuation and expansion of professional exchanges for the purpose of sharing knowledge and experience.

The magnitude of the challenge of health and medicine in Russia has frequently discouraged any investment in that sector from the outside. Yet one realistic and exceptional opportunity, the sharing of professional knowledge and experience, stands out as a particularly compelling opportunity. Seventy years of isolation from Western medicine and medical science have led to a strong appetite among Russian medical practitioners for “catching up.” The AID-sponsored Hospital Partnership Program and the program of the American College of Physicians should be expanded and reasonable continuity assured.

Pharmaceutical products and the interests of the pharmaceutical industry.

There are approximately 50 Western European, American, and Japanese pharmaceutical companies poised in Russia to satisfy a need for modern pharmacologic agents and capture a market there. American firms in the Russian market are owed between $300-$600 million, a debt worsened by the present economic crisis. As a result, those firms have ceased making drugs available to the existing Russian distribution systems. Clearly, this immediate logjam needs to be broken, but in a way that preserves the economic integrity and interests of the companies. We should examine general relationships between the US and Western pharmaceutical firms and the goals of the Russian federation and oblast governments, in line with the Russian admonition to minimize humanitarian assistance and encourage direct investment in manufacturing.

Interests of US and other Western and Japanese oil exploration companies.

An important economic sector operating in Russia with aspirations for long-term investment is the petroleum industry. These companies, in the past, have had a tradition of social investment in the communities where they have centered their operations. Most recently, two major US oil companies with interests in the Russian federation have moved to develop a broader strategy for health care both for the benefit of their immediate employees and that of the communities or territories where they are operating (“social investment”). This strategy should be encouraged and taken account of in any general consideration of health assistance for Russia.

Use of NATO as one of the vehicles for health-related programs.

Article 2 of the NATO treaty provides that member countries “...will contribute toward the further development of peaceful and friendly international relations... by promoting conditions of stability and well-being.” The existing instrument within the NATO framework is the Committee on the Challenges of Modern Society (CCMS), established in 1969 to give a “social” dimension to the organization. Areas of emphasis have included health, environment, and science. The United States strongly supported a number of health projects within the CCMS framework in the 1970s. At present, a single health program (Advanced Cancer Risk Assessment Methods) is sponsored by Italy and the United States. In the spirit of seeing a broadened NATO mission and in the face of concerns in some quarters over NATO enlargement, it would be timely to use this vehicle alongside others to achieve selected health goals.

Coordination with other governmental and non-governmental organizations.

A concerted attempt should be made to coordinate US initiatives in this sector with those of other Western governments and philanthropic organizations. An example is the TACIS organization of the European Union, designed to provide technical assistance to the Russian federation. n Combined private and public funding. A partnership of private and also public funds should be developed for the support of health as well as other initiatives. The US private philanthropic community generally absented itself from support of institutions and activities in Russia during the past decade of economic and political transition. Very recently, some of the foundation leaders have begun to re-think their positions because of anxiety over the possibility of social instability abroad, concern for security matters, and the realization that there is an unfinished agenda in Russia. A Baltic-American Partnership Fund was established in 1997 combining financial contributions from AID and the Soros Foundation. A similar but larger Trust Fund for Central and Eastern Europe, with possible contributions from several US foundations, is under consideration presently. There is a place for a similar initiative for the Russian federation.

Management by an institution outside the immediate bureaucracy of government.

The success of previous, similar assistance initiatives, such as the Institute for Inter-American Affairs in the 1940s and the Marshall Plan, was due in part to the fact that the authors in each case insisted that the management of these programs be vested in organizations created close to, but just outside, the walls of government. The aims in these cases were flexibility, freedom from the constraints of civil service rules, and the ability to move decisively and quickly. These features are similarly important today.

Provisions for outside advice.

It is important to supply any initiative in this sector with expert advice concerning health needs and effective approaches to supplying those needs. A small, well-founded, and respected advisory group would serve several purposes: wise counsel; linkages to academic institutions and other technical resources; and an extra-governmental constituency supportive of, at times, difficult political decisions.

SECURITY, NOT CHARITY

To maintain a civil society and avoid civil unrest in Russia, attention must be given to social conditions and social safety net factors, particularly health. Deputy Secretary of State Strobe Talbott, in a speech at Stanford in November 1998, underscored the serious and real possibility of disintegration of the Russian state. “Economic decline,” he said, “carries with it the danger of political drift, turmoil, and even crackup.” He continued by saying “Russian foreign and defense policies could...come under the sway of nationalism in its more contentious, self-delusional and self-isolating form....”

The social costs of attempting to transform a command economy into a market-driven one have been far higher than anyone had anticipated at the beginning of the transition. Even more strongly, some have warned of the specter of Weimar Russia because of the impacts on health and the possibility of social breakdown. The matter seems to have taken on yet an even greater urgency, with increasingly strained relations over the war in Kosovo. Alexei Arbatov, member of the Duma and Deputy Chair of the Duma’s Defense Committee, in a recent speech before the Atlantic Council, warned of a dramatic turnaround in US-Russian relations because of Russian anxieties over NATO’s strategy in Kosovo and the US leadership in that campaign.

Any effective initiative toward health in Russia should be incorporated within a general strategy whose focus is maintaining security and social order. Not uncommonly in the course of economic development, concern for social safety net issues has been treated as an afterthought or adjunctive to the “harder” course of pure economic concerns. Properly, as some have urged, investing in social safety net matters is not “...merely charity...but an investment [itself] in the economic reform of particular countries and in their long-term political stability and responsibility on the international stage.” This explicit linkage between health and military security was the rule in earlier, highly successful foreign policy efforts in Latin America in 1940 and in the Truman Point IV Program in Greece in 1947.

Finally, as others have urged from time to time, an effective program for health in Russia does not necessarily require large, new sources of money. What is most needed is a coherent strategy and clear and wise direction.