The Coming Plague (89 page)

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Authors: Laurie Garrett

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For three years Soviet health leaders counted the numbers as similar
hospital outbreaks of HIV surfaced in Rostov, Astrakhan, and Stavropol.
By June 1990, Vadim Pokrovsky was telling the world that 260 children had become infected with HIV as a result of unsterile needles.
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Moscow's Second City Hospital for Infectious Diseases was designated the nation's AIDS treatment center and half the patients on its wards were children under five years of age. As fear of AIDS mounted in the Soviet medical community, widespread shortages were reported not only of syringes but of latex gloves, sterile catheters, surgical gowns, transfusion equipment, dental drills and probes, and other essential supplies. In the new atmosphere of
perestroika,
young physicians for the first time spoke frankly about the inadequacies of the Soviet medical system.
The result was widespread public panic and a sharp decline in willingness to undergo invasive medical procedures. Dentists, vaccinators, physicians—all health providers noted a drop in attendance, particularly in large cities where the media gave serious attention to the young physicians' disclosures.
Dr. Mikhail Narkevich, newly appointed head of AIDS education in the Ministry of Health, was forced to concede that the nation's economic difficulties were so grave that adequate medical supplies could not possibly be available until 1992–93. By 1994 Russian physicians would be crying out even more loudly for supplies that still hadn't materialized.
In the absence of supplies sufficient to limit the spread of HIV within medical facilities, panic further increased. There were anecdotal reports of people beating AIDS patients and of health care workers refusing to go near people who carried the virus. The Ministry of Health was forced in 1991 to offer higher salaries to doctors and nurses who worked with HIV/ AIDS patients as compensation for the perceived risks involved.
But Soviet leaders were preoccupied with far more pressing issues than supplies of syringes. The country was literally falling apart. Food shortages, riots, separatist uprisings, political instability, and a face-off between the hero of
glasnost,
Mikhail Gorbachev, and upstart leader Boris Yeltsin monopolized national attention. By 1991 the Soviet Union no longer existed. By 1993 two major coup attempts had threatened the stability of the Russian Republic, and insurrections had occurred inside most of the former Soviet socialist states.
AIDS was overshadowed by history. And the microbe spread, unfettered by any serious efforts on the part of human beings to limit its modes of transmission. Prostitution and drug abuse stepped into the economic vacuum of social restructuring. Criminal elements gained control of many foreign trade sectors, and syringes remained in short supply.
By late 1993 the microbial situation was clearly out of control. Before the Berlin Wall fell, Russia's syphilis rate was 4.3 cases per 100,000 people annually. Amid the national chaos, health officials said they were witnessing a syphilis epidemic. In St. Petersburg, for example, the incidence of syphilis increased eightfold between 1989 and 1993, with most
of the newly infected individuals young, destitute female prostitutes. In the same city the incidence of gonorrhea among teenagers had soared 150 percent by 1993, as compared with 1976 levels. And in the same subpopulation syphilis incidence was up 400 percent.
Dr. Nikolai Chaika, of the St. Petersburg Pasteur Institute, announced that all Russian disease data, including numbers of HIV/AIDS cases, were unreliable due to the “complete collapse of Russian medicine.” The social fabric of Russian society was unraveling, he said, and people were turning to behaviors that virtually guaranteed the spread of disease.
Thirdworldization had set in. Russia, as well as nearly all of the other former Soviet states, was rolling backward on the development scale. Epidemics of all sorts of diseases were reported anecdotally, though most were impossible to verify given the collapse of epidemiological systems. In the summer of 1992 cholera outbreaks were reported in Makhachkala, Nizhny Novgorod, Krasnodar, Naberezhnye Nizhny, and Moscow. The Tass news agency reported an outbreak of anthrax among peasants in the Altai region and typhoid fever in Volgodonsk. Even a case of bubonic plague was reported from Kazakhstan.
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In March 1993 special counsel to President Boris Yeltsin, Dr. A. V. Yablokov, addressed the grave state of the Russian people's health in a speech before the nation's Security Council.
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He revealed that in 1991 Russia's “total losses due to premature mortality amounted [to] 2.23 million person-years of labour activity … . It is obvious
that prevention of population health losses due to premature mortality from socio-economically conditioned causes is the most important strategic direction in improving safety and security of life of peoples of Russia
[his emphasis].”
The primary cause of Russia's massive excess death burden was suicide, which rose by 20 percent between 1991 and 1992. Alcoholic self-destruction, drunk-driving accidents, and homicides ranked as the remaining top causes of the excess death rates.
Meanwhile, he said, the nation's medical and public health system had deteriorated to the point where in 1991, 70 percent of all pregnancies involved serious complications, “only half of deliveries were considered normal,” anemia rates among pregnant women had increased by 61 percent in just three years, and maternal mortality rates were five times those in Western Europe. And preventable deaths—those ascribed directly to drug shortages or medical and public health failures—had risen sharply since 1990.
“Among these are all forms of tuberculosis, some infectious diseases (measles, whooping cough, tetanus, typhoid fever) … respiratory diseases, pregnancy complications, diseases of the perinatal period,” Yablokov said.
Life expectancy in Russia was lower in 1990 than in 1964 (70.1 years versus 70.4) and real life-span measurements for some areas of the country were as low as 44 years.
Separate EC studies of Russian health revealed that tuberculosis rates
were climbing sharply. In Siberia in 1990 there was a TB incidence of 43 cases per 100,000 people (as measured by positive sputum). By 1993 that ratio had more than doubled, to 94:100,000. Over the same period Moscow's TB rate jumped from 27:100,000 to 50:100,000. The principal cause of the escalation was said to be the lack of foreign exchange with which to purchase European- and American-made antituberculosis drugs; without treatment an ever-expanding pool of contagious individuals was spreading the disease to others.
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Perhaps the most striking example of Russian Thirdworldization was the 1993 outbreaks of diphtheria in St. Petersburg and Moscow.
A hallmark of the old Soviet Union had been its tremendous success in universal vaccination and resultant declines in the incidence of former scourges such as measles, whooping cough, polio, and diphtheria. By 1976 the numbers of diphtheria cases diagnosed in the U.S.S.R. approached zero.
But in 1990 diphtheria reemerged in Russia, with 1,211 cases reported from St. Petersburg, Kaliningrad, Orlovskaya, and Moscow. The epidemic took off, with reported cases and geographic spread increasing steadily well into 1994. In 1991 nearly 1,900 diphtheria cases and 80 deaths were reported in Russia. Though the bacterial disease could be treated with antibiotics, deaths occurred due to the sorry state of the nation's health care systems.
During the summer of 1993, when nearly 1,000 cases were reported in a single month in Moscow and St. Petersburg, the British government issued travel advisories recommending that its citizens be revaccinated prior to traveling in the former U.S.S.R. And the numbers kept rising: between January and August 1993, nearly 6,000 Russians came down with diphtheria, 106 died.
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There had been massive waves of migration from outlying rural and rustbelt areas of Russia into Moscow, St. Petersburg, and, to a lesser degree, Kaliningrad and Orlovskaya. Most of the migrants were economic refugees, hoping to find work in the country's largest cities. But they soon discovered quite the opposite, according to Russian authorities, and many thousands ended up living inside public transport stations—train depots, airports—in squalid conditions. Over 40 percent of the diphtheria cases occurred among these homeless.
Diphtheria had been virtually eradicated from the United States because of strict rules about preschool vaccination of children with the so-called DTP shots. But DTP shots had also been meticulously administered in Russia since the early 1960s. Nearly every new diphtheria case in the country had involved individuals who were previously vaccinated.
Officials concluded that the vaccine didn't, as previously thought, work for a lifetime. It might offer less than five years' protection against the disease. The reason, they said, was not a failure of the vaccine, but its success.
It seemed that thirty years of worldwide vaccination had drastically reduced the numbers of diphtheria microbes in the world, and most people lived their lives never being naturally exposed to the bacteria. Natural exposure in the 1960s, however, acted like booster shots, constantly rejuvenating lagging immunity: that explained why health officials had then mistakenly concluded that the vaccine provided lifetime protection. But by the 1980s most people's immune systems never saw diphtheria, and the natural booster effect didn't take place.
In response to global concern that the Russian epidemic might spread to other parts of the former Soviet Union, the Baltic States, or Scandinavia, the Russian Ministry of Health announced in 1993 a five-year plan to revaccinate up to 90 percent of all the nation's citizens. Some UN officials privately questioned whether the Russians were responding with the proper amount of urgency and haste: a handful of diphtheria cases were reported during the summer of 1993 in Finland and the Baltic States.
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Still other skeptics questioned the wisdom of a mass adult vaccination campaign in Russia, given the country's acute shortage of syringes. Considering the lesson of Elista, they asked, might such an effort only hasten emergence of blood-borne microbes, such as hepatitis B and HIV?
The Elista tragedy was closely mirrored by events in Romania, where the government of communist dictator Nicolae Ceausescu covered up the existence of thousands of institutionalized orphans who were the legacy of decades of strict bans on all forms of contraception. Further, the Ceausescu regime hid evidence that many of these children were infected with HIV,
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the tragic outcome of common use of contaminated syringes
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and the primitive belief that injecting adult blood into children gave them strength.
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When the Iron Curtain was lifted, it revealed the Third World status of the old communist regimes, and conditions which only worsened amid the infrastructural chaos. And with that revelation came recognition of countless opportunities for the further emergence of not only HIV but all manner of microbes.
But there was no need to search behind the Iron Curtain, the Bamboo Curtain, or below the Sahara to witness microbial exploitation of Thirdworldization. The process was occurring during the 1980s and the early 1990s inside the wealthy nations of North America and Western Europe.
Despite the AIDS epidemic, most of the public health community, which was not involved in infectious diseases work, remained optimistic during the 1980s. So much so that health became a matter of personal responsibility. Health economists tallied up the costs of diseases that were preventable through diet, exercise, cessation of tobacco or illicit drug use, elimination of alcoholism, and the like, reaching the conclusion that personal health decisions were no longer the exclusive purview of individual choice. Smokers, they concluded, cost the rest of society billions of dollars. So did alcoholics. And fat people.
“The cost of sloth, gluttony, alcoholic intemperance, reckless driving, sexual frenzy, and smoking is now a national and not an individual responsibility,” wrote Dr. John Knowles, president of the Rockefeller Foundation. “This is justified as individual freedom—but one man's freedom in health is another man's shackle in taxes and insurance premiums. I believe that a right to health should be replaced by the idea of an individual moral obligation to preserve one's own health—a public duty if you will.”
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Public health advocates warned, however, that it was exceedingly unfair, and unrealistic, to hold poor Americans responsible for their health—to condemn them, as it seemed Knowles did, for their inability to afford ideal foods, membership in exercise clubs, and temperance in all sexual and intoxicant affairs. Further, they warned that the medical triumphs that had sparked such rosy calls for personal responsibility were fleeting. In the face of rising poverty, they said, the old scourges would return.
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It wasn't necessary to go to Africa to see AIDS orphans or whole families buried side by side. New York City alone would have more than 30,000 AIDS orphans by the end of 1994, Newark over 10,000. The U.S. Department of Health and Human Services predicted that there would be 60,000 AIDS orphans in the country by the year 2000.
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Just as AIDS was exhausting the extended-family networks in much of Africa, so it was taxing the social support systems in America's poorest communities.

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