When I'm sick, I go to Finland!

The IMC is located on the top floor of a Russian polyclinic, and is an odd dose of Western style in an otherwise drab building. The staff is nice and bi-lingual, but the service is the same as any Western clinic, disorganized at best. They do fly in a Finnish orthopedic surgeon once a month to check up on people like myself, but there is only one Western physiotherapist in Moscow to treat us after he recommends physical therapy. She is thinking about leaving in spring, and the entire sports community here is in a panic. If you are, or know of someone who is a good physiotherapist, and wants a change, please email me! There is a waiting list for the current specialist, and we all are willing to pay whatever it takes to walk again! Oops, got a little emotional there.

Ok, so the Western clinic is just like the ones in the West, hence the name. The Russian clinics are an odd bunch. Wandering around the different floors of the polyclinic where I have my physical therapy, I see an odd assortment of healing styles. Everything from high tech CAT scans, to leaches. I know of a hospital somewhere near the Kremlin, where an entire cardiac center was sent straight from Iowa for Yeltsin when he had his heart trouble. I also know of people who have regular acupuncture sessions to cure illnesses like cancer. The Russian healthcare system is even more cash-strapped than the American system, so for a price, you can have anything you want.

For Russians, without access to the international clinics, its a whole different story:

Moscow Times, July 25, 1998

Young, Russian And Pregnant

By Anna Badkhen

When she waited too long and missed her chance to have an abortion, St.Petersburg journalist Anna Badkhen entered Russia's prenatal care system. She still managed to have a healthy baby boy.

Gynecologist Tamara Rudenko glanced absently through her gold-rimmed glasses at my name written on top of a medical file while I rested my belly on a corner of her table. I had just told her my last menstrual period was six months ago.

"Did you come to see me about the delay?" Rudenko asked with a bored look.

I told her I had come to register. In Russia, all pregnant women are required to register their pregnancy with a zhenskaya konsultatsiya -- a city gynecological office that provides pre-natal care and the papers necessary for acceptance to a maternity hospital. Rudenko was a doctor at St. Petersburg's Zhenskaya Konsultatsiya No. 30.

"What are you, pregnant?" she asked, finally looking at me. And so went my introduction to free prenatal care in Russia.

Elsewhere in St. Petersburg during the months I was visibly pregnant, it was an entirely different story. I was the object of great care and concern from almost everybody I met. People allowed me to go to the head of the line in department stores and at currency exchange windows. Cabdrivers gave me free rides. Soviet-bred waitresses became paragons of politeness. Crippled, 90-year-old babushki, who ordinarily seem to derive unspeakable pleasure from scolding everyone in sight, eagerly yielded their seats in trams and buses. One elderly woman who insisted that I take her seat explained to the other babushki: "We have to take care of pregnant women. There are so few of them nowadays."

Pregnancy would have felt like an extended bubble bath had it not been for my sobering encounters with the medical personnel who were in charge of my prenatal care. When I first learned that I was pregnant at the age of 21, I panicked. Having a baby would put an end to my youth and to my career as a journalist, I thought. After a brief discussion with my boyfriend of two years, Andrei, I decided to have an abortion -- the most popular form of birth control in Russia.

In St. Petersburg alone, doctors performed last yea over 60,700 abortions -- versus 32,900 births, according to the city health committee. Compared with other industrialized countries, Russia has an extraordinarily high abortion rate, according to the most recent figures from the nonprofit, New York-based Alan Guttmacher Institute, which researches reproductive health. In 1994, for example, there were 80.8 abortions per 1,000 Russian women between ages 15 and 44. In the United States, by comparison, the number of abortions in 1992 was 25.9 per 1,000 women in that age group, and in Finland, 9.4 in 1994.

At the time, I knew nothing of this. My expectations of what the abortion would be like were colored by an experience I had in 1994, when I volunteered to assist as a translator at an abortion in a Planned Parenthood clinic in the small city of Utica, New York. Larissa, a Russian woman in her 30s who was getting an abortion, arrived at the clinic and was taken to a private room. There she was asked to sign documents saying that she was making the decision of her own free will.

A counselor duly gave Larissa a detailed -- and terrifying -- description of the negative consequences of an abortion: the possibility she might never get pregnant again, the increased likelihood of future miscarriages. Larissa was then taken to an operating room, where a doctor, a nurse, and two volunteers explained to her what the procedure would be like. I held Larissa's hand during the operation -- to keep her from feeling "alone," the nurse explained. When the abortion was over, nurses brought her cookies and tea in a private room. She ended up spending about two hours at the clinic before returning home.

Two years later in St. Petersburg, I learned that abortions in Russia are a much different affair. When I told the doctor at Konsultatsiya No. 26 that I wanted to have an abortion, she told me to have a blood test for AIDS and syphilis, and set the operation date as soon as possible. "In a week, it won't be safe for you to have an abortion," she said. So much for the warnings.

When I returned two days later for the procedure, I found seven other women who had also come to terminate their pregnancies. We sat together in the main hallway near the door that led to the operating room, watching other women visiting their gynecologists come and go. When I returned from a brief visit to the toilet, my seatmates had all disappeared. I sat in the hallway for about 90 minutes before they started to emerge from the operating room one by one. I knocked at the door. A doctor came out and asked me why I didn't come to the operating room when everybody else did. I said I thought they were assisting one woman at a time.

"We have eight beds in here," the doctor replied. "We operate on you all simultaneously."

She then told me that I could not have an abortion that day because her shift was over. The konsultatsiya, indeed, seemed abandoned. When I told her about my deadline, she took me to an examination room, where I saw a row of washed one-time-use-only medical rubber gloves drying on a radiator, so they could be used again the next day. She examined me and told me that the period when it was safe for me to have an abortion had passed three weeks ago.

"The doctor who examined you must have been mistaken," she said in a matter-of-fact tone. "It's a good thing you didn't have an abortion. It could have only done you harm."

I took the metro home, and over the next day, Andrei and I wrestled with the prospect of bringing the baby to term. Although I knew that having a baby would complicate my life a lot, I also had a confusing feeling that to terminate a pregnancy means to murder a living being. While I was getting ready to have an abortion, I had a sense that I was doing something wrong, and I was surprised to feel a relief when I learned that I had no other choice but to have the baby. The attempt at abortion behind me, I began to prepare for motherhood.

The first step was to visit the konsultatsiya in the neighborhood for which I have a residence permit, or propiska. Other options were limited. With a monthly salary of $500, the $210 charged by one Western clinic for each prenatal care visit was certainly out of the question, as was even the $20 per visit charged by a private Russian clinic. I had to be especially frugal since I was spending more and more on necessities like food. I remember eating seven cans of canned peaches and then immediately consuming a kilogram of smoked sausage. I could eat two kilograms of blue cheese in 20 minutes. It was easy to spend $20 a day on french fries.

So I turned to Tamara Rudenko, the stout, middle-aged -- and above all, free -- doctor at the district konsultatsiya who was to register my pregnancy and, in theory, take care of me. Rudenko -- just like any other doctor at any other konsultatsiya in St. Petersburg -- earned a monthly salary of 300 rubles ($49).

Having timed my first appointment with her at the end of her shift at 7:30 p.m., I might well have been her 30th visitor that day. As soon as I entered Rudenko's office, I was introduced to the trademark of the konsultatsiya: The client is always humiliated.

"Leave your dirty bag there! No, there!" Rudenko's nurse ordered as soon as I stepped inside the office with a backpack slung over my shoulder. Later, after I had dismounted from the gynecological chair and accidentally stumbled over a couch, Rudenko said, "I see 90-year-old women here, and yet they are not as clumsy as you!"

During another visit, I had trouble understanding something Rudenko was saying, and she commented, "All pregnant women have something wrong with their heads." Whenever I came to see Rudenko, she addressed me as "beremennaya," or "the pregnant one"; her nurse, who never introduced herself, did not address me at all. But even more humiliating than Rudenko's rudeness was the lack of intimacy that her konsultatsiya provided.

Although she and her nurse shared a separate office, Rudenko shared the examination room with another doctor. The examination room had two examination chairs and one short sofa where the clients of both doctors were to leave their pants, socks, and underwear. Sometimes, both Rudenko and the doctor from the adjacent office examined their clients at the same time: an intimidating striptease, if you will. As if to underscore the fact that there is no privacy in her office, Rudenko often saw two patients at a time, and the women had to share their intimate problems not only with their doctor, but also with other women who happened to be in the room. During one of my visits, Rudenko scolded a pregnant 19-year-old patient in front of me. "Are you serious about keeping the baby? But you are too immature to take good care of him! Are you married?" Rudenko screamed at the crying girl.

I endured all this for months, never once having Rudenko ask how I felt or if I had any questions. I needed medical advice badly, so I called a friend who knew someone at Snegiryovsky Maternity hospital, popularly known as Snegiryovka. Ida Vanovskaya, a doctor at Snegiryovka's intensive care ward, examined me three times. I called her for advice four times more. She took me to have ultrasound tests. She was not authorized to fill out the papers that would get me into a maternity hospital -- and, therefore, could not substitute for Rudenko -- but she gave me advice on what to eat, what to drink, what vitamins to take and even what kind of washing machine to buy when the baby is born. She never charged me a kopeck.

Once I complained to Vanovskaya about my humiliating visits to the konsultatsiya. "I know, dear," she said. "All konsultatsii have the same terrible way of treating people. It is free health care. Deal with it."

Free health care means a St. Petersburg woman in labor is entitled to one of four to six beds in a delivery room. It also provides her with one of up to 12 beds in the postnatal ward. It pays for the nurses to take care of the infant for the first three days after birth: The hospital staff only brings the newborns to their mothers for short periods of time to nurse, five to seven times a day.

One of the best indicators of the quality of prenatal care and maternity wards is a country's infant mortality rate. According to the World Health Organization, the rise in Russian infant mortality rates following the breakup of the Soviet Union stopped in recent years. Still, the figures from WHO's division of health statistics in Geneva are telling. In Russia, there were 18 infant deaths for every 1,000 live births in 1995, the most recent year for which statistics are available. In the U.S. in 1994, there were eight infant deaths for every 1,000 births, and in Finland, the figure was four per 1,000 in 1995.

Free health care in St. Petersburg comes at a definite price. Mida Samarskaya, an inspector at the city's health committee, said that in 1997, four women died from infections contracted while giving birth in maternity wards with unsterile conditions. Another woman died last year because of an infection that was contracted during an abortion. In some cases, Samarskaya said, doctors and midwives are to blame, but she cannot remember an instance of someone losing their job over a death. By the time I was ready to have a baby, I had had enough of free health care.

Four hundred dollars bought me a separate room at a special "family confinement" ward in Maternity Hospital No. 16. When I arrived at the hospital in June 1997, the private ward was a local innovation. It allowed my boyfriend to be present at the childbirth. It provided a separate room and private bath for my baby, my boyfriend, and me. Our room was furnished with two beds, a crib, a refrigerator, and a television. ("Wow! A fridge! A shower!" my mother exclaimed when she came to see me at the hospital. She said that when she was in labor before giving birth to me in 1975, she was offered a bed in the hallway, because there was no free space in the hospital.)

Later, the ward's personnel told us that we were the fourth couple to ever use the new facilities since they opened a month earlier. In the four days we stayed at the hospital, two more women arrived to give birth there. The ward had a doctor, a midwife, a pediatrician, and a pediatric nurse. Galina, the midwife, told my boyfriend that in the regular maternity ward downstairs, there were 32 women, 4 to a room, all served by three nurses and one doctor.

On June 5 last year at about 10 a.m., the contractions started. Some nine hours later, Andrei and I took a cab across town to the hospital. We arrived at 8 p.m., after the private ward's doctor was gone. By the time we had come, I was in labor, and Galina had to call a doctor from the maternity ward downstairs.

"What a stupid novelty," the doctor said, regarding the private department. "Why not have a baby the way everyone else does?" There was something about her that immediately reminded me of my experience with Rudenko.

The doctor, who failed to introduce herself, examined me and said my cervix was not adequately dilated. She gave me shots. Then more shots. The cervix still wouldn't dilate. At 8 a.m. the next day, the doctor told my teary-eyed boyfriend that she would have to perform a Caesarian section. She kept coming and going from our room, shaking her head at my stubborn uterus.

At 9 a.m., Olga Kordunskaya, the head doctor of the ward, arrived on duty. "Why have a C-section?" she asked. "In order to open the neck, just turn it to the side, like this."

Two and a half hours later, my boyfriend rushed across the delivery room to count the wrinkled toes of our newborn son, Fyodor.

After Fyodor was born, my boyfriend met the doctor who had advised a C-section in the hallway.

"So, did Anna have the baby?" the doctor asked. My boyfriend said, "Yes."

"And she had no ruptures?"

"No," he said.

"And is the baby O.K.?" she asked.

"Yes," he said.

"Very strange," she said with a puzzled look.

(The next day, when my mother came to meet her grandson, the same doctor stopped by. She looked at Fyodor and said to my mother with surprise: "Bizarre. I thought they would both die.")

Four days later, we left the hospital. Rudenkos, Caesarian sections, and washed one-time-use-only medical gloves drying on a radiator were left behind.

Moscow, Sept 15 (Reuters)

Russia's Crisis Stuns Expectant Mother

By Adam Tanner

Life seemed pretty stable in Russia eight months ago when Lena Golubeva decided to have a baby as a single mother. She had a good job with a firm importing foreign goods, inflation was low and the situation in the Russian capital appeared to be getting better as economic reform seemed to be bearing some fruit at last. Then four weeks ago the government devalued the rouble, shrinking the value of her 5,000 roubles savings threefold to about $300. Her company took a major hit, and she says it is unlikely she still has any future there after maternity leave.

'If I had to think today whether I would have a child or not, I'd probably decide against it,' she said in her Moscow apartment where she has abandoned a planned sprucing up midway though the job. 'Everything seems so terrible now.' 'I think that those in the first three months who are not well off will do something about it,' she added, referring to abortion which is common in Russia.

Golubeva, 36, who is due in early October, is only one of millions facing hardship after severe economic changes in recent weeks have led to empty store shelves and have made some medicines hard to find. But as Lev Tolstoy wrote in Anna Karenina, every unhappy family suffers unhappiness in its own way. For Russia's expectant parents the twist of fate that left the economy reeling is particularly bitter.

'Stability then played a role in my decision. It was all thought out,' she said of her decision to have a baby outside of marriage. 'But I'm afraid that I cannot survive in this Russian economy, or won't be able to find a job, or won't find a social safety net in case of need.'

ECONOMIC CALM BRINGS MORE BABIES

For years instability in Russia after the 1991 collapse of the Soviet Union deterred would-be parents from having children. The birth rate plummeted from about 17 births per 1,000 people in 1985 to nine per 1,000 last year. But as some families began to see light at the end of the transition period from communism, the trend began to show a reversal. Russian women gave birth to 645,000 children in the first six months of 1998, up from 639,000 during the same period a year before, during a time that the overall population fell slightly.

'From about 1996 or 1997, people began to feel that they could raise children again,' said Zinaida Kanasyova, head of the newborn section of the Birth House 32 maternity hospital where she has worked since 1952. 'We have seen more births in 1997 and 1998.' Kanasyova said a better economy played a role in the rise, and some experts say the latest wave of economic setbacks are likely to send the numbers shrinking again.

The chaos in Moscow markets outside seems far away for the new mothers in Birth House 32 overwhelmed by the joy of their new babies. 'We have forgotten about everything that's happening out there,' said Layla Mukhameta, 25, a beauty salon administrator who had just given birth to a daughter. 'We don't care at all about the course of the dollar, that one prime minister was rejected and another chosen.' 'We are just waiting for the moment when they bring us our babies and it's then that we are happiest.'

As in Soviet times, mothers usually spend about a week in maternity hospitals, and the infants are kept away except at regular feeding intervals. The husbands are also barred. Mukhameta's husband is a hockey player who earns a salary designated in dollars so she is not worried about finances.

'Of course everything that's happening (in the economy) is terrible but we wanted children anyway,' she said. Another new mother in the ward, Maryam Mogamedova, 26, does not have a husband, but maintains a cheery, upbeat outlook. 'My mother had six children and she, an uneducated woman, raised us practically by herself,' she said, wearing the hospital's standard-issue loose robe. 'So why shouldn't I be able to raise one?' Mogamedova said she does not plan to use imported disposable nappies which have become scarce in Moscow in recent days, and she will supplement her food through her mother's garden plot outside the city. 'Of course it will be hard,' she said with a smile. 'We are already used to the fact that things will always be unstable.'

PARENTS BUY NAPPIES IN PANIC

On the streets of Moscow where panic buying over the past weeks has sucked goods off stores shelves, Golubeva feels a more glum apprehension only amplified by a visit to one of the city's baby supply stores. Disposable nappies -- called pampersy in Russian after the Pampers brand that became widespread after the fall of the Soviet Union -- have again become rare as during Soviet times, and even new cribs have sold out in some stores.

'It's not that I'm afraid that I won't find imported nappies or food,' she said before spotting nappies for more than $30 a pack of about 40. 'The problem is what happens if he falls ill or I fall ill? The other day I had to wait 40 minutes in line at a pharmacy.' Golubeva's only significant asset is her apartment which she could either rent -- she said a neighbour rents a similar apartment for $1,000 a month -- or sell and move to the periphery of the city. She wants to stay put of course.

But Golubeva and millions of other Russians now have to cope with the reality of less in life after years of rising expectations. 'Of course ultimately I'm not sorry to be pregnant, I want the baby,' she said. 'But things are so grim now. I've never been in such a situation before.'

Johnson's Russia List, November 30, 1998

Russia Carried out 2.5 Million Abortions in 1997

Agence France Presse

Some 2.5 million abortions were performed in Russia in 1997, with seven pregnancies in 10 ending in terminations, Interfax news agency reported Sunday, citing Health Ministry figures. The agency said the figures were published to coincide with Russian Mothers Day, which was being marked for the first time on Sunday.

According to the ministry's statistics, every tenth abortion is performed on women under 19 and more than 2,000 on girls under 14. Two women in three suffer from health complications as a result of the terminated pregnancies, the statistics indicated.

Abortion has long remained the leading method of birth control in Russia, though the 1997 figures indicated that the number of abortions has fallen by 25 percent in the past four years. The abortion statistics take on even more significance in light of Russia's overall population figures. The Russian population has declined by well over 1.5 million people since 1992.

Johnson's Russia List, Monday, 12 October 1998

Financial Crisis Deals Health Service a Death Blow

Reuters News Service

Russia's financial crisis has dealt a deadly blow to the country's faltering health service, leaving doctors and nurses without wages and medicine and equipment in short supply, the health minister said on Friday.

"The socioeconomic crisis has hit all aspects of the health system, stopping us from doing our job," the newly appointed minister, Vladimir Starodubov, told a news conference. "People cannot get medical help when they need it...and the crisis is making people ill." He said the rate of illness in Russia had grown in the first eight months of this year, with 21.5 million registered cases in a population of 150 million.

Cash earmarked for the sector in the government budget fell by 26 percent. He gave no further figures. "We want to support our employees, but we are not in a position to support them," Starodubov said. "They want do their job and they've got hands and brains, but not the necessary materials."

Some doctors, nurses and other public health employees have not been paid for between three and eight months and, according to official figures, were owed some 3 billion rubles ($187 million), he said. Trade unions say the backlog stands at 5 billion to 10 billion rubles.

Millions of Russians in both the public and private sectors are owed wages stretching back many months, prompting some to attend rallies calling for President Boris Yeltsin's resignation on Wednesday.

The government blames the delays on a complex web of debt that has built up between companies and between firms and cash-strapped state bodies including the armed forces. Starodubov called for some additional capital to encourage a greater domestic involvement in the pharmaceuticals market, which is swamped with Western tablets and syrups. The supply of imported medicine has declined sharply in the past two months as the ruble has lost two-thirds of its value.

"We have worked on far-reaching reforms for the health system despite living through this country's crisis," he said.

He said he hoped to introduce standardized training for doctors, new equipment for hospitals and guarantee people an effective health service. Many Russians lost faith in public medicine after the collapse of communism and alternative medicines have thrived as the average life expectancy for men has plunged by some six years to 58 over the past decade due to a combination of poor health care and diet and heavy drinking.

Some Westerners have begun to campaign for a higher level of public health awareness in Russia. Bob Swan, president of the Corporation for Russia-American enterprise, has set up a campaign called "Heart-to-Heart" to fight heart disease and set up an AIDS awareness program. "Russia's health care crisis can only be solved if the private sector steps forward in this hour of need," Swan said.

He said he has called on foreign firms to give one percent of their sales in Russia to support the public health education drive. Cough and cold remedy maker Quigley Corp. has agreed, he said. "What is at stake is the very future of Russia and her magnificent, although presently quite unhealthy, people."

Financial Times November 28, 1998

MEDICINE: Russian doctors left to face empty cabinet

By John Lloyd

City Hospital No 2 is buried in a suburb of St Petersburg composed of row after row of massive, already-sagging apartment blocks. Although the hospital opened in the early 1990s, it too is scruffy looking; its entrance hall is echoing and empty, with an air of indifference where some attempt at warmth might be expected.

But its operating theatres and intensive care units are sparkling, high-tech and carefully tended. Racks of medicines stand in whitewood cabinets. In the ophthalmic department - the treatment of cataracts in the disproportionately elderly population of St Petersburg is a specialty - state-of-the art machines jostle for space in the crowded examination rooms. City Hospital No 2 is a show hospital, well funded and generously staffed. Yet it illustrates, better than the dank, stench-ridden barracks which are often the norm for hospitals in the Russian provinces, the crisis in Russian healthcare.

The state now supplies no more than 20 per cent of City Hospital No 2's budget - the rest comes from paying patients. The doctors and administrators give a clear impression that those who can afford it buy treatment while those who cannot are treated as and when they can be fitted in. To repeated questions of "How do you actually manage?" the answer is most often something like: "We do it with patience," the response of Vitaly Khilko, a senior surgeon.

This obfuscation springs largely from wounded pride. Professor Khilko is an innovative neuro-surgeon who claims to have pioneered new forms of surgery in the 1970s. He and his colleagues, especially the more senior ones, find the present state of Russian medicine hard to bear. And to face the certainty that it will deteriorate is hideous. But it will. "We have spent a lot of money and energy bringing our practices up to the highest levels," says Yuri Shulev, another neuro-surgeon. "But now there are no funds to renew the medicines, and no funds to service and maintain the equipment. Strokes are one of the most common causes of death - and if we can get the patient to hospital in time we can often save him. But the ambulance service is not geared up to this, and we have no funds to reform it."

No funds. It underlies all of the conversations in the hospital, as the shock of what happened in August - when the rouble crashed and the scale of the fiscal crisis was revealed - sinks in. The crash came on top of already exiguous funding. The state pays the equivalent of ú5 to buy food for one patient for two weeks, with a further ú4 for medicines over the same period. Now the doctors fear they will soon be looking at an empty budget.

Private medical insurance companies, both Russian and foreign, have started up in the past few years but, says Oleg Vasiliev, dean of the Academy of Military Medicine who practises at the hospital, they represent a tiny fraction of the hospital's income. "Our psychology is against it. They really only exist for foreigners. Russians have the psychology of fatalism, which is mixed with the feeling that the state will take care of it. If they have money, they buy vodka. You can avoid strokes if you lead a healthy life and don't drink heavily. But who listens?"

When poverty and fatalism meet, it seems hopeless. Worse, the unbalanced age structure of St Petersburg, a legacy of the second world war when men were slaughtered, means there are 1.2m pensioners in the city, mostly women, and a birth rate which is dropping fast. The population fell by 600,000 last year. Russian men are dying in their late fifties and Russian women are not reproducing.

It had been getting better here and there. Christopher Davis, a fellow of Wolfson College, Oxford, and an expert on Soviet and Russian health, says that many infectious diseases were on the decline and the infant mortality rate, high by international standards, was falling slightly. But cancer, heart problems and tuberculosis have all worsened; and the brutal fact that Russians live on average 10 years less than western Europeans has not changed. Now, says Dr Davis, further decline is inevitable. "The cuts in the budget only mean they can't afford western medicines - which make up 70 per cent of the total.

"And the fact that western drugs replaced Russian ones has severely damaged the pharmaceuticals industry here, so it can't respond. The same with the medical equipment industry. It is a serious, a very serious situation." The doctors of City Hospital No 2 - who earn $125-$360 (ú75-ú220) a month on their state salaries - see colleagues leave the profession to go abroad or seek more lucrative work.

They see their equipment rendered inoperative and their medicines run short and struggle with patients aged and fearful, who often refuse to leave their hospital beds to go back to the isolation of bleak rooms.

"We will manage with patience," says Prof Khilko, but patience is becoming a much abused commodity in Russia.

21 January 1999, The Moscow Times

Dying Souls of Russia

By Murray Feshbach

Health in Russia is even worse than most Russians and foreign commentary would indicate, and the consequences for Russian society, the Russian economy, and the Russian military will be enormous.

Environmental issues lurk behind much of the public-health problem. Radioactive contamination is rife. Chemical contamination, such as dioxin, is largely to blame for the fact that life expectancy for both men and women in the town of Dzerzhinsk, in the Nizhny Novgorod region, is no better than 50 years. At least until 1995, DDT continued to he used, despite an announcement by the Soviet government almost three decades ago of a ban on its production and use.

Bad water nationwide has led to high rates not only of bacterial dysentery but also of hepatitis and cholera. The air in Omsk is polluted: Authorities two years ago distributed some 60,000 gas masks to residents. And thermal-power plants throughout the country are spewing forth carcinogens, owing to incomplete combustion. Lead emissions in Russia are about 50 times those in all of the European Union. I have seen a Russian government report indicating that as a result of lead pollution in one locale, "76.5 percent of the children in the town are mentally retarded."

But even absent of these environmental problems, public health in Russia would be appalling. I anticipate that an unprecedented surge in the incidence of infectious and parasitic diseases, combined with existing high levels of alcohol poisoning and violent death, will contribute to a continued lowering of life expectancy. The Russian population is likely to decline as well, by about 800,000 to a million people a year until 2010, when the total may well he no more than 138 million. Alcoholism, drug abuse, sexually transmitted diseases, malnutrition and various chronic and infections diseases already mean, among other things, that a third of the adult population is incapable of reproduction.

The incidence of tuberculosis in Russia has skyrocketed. The number of deaths ascribed to tuberculosis in Russia in 1996 (24,877) was almost 15 percent greater than the number of new infections (usually nonfatal) that year in the United States. The Russian mortality rate for tuberculosis is 16.9 per 100,000; the U.S. rate is 0.5.

According to the State Statistics Committee, the number of new cases of tuberculosis that occurred in Russia in 1996 is 99,000 -an official number that is in fact too low. It is known that at least a tenth of prison inmates in Russia have tuberculosis, and that some 850,000 to 1 million Russians are in prison. Are these infected prisoners in the official data? For that matter, do the agency figures include the homeless, forced migrants, refugees, people living in railroad stations, people who avoid the medical establishment and so on? I believe that the number of new cases is actually closer to 150,000 each year. And given that everyday ordinary pharmaceuticals are pathetically scarce, are not most of these people going to die of the disease?

If a memorandum titled "Epidemic Tuberculosis in Russia," prepared by the Interior Ministry and described in a Newsday article by Laurie Garrett, is even close to being correct, then the Russians face a bleaker future than they (or we) could have thought possible. To quote: "By the year 2000 the incidence of [tuberculosis] will increase '50 times compared with now'; mortality will increase seventy-fold; and deaths in children are expected to rise ninety-fold."

If these predictions prove true, then Russian deaths attributable to tuberculosis will be more numerous than the total reported for heart disease and cancer, In 2000, according to these numbers, tuberculosis deaths in Russia will reach approximately 1,75 million, whereas 1 estimate that heart-disease and cancer deaths will number about 1.5 million. This says something extraordinary about the state of public health.

HIV and AIDS cases in Russia and deaths from AIDS are also on the verge of exploding. The former health minister, Tatyana Dmitriyeva, has forecast that a million Russians will be infected with H IV by 2000. Assuming that only half that many are infected and that it costs "only" $15,000 per patient per year to administer protease inhibitors, AZT and 3TC, where is the $7.5 billion a year for these drug cocktails to be found? The answer is nowhere. AIDS patients in Russia will die.

The growing number of Russian AIDS cases reflects a sharp rise in sexual promiscuity and hard drug use. In the past five years, syphilis cases among girls who are 14 or younger have increased thirty-fold. Chlamydia rates are said to be very high in the same age group, though very few, and likely unreliable, data are available. How sick will these children he in subsequent years? Will they he able to have children themselves'? Will their children also be sick? Will they become part of Russia's growing army of drug abusers, now thought to number 4 million to 6 million? Many of them, of course, will simply die young.

Here is another way of viewing the overall situation: How many of today's 16-year-old males will survive to age 60? In the United States, the figure is about 83 percent. In Russia it is only 54 percent; 1 00 years ago in the European part of Russia the figure was about 56 percent. Of course, many of tile Russian men who survive to age 60 will be very sick.

Analysts specialized in geopolitics, economics, or the military who ignore these issues do so at the risk of overlooking Russia's most fundamental realities. So much of the shrinking Russian population may soon be so ill that long-term solutions to the country's political, economic and military, problems will be inconceivable.

Murray Feshbach is a research professor at Georgetown University. He contributed this comment to The Moscow Times