The Moscow Times reports:

When Moscow photographer Serge Golovach decided to present portraits of beautiful women for an HIV/AIDS awareness project, he was revealing a startling truth about AIDS in Russia today -- it is quickly becoming a problem with a woman's face.

At the beginning of the AIDS epidemic in Russia, those infected were predominantly male. Unlike in much of the rest of the world, the vast majority of AIDS cases in Russia and the CIS were the result of intravenous drug use -- a behavior usually associated with men. But of the 415,000 people infected with AIDS in Russia today, 135,000 of them -- 32 percent -- are women, according to the latest figures from the Federal Consumer Protection Service. A higher percentage of cases among women can be found only in Moldova or in African countries. In Moscow, the situation is even worse. Out of the 28,000 cases of HIV registered in Moscow as of January 2008, more than a half were women -- up 14 percent from last year, according to the Moscow branch of the consumer protection service. More disturbing, most of the newly infected women are young and in their best reproductive years, from ages 20 to 29. Around 5,000 of these women found out that they were infected while undergoing blood tests as part of prenatal care.

The ongoing feminization of the AIDS epidemic in Russia will no doubt affect the health and future of the nation. An increasing number of HIV-positive children born to these women are the predictable result. But there remains the disturbing question of why more Russian women are becoming part of this epidemic. Experts say it is a result of both the changing nature of HIV transmission in Russia and changes in gender-based social norms and sexual customs. While officials say intravenous drug use remains the main way of transmitting the virus, contracting HIV as a result of heterosexual intercourse is rising. The Moscow AIDS Center's web site says 86 percent of new cases of HIV are the result of intercourse. This change suggests that HIV is now affecting the general population rather than the marginalized elements of society, such as prostitutes or drug addicts, who have long been considered at high risk for acquiring HIV.

Of course, it remains true that mass unemployment and economic insecurity in the depressed regions of Russia sometimes force women into commercial sex work, which contributes to the rising numbers of HIV-positive women. Surveys of regional Russian cities show that most sex workers are between the ages of 17 and 23 and that condom use among these prostitutes is erratic at best.

But what makes the changing situation alarming is that ordinary women are increasingly at risk in a country where sexual coercion and gender inequities are tolerated, and double standards make it acceptable for men to have multiple sexual partners. While using condoms could be a solution in many cases, condoms have traditionally been extremely unpopular among Russian men. This is especially the case among the segments of the population with lower income and educational levels, where HIV is spreading most rapidly. The economic dependency of some women on their husbands and sexual partners leaves them with little bargaining power when it comes to negotiating condom use.

"Some women suspect their husbands have many sexual partners but fear to be abandoned or beaten if they resist their husbands' sexual demands," says Maria Ivannikova, the head of the informational department of the nongovernmental association AIDS Information Service.

Since women are biologically more vulnerable to acquiring HIV, it is two to four times more likely that a woman will contract HIV from a man than a man from a woman. The explanation is that women have a large surface area of reproductive tissue that is exposed to their partner's secretions during intercourse, and semen infected with HIV typically contains a higher concentration of the virus than a woman's sexual secretions. Specialists say young women are especially at greater risk, because their reproductive organs are immature and more likely to tear during intercourse, specialists say. Women also face a high risk of acquiring other sexually transmitted diseases, which increases the risk of contracting HIV 10-fold when left untreated.

The female condom could be a solution, since it is the only safe and effective HIV prevention option available that is completely controlled by women, but at the moment the method is mostly unknown in Russia. And even when women are familiar with female condoms, they have a hard time finding them. Pharmacies do not stock them because of their relatively high cost and a lack of demand, according to Igor Peskarev, the director of Humanitarian Action, a UNAIDS partner NGO in St. Petersburg.

"You may find women's condoms only in sex shops in our city, and the price will be around 3 or 4 euros, more than 100 rubles. It's relatively expensive for a one-time use item," he said.

Microbicides, which can be applied in the vagina for the prevention of HIV and other STDs, are still in the developmental stage, although Russian scientists are working along with others around the world to develop an effective one.

Every day, more than 100 new cases of HIV appear in Russia, and if current trends continue, women will soon make up a majority of the victims. And the fact that Russia is currently in the midst of a serious demographic crisis compounds the problem. According to data from the Center for Strategic and International Studies, the combination of falling birth rates and rising death rates from chronic and infectious disease means that by 2025, Russia's population will fall from about 144 million to about 125 million. Add to that 5 million to 15 million excess deaths from AIDS, and the country may lose 20 percent of its citizens over the next 20 years.

In an attempt to raise awareness of this problem and help lift the stigma of people with AIDS, UNAIDS recruited 25 famous women from Russia and Ukraine who agree to be photographed. By displaying the photographs of women who are well-known and in the news, the organization hopes encourage both public and private discussions about HIV/AIDS, particularly among women. The exhibit, which will run for two weeks in Moscow, will then tour the country, and a selection of the photographs will be published as a 2009 calendar to be launched on Dec. 1, World AIDS Day.

The Washington Post reports:

When a new cardiac unit opened at the municipal hospital here last month, Russian Health Minister Tatyana Golikova sent a letter of congratulations, calling the new facility a "vivid example" of the medical community and private donors working together to improve the lives of ordinary Russians.

The good feeling didn't last long.

Three days after the unit's opening, Tarusa's mayor fired the hospital's head doctor and sent in the police to check for possible fraud in the refurbishing of the hospital, all of which had been financed privately.

Doctors at the hospital said the crackdown was the culmination of a two-year campaign by local officials to wrest control of tens of thousands of dollars that were to transform the once-crumbling hospital into a model of preventive medicine in a rural community.

The hospital funding was a bright example of the growing philanthropy of Russia's wealthy. But it was also a window into the stifling role Russia's bureaucracy can play, even in a sector deemed a national priority by President-elect Dmitry Medvedev.

"Every improvement caused difficulties," said Maxim Ossipov, a Moscow cardiologist who works three days a week at the Tarusa hospital. "Bureaucrats have to fight for their existence, and if they don't control something, then they are no longer bureaucrats. They are a real disaster for today's Russia."

Tarusa is a river town of 9,000 people about 85 miles south of Moscow. Popular with Muscovites, such as Ossipov, who maintain second homes in the region, the town's summer population swells to 80,000.

In an interview, Ossipov said he started volunteering at the 135-bed hospital in 2005 as a route back into regular practice, which he had abandoned in the 1990s to open a medical publishing company in Moscow. He had old ties to the town -- his grandfather, also a doctor, was exiled there after a prison camp term during the repressive rule of Joseph Stalin.

"By Western standards, it was not a hospital at all," said Ossipov, who was a research fellow at the University of California at San Francisco in 1991 and 1992.

Ossipov said he began turning to friends and colleagues for equipment, such as defibrillators, and even basic drugs to improve the quality of care. At the same time, the Russian government's $6.5 billion spending plan to improve health care brought a much-needed ambulance and pay increases for the hospital's medical staff.

The effects were quickly apparent, doctors at the hospital said. Its mortality rate was halved, and the death rate in Tarusa from heart attacks, a major killer in Russia, was cut by five-sixths, according to regional government figures.

"I have problems with my heart and I remember when they couldn't help me here and they would immediately sent me to Kaluga," the provincial capital, said Pyotr Dovbnyak, a 65-year-old pensioner. "Now they call me on the phone and invite me in for examinations."

In 2006, the hospital was offered a new X-ray machine through the "national projects" led by Medvedev. But the hospital's electric wiring was unable to support the new equipment. Mayor Yury Nakhrov refused to upgrade the hospital's power supply, the doctors said. Irina Oleinikova, the head doctor, reluctantly turned down the X-ray machine.

Nakhrov was reprimanded by the regional administration for "frustrating" the national projects, and he, in turn, reprimanded Oleinikova for "safety violations" and for failing to properly treat a patient. Oleinikova appealed to the courts and the reprimands were overturned, which she said infuriated the local administration.

Nakhrov was not available to answer a reporter's questions; officials in his office said no one else could comment.

In the meantime, Valery Balikoyev, a Moscow businessman, committed approximately $130,000 to renovate one of the hospital's wings for the new cardio-therapy unit. According to the doctors, Nakhrov told Oleinikova her "sponsor" should visit him to introduce himself. She declined to make the introduction. Nakhrov also told her she should move the town's pharmacy -- which was located on a prime piece of real estate -- into the hospital. She again refused.

In another example of bureaucratic pressure, Ossipov said that an official, whom he wouldn't name, suggested overbilling -- doubling the amount on an invoice for some new equipment that another wealthy sponsor was willing to buy, so that the balance could be used for other purposes. Ossipov declined.

Researchers at the Russian Academy of Sciences have estimated that corruption absorbs about 35 percent of all health-care spending in Russia. Ossipov said the hospital deliberately never accepted cash donations, only equipment or physical improvements, to avoid any suggestion that its personnel could benefit financially.

"My language is as impossible for them to understand as theirs is for me," Ossipov said of the local officials who, by his account, found it hard to believe that the doctors had no personal stake in the improvements.

Local officials eventually tried to close the hospital on grounds of fire safety violations, according to Oleinikova, but a higher court blocked the effort.

On March 3, Mayor Nakhrov fired Oleinikova and ordered a criminal probe into the construction of the cardiac unit. Ossipov, Balikoyev and others appealed to the regional governor, who ordered a separate investigation. He also recommended that that the local council fire Nakhrov, but it refused.

The mayor later checked into a Moscow hospital where he could not be reached by either investigators or the news media; Oleinikova was reported Thursday to be headed back to her job after the investigation by the regional government.

"We are taking the whole thing as a slap in the face," Ossipov said. "Small bureaucrats don't believe in philanthropy and they can't stand any independence on their own territory."

The Chicago Tribune, showing itself to be a world leader on Russia coverage, continues its series exposing the sick underbelly of Russia:

Health care is supposed to be free in Russia, but Russians know that every hospital has its under-the-table price list.

That's why the family of Khazerya Ziyayetdinova, a 70-year-old woman suffering from severe bedsores, brought cash every time they visited her at Hospital 67 in Moscow. To have Ziyayetdinova recover in a room instead of the hallway, relatives slipped an orderly $300. They paid nurses $20 to give injections, change bedpans and unclog catheters. Every chat with Ziyayetdinova's doctor cost $40.

"Our health-care system is still in the Middle Ages," said Vera Pavlova, Ziyayetdinova's daughter-in-law, sitting in her home in this small town 54 miles southwest of Moscow. "There's low professionalism, corruption -- it makes me very worried about finding myself in a situation where I might need medical treatment."
Russia is an unhealthy nation, and its health-care system is just as sick. Its hospitals are understaffed, poorly equipped and rife with corruption.

The biggest reason Russia's population plummets at a rate of more than 700,000 people each year is not that its birthrate is so low, but that its death rate is so high. The average life expectancy for Russian men is 59. In the U.S. it's 75; in Japan it's 79.

Alcohol and smoking are major culprits. Both are linked to heart disease, and in Russia, the rate of men ages 30 to 59 dying from heart disease is five times that of the United States, according to researchers at Columbia University.

Prevention and better health care can help reverse that trend. The Russian government is pumping $6.4 billion into revamping health care; much of that money is paying for the construction of eight high-tech medical centers across the country, new X-ray machines, electrocardiograms and ambulances at hospitals, and raises for family doctors.

But doctors and nurses in the Russian Far East city of Amursk are still waiting for the overhaul to reach their hospital. In January 2007, the hospital ran out of syringes and asked patients to bring their own, said Olga Cherevko, a nurse at the hospital. Even something as fundamental as keeping pharmacies stocked can prove problematic for Russia's beleaguered health-care system. A bureaucratic breakdown in late 2006 led to a severe shortage in government-supplied prescription drugs.

Russians with enough money were able to buy medicine privately. But hundreds of thousands of Russians with high blood pressure, diabetes, asthma and other diseases had to do without the drugs for weeks.

Russian officials have promised that the errors that led to the drug shortage won't happen again. They can't be as reassuring when it comes to corruption that demands bribes for everything from surgery to clean sheets.

Researchers at the Russian Academy of Sciences' Open Health Institute estimate that corruption siphons off as much as 35 percent of money spent on health care. Low wages perpetuate the problem; yearly doctor salaries in Russia average $5,160 to $6,120. Nurses make an average of $2,760 to $3,780 annually.

Pavlova estimates that Ziyayetdinova's family shelled out nearly $5,000 in bribes during the time Ziyayetdinova was hospitalized.

At a skin clinic in Moscow, nurses charged $20 each time they applied ointment to Ziyayetdinova's bedsores. One of her sons began sweeping up her ward during visits because a nurse said room cleanup was the responsibility of patients or their families -- not hospital staff.

The money never really helped. Ziyayetdinova died. Doctors said she died of a heart deficiency, but Pavlova and Ziyayetdinova's sons are convinced the indifference and neglect Ziyayetdinova endured during her hospitalization contributed to her death.

"It was as if their goal wasn't to save someone's life," Pavlova said, "as if they thought their role was to be a last stage before death. To be a place that prepares a person to die."

The Chicago Tribune reports on the horror of so-called "health care" in Vladimir Putin's Russia (for more on this subject, check out Grigori Pasko on Robert Amsterdam):

Health care is supposed to be free in Russia, but Russians know that every hospital has its under-the-table price list.

That's why the family of Khazerya Ziyayetdinova, a 70-year-old woman suffering from severe bedsores, brought cash every time they visited her at Hospital 67 in Moscow. To have Ziyayetdinova recover in a room instead of the hallway, relatives slipped an orderly $300. They paid nurses $20 to give injections, change bedpans and unclog catheters. Every chat with Ziyayetdinova's doctor cost $40.

"Our health-care system is still in the Middle Ages," said Vera Pavlova, Ziyayetdinova's daughter-in-law, sitting in her home in this small town 54 miles southwest of Moscow. "There's low professionalism, corruption — it makes me very worried about finding myself in a situation where I might need medical treatment."

Russia is an unhealthy nation, and its health-care system is just as sick. Its hospitals are understaffed, poorly equipped and rife with corruption. The biggest reason Russia's population plummets at a rate of more than 700,000 people each year is not that its birthrate is so low, but that its death rate is so high. The average life expectancy for Russian men is 59. In the U.S. it's 75; in Japan it's 79. Alcohol and smoking are major culprits. Both are linked to heart disease, and in Russia, the rate of men ages 30 to 59 dying from heart disease is five times that of the United States, according to researchers at Columbia University.

Prevention and better health care can help reverse that trend. The Russian government is pumping $6.4 billion into revamping health care; much of that money is paying for the construction of eight high-tech medical centers across the country, new X-ray machines, electrocardiograms and ambulances at hospitals, and raises for family doctors. But doctors and nurses in the Russian Far East city of Amursk are still waiting for the overhaul to reach their hospital. In January 2007, the hospital ran out of syringes and asked patients to bring their own, said Olga Cherevko, a nurse at the hospital. Even something as fundamental as keeping pharmacies stocked can prove problematic for Russia's beleaguered health-care system. A bureaucratic breakdown in late 2006 led to a severe shortage in government-supplied prescription drugs.

Russians with enough money were able to buy medicine privately. But hundreds of thousands of Russians with high blood pressure, diabetes, asthma and other diseases had to do without the drugs for weeks. Russian officials have promised that the errors that led to the drug shortage won't happen again. They can't be as reassuring when it comes to corruption that demands bribes for everything from surgery to clean sheets. Researchers at the Russian Academy of Sciences' Open Health Institute estimate that corruption siphons off as much as 35 percent of money spent on health care. Low wages perpetuate the problem; yearly doctor salaries in Russia average $5,160 to $6,120. Nurses make an average of $2,760 to $3,780 annually. Pavlova estimates that Ziyayetdinova's family shelled out nearly $5,000 in bribes during the time Ziyayetdinova was hospitalized.

At a skin clinic in Moscow, nurses charged $20 each time they applied ointment to Ziyayetdinova's bedsores. One of her sons began sweeping up her ward during visits because a nurse said room cleanup was the responsibility of patients or their families—not hospital staff. The money never really helped. Ziyayetdinova died. Doctors said she died of a heart deficiency, but Pavlova and Ziyayetdinova's sons are convinced the indifference and neglect Ziyayetdinova endured during her hospitalization contributed to her death. "It was as if their goal wasn't to save someone's life," Pavlova said, "as if they thought their role was to be a last stage before death. To be a place that prepares a person to die."

Writing in the Moscow Times Daniel Kashnitsky, an associate at Transatlantic Partners Against AIDS and the Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria, explains how Vladimir Putin's total failure to address Russia's AIDS crisis forces private business to try to do so in his stead.

Russian business leaders are very aware of the negative role that alcohol and drug abuse play on the workplace, but the potential threat that HIV poses to the strength of the private sector is not as high on the corporate agenda. It should be.

The spread of AIDS should be a concern to all of us. Russia has the highest number of HIV-positive cases in Europe. Failure to address this problem could significantly hamper the ability of companies to effectively operate in the highly competitive global marketplace.

Corporations can protect themselves by integrating education and prevention into workplace health care programs. The number of companies with workplace policies on HIV has almost tripled over the past two years, but more needs to be done. Only 15 percent of Russian companies have initiated AIDS prevention programs, and only 10 percent have adopted special policies protecting the rights of HIV-positive employees.

Today, there are more than 300 governmental and nongovernmental AIDS prevention projects in Russia. Most of these initiatives, however, are targeted at either students or other risk groups. Very few of them address the adult working population.

Although many companies have taken action to protect their employees' health and some even support community initiatives, it's clear that we have more work ahead of us to convince business leaders that AIDS poses a direct and serious threat to their work force.

More than 74 percent of Russian business leaders say alcohol has a significant negative impact on the competitiveness of their companies, according to a survey that was conducted by the Transatlantic Partners against AIDS and the Russian Managers Association. Nearly half of the respondents said drug abuse had a negative effect on their companies' operations. But only 12 percent of respondents said AIDS was negatively influencing their companies' competitiveness.

Many of our CEOs and executives have not yet experienced the direct impact of AIDS because most employees who are HIV-positive have not yet developed AIDS-related illnesses. But the epidemic is a ticking time bomb that, if left ignored, will explode in the next few years.

We cannot ignore the fact that Russia faces the fastest growing epidemic in Europe. Corporations need to act now to help our employees remain healthy and disease-free.

The Russian websites Noviye Izvetiye and Newsru.com report that Putin's Russia is now a world leader . . . in suicide, especially among children.

Russia ranks second in the world in the number of suicide. This information was reported at the end of last week by Tatyana Dmitriyeva, Director of the Serbsky State Scientific Center of Social and Forensic Psychiatry. And increasingly suicidal are children and adolescents. In 2007 alone almost three thousand Russians aged from 5 to 19 years committed suicide. In the past thirty years, the rate of suicide has risen by a factor of thirty. Moreover 70% of adolescent cases involve children from the very affluent families. Experts believe that apart from the major causes - conflict in the family and with other people - the decision to withdraw from the life by teenagers s driven by the accessibility of alcohol and drugs. In addition, Russia still has no system for preventing suicide.

Ah, the paradise that is Vladimir Putin's Russia. Why, of course there is no program to counsel suicide cases -- because everyone knows that nobody wants to kill themselves in Putin's paradise -- just as was the case in the USSR.

Speaking of the USSR, did it occur to these doctors that perhaps the reason suicide numbers appear to be rising is that information is more available now than under the totalitarian dictatorship? And more important, did it occur to anyone that if suicides really are way up recently, it might be because of the trauma associated with the collapse of the USSR, in which case it might be a really bad idea to make the same mistakes all over again, such as being ruled by the KGB, and thus causing Russia as well to collapse?

Apparently not.

The St. Petersburg Times heaps on more horror:

Russia’s current healthcare system cannot cope with the scale of what they see as a cancer epidemic in the country, a number of Russia’s top oncologists admitted at a conference in Moscow on Monday.

Each year in Russia, 300,000 people die of cancer. Around 2.5 million Russians suffer from cancer, and more than 450,000 new cases are registered annually. The average age of cancer patients in Russia is 63.3 for men and 62.9 for women.

Cancer specialists are calling for the government to take immediate steps, including funding a federal program aimed at combating cancer. “A special service must be created that would be directly responsible to the government and the parliament,” said Mikhail Davydov, the president of the Russian Academy of Sciences. Davydov was speaking at the “Movement Against Cancer” forum that opened in Moscow on Monday. “But most importantly, the state is responsible for the health of its citizens, including the two million cancer sufferers,” he said. Davydov urged the government to substantially increase the funding for buying more equipment and medicines to enable doctors to provide the necessary treatment for all patients.

“For instance, Russia has only 70 radiation therapy machines, while there are around 3,000 in U.S. clinics,” Davydov said. To make matters worse, of the very few machines that Russia does have, a large proportion are outdated and are therefore of little help.

The gap between conditions in some Moscow clinics and hospitals in small towns in other regions is huge and felt on all levels, from equipment to training, experts say.

Healthcare is one of Russia’s four declared “national projects,” along with education, housing, and agriculture. First Deputy Prime Minister Dmitry Medvedev, President Vladimir Putin’s handpicked successor, is responsible for these projects. However, oncology or cancer treatment is not listed as a priority in healthcare projects, Davydov said.

Cancer is widely seen in Russia as an untreatable illness. Public awareness of new methods and medicines is very low, the doctors said. Vladimir Semiglazov, the director of the Petrov Oncology Institute, said many Russian women are reluctant to undertake regular breast screening, and often contact clinics when the illness is in an advanced stage. “In countries where women undergo regular breast screening, the number of fatal cases of breast cancer has been in decline,” Semiglazov said. “In Russia, by contrast, breast cancer fatalities have increased by 13 percent during the past 8 years.” Semiglazov said the breast cancer statistics for Russia today are seemingly worse than Soviet era figures, when fewer opportunities were available in terms of both screening and treatment. In 2006, almost 20 percent of all breast cancer patients died in Russia, whereas only 13.5 percent of patients died in 1980. Many people postpone seeing a doctor until it becomes impossible to ignore symptoms and the disease progresses to its final stages.

Boris Poddubny, head of the endoscopic division of Russia’s Blokhin Oncology Medical Center, urged doctors to change their attitudes and be more outspoken both with their patients and the media. “People need to know as much as possible about their condition and what can be done to help it,” Poddubny said. “They need to know that there are methods and medicines to treat their illness. At the very least we need to get everyone to learn once and for all that a timely diagnosis can lead to a complete recovery.” However, with many treatments unavailable, education is only part of the answer. Drugs for certain illnesses, including many types of cancer, are free on prescription and according to government estimates, about 5 million people can technically benefit from the system. But the government has failed to provide enough funds for the program. In 2007, the 34.9 billion rubles ($1.4 billion) allocated to the system was less than half the 74.5 billion rubles spent in 2006, Dmitry Reikhart, head of the Federal Fund for Obligatory Medical Insurance, told reporters at a Moscow press conference in October 2007.

To complicate matters further, the government has been slow to pay drug providers, resulting in diminished supplies. The state debt amounts to about 20 billion rubles, down from about 36 billion rubles in January 2007, according to Tatyana Golikova, minister for health and social development.

Paul Goble reports more evidence of the Kremlin's total indifference to the plight of the vast majority of Russia's people outside Moscow as it continues its obscession with waging cold war and turning Moscow itself into a Potemkin-like showpiece:

The network of apothecary shops that had supplied Russians living in rural areas with medications in the past has almost completely disintegrated, and as a result, some 38 million Russians -- almost 30 percent of the country’s total population -- cannot easily obtain the drugs they need even when they have the money to buy them. Not only are many of these people suffering horribly as a result, but a significant percentage of them is dying prematurely, driving down life expectancies among Russians and further complicating the resolution of the country’s much-discussed demographic difficulties. Such a situation is especially tragic given the Russian Federation’s celebrated wealth from oil and gas, but it is even more disastrous because it appears to be in large measure the result not so much of the transition from communism to capitalism but rather of pathetically bad planning by legislators and other officials.

In the words of the Moscow newspaper Gazeta [on December 26th], these officials “successfully destroyed the old system” in which often poorly trained medical workers dispensed medications in rural areas without figuring out how to put “in its place” a new and more effective one. As is often the case with such situations, there were good intentions all around. Moscow officials wanted to ensure that apothecary shops would be large and well-stocked and that these outlets would be operated by licensed pharmacists to ensure that the right medicines were dispensed. In principle, of course, that is laudable, but such licensing requirements ignore several fundamental realities. On the one hand, most of the relatively small number of licensed pharmacists have gravitated to the cities where incomes are higher. And on the other, most villages are too small to support either one of them or a modern apothecary shop.

Moscow officials seem to have been operating on the assumption that village residents could easily travel to district or regional cities for their medicines. But that ignores two of Russia’s biggest problems: its impassable roads and its often even more horrible weather.
At the present time, approximately one-third of Russia’s villages are not connected to the outside world by roads of any kind. And even those that are find themselves in difficulty: in the spring and fall because of mud and in the winter, often very long in Russia’s northern regions, because of unplowed snow. Of course, as the Moscow newspaper pointed out, access to medications is far from perfect even in the cities. The Russian Federation does not produce some basic medications or import enough for those who could benefit from them. And not every urban resident has the money to purchase those that may be on the shelves.

According to Gazeta, officials at the Russian Federation’s health ministry have discussed all these problems repeatedly. But they lack the funds to buy more drugs or to pay for the upkeep of pharmacies in most rural areas, and market forces Moscow now hopes to rely on are typically insufficient to address in a serious way either problem. Unless something is done and done soon, however, many more Russians in rural areas are going to become victims of a system that may reward young people in the major cities with new wealth and opportunities. And as these rural Russians become conscious of their common status and their large number, they could become politically important. The daily paper suggested that in many villages, the only thing such Russians could do is to pray so that they will get well without having to take any medications. But it is entirely possible that at least some of them will first focus their anger at those politicians and commentators who suggest that life is getting better in Russia with each passing year.

The International Herald Tribune reports:

Authorities have culled more than half a million domestic birds on a farm in southern Russia hit by the H5N1 strain of bird flu, officials said Tuesday. More than 600,000 chickens on the Gulyai-Borisovskaya farm in the Rostov-on-Don region have been destroyed to prevent the virus from spreading, said Oleg Ugnivenko, a spokesman for the regional branch of Russia's Emergency Situations Ministry. The virus also sickened birds in the neighboring Tselinsky district, and authorities have taken steps to stop it from spreading, Ugnivenko said.

In September, authorities reported an H5N1 outbreak at a poultry farm in the neighboring Krasnodar region, and early in the year the strain was confirmed in several other regions across Russia.

No human cases of bird flu have been reported in Russia, which had its first reported cases of H5N1 in Siberia in 2005. World health authorities are tracking the H5N1 strain out of concern that it could mutate into a form more easily transmitted among people, sparking a global flu pandemic.

Writing on Robert Amsterdam, hero journalist Grigori Pasko extols the glories of Vladimir Putin's healthcare system. Oh, what a country!

I’ve got the compulsory medical insurance policy of a citizen of the Russian Federation. According to this piece of paper, I have guarantees of receiving medical aid at medical institutions under the compulsory medical insurance program. At any rate, that’s what the paper says: “have guarantees”. And I had always thought that I had these guarantees. Until today.

Today (I’m almost embarrassed to say!), I cut my finger. At home. In the kitchen. It can happens to anyone. Unfortunately, I cut it in such a way that it didn’t stop bleeding for a long time. No matter what I tried, the blood just kept gushing out like a river.

I had to go seek medical attention. Good thing there was a «Family medical center» right next to my home. I had never been there before, and figured this was probably as good a time as any to pay them a visit. With my finger.

The Moscow Times reports:

A bird flu outbreak has killed 35,000 chickens at a Rostov region poultry farm, the Emergency Situations Ministry said Tuesday. The chickens began to die off at the Gulyai-Borisovskaya Poultry Farm last week, but experts were only able to confirm on Tuesday that they were afflicted with the deadly H5N1 strain of bird flu, said Oleg Grekov, a spokesman for the ministry's southern regional center. The highly pathogenic strain can spread to humans. "A quarantine is in place, and the appropriate services are taking the steps needed to stop the outbreak," Grekov said by telephone from Rostov-on-Don. Grekov said there were 500,000 chickens at the farm. A woman who answered the phone at the farm said she did not know about the outbreak and denied that chickens were infected with bid flu. She declined to give her name.

Writing for Transitions Online, Galina Stolyarova of the St. Petersburg Times reports on the horror of getting sick in Vladimir Putin's wealthy, resurgent Russia:

The old man standing in front of me in the line seemed on the verge of fainting, his eyes scanning the walls without seeming to focus. Several times I thought he would fall over. Finally he reached the front of the line and the pharmacy clerk inspected his prescription. Then she handed it back to the old man, saying his medicine was no longer in stock. The old man closed his eyes. He barely seemed able to move his lips, but eventually I heard the words, "Then why didn’t you tell people? So painful to stand." He stood there in the pharmacy in the Kirovsky district of St. Petersburg, not knowing what to do, as a short elderly lady came up to me. She, too, had been unable to get the medicine she urgently needed. "My blood pressure is so high, I really should be lying in bed," she said. "It has been pretty bad recently, and I don't know how I'm going to get home. There are probably too many ill people in Russia. The authorities can't just pick up a gun and shoot us, so they're killing us like this, leaving us with without help. This is killing! Killing!" she repeated. “Why did you move the cancer patients here?” a pale middle-aged woman hollered, as she waited, almost doubled up in pain. Apparently those needing cancer drugs had been getting them until recently from another pharmacy nearer her home. She was at the back of line of about 30 people clutching their prescription forms. After a while, no longer able to stand, she slumped to the floor.

I stood with them for three hours, holding insulin prescriptions for my diabetic relative. Throughout that time the elderly and sick people groaned and cried out in pain and desperation. One woman burst into tears when she was told the pharmacy had only half the pills she needed. At one point a group of the less frail patients seemed close to storming the counter and breaking the windows. “Shut up, or we will close the window right now!” a pharmacy employee shouted at the crowd. There was a sudden shocked silence. I could sense the almost physical panic and fear as those people faced the prospect of walking home empty-handed.

The reason why so many sick and infirm people were jammed into that one pharmacy was simple. It was the only one in three adjacent districts of St. Petersburg that supposedly had those precious medicines in stock. Every day in Russia, an army of severely ill people ­ suffering from cancer, diabetes, heart problems, and other diseases strugglees and jostles for the chance to get medicines. In theory, drugs for certain illnesses are free with a prescription. According to government estimates, about 5 million people can technically benefit from the free drug system at the moment. But the government has failed to provide enough funds for the program. This year’s budget for free drugs, 34.9 billion rubles ($1.4 billion), is less than half the 74.5 billion rubles spent last year, Dmitry Reikhart, head of the Federal Fund for Obligatory Medical Insurance, told reporters at a Moscow press conference earlier this month. To complicate matters further, the government has been slow to pay drug providers, resulting in diminished supplies. The state debt amounts to about 20 billion rubles, down from about 36 billion rubles in January, according to Tatyana Golikova, the country’s new minister for health and social development. As a result, those who have no other way to buy their medicine are effectively forced to compete for survival.

SICK AND TIRED

My relative undergoes this ordeal every two months. And, as in a triathlon event, she has to complete every stage correctly to get to the end.

• Step 1 is to secure an appointment with a doctor and get the prescription written. Because of the shortage of doctors she may wait up to half a day in a clinic even after getting the appointment.

• Step 2 is more hit-or-miss. She has to phone around to find the nearest pharmacy with her medicines in stock. Many of the calls are fruitless, and this quest can take days or weeks.

• Step 3: Get to the pharmacy and spend hours in line, hoping that supplies will last until you reach the counter.

A prescription is valid for only a month, and if that time runs out you must go back to stage one and get a new one. I know diabetes patients who have to beg and borrow insulin shots from fellow sufferers just to stay alive for the next few weeks, due to the scandalous chaos of Russia’s drug supply system. Of course if you can pay full price for the drugs, there is no delay. But a monthly supply of insulin costs more than a monthly disability pension of, say, 3,000 rubles, or about $120. For cancer sufferers the market price of drugs can be far greater and well beyond the reach of all but the wealthy. A course of the anti-cancer drug Avastin might be around $10,000.

Russian writer Igor Alexeyev, a resident of the southwestern city of Saratov who suffers from advanced intestinal cancer, chronicles the experience in a weekly blog. He describes the insomnia by night and the torture to his body by day as he endures endless journeys along rutted provincial roads trying to get treatment and medicines. Readers of his blog have responded by sending donations, which he uses to pay for his Avastin. On one occasion Alexeyev reported his amazement at actually being able to get the medicine from his local pharmacy. But in this deadly game the rules can change without warning. The regulations about what details to put on the prescription form may be altered. And if a stamp or signature is missing, or if there is a typing error, the pharmacy may reject it, and the triathlon starts all over again. And while a new prescription is being obtained supplies of the medicine may run out again.

With the Duma election campaign in full swing, political parties are making wild promises, including re-nationalizing natural resources. However, despite Russia’s vast oil and gas wealth and the country’s massive $141 billion stabilization fund, no party has yet promised to provide enough medicines to end the nightmarish ordeal of millions of cancer, diabetes, and heart patients. Health care is one of Russia’s four declared national priorities, along with education, housing, and agriculture. First Deputy Prime Minister Dmitry Medvedev constantly tours the country to check on progress in these areas. Lengthy TV reports show him visiting new clinics and smiling at the happy faces of the patients. But never have we seen the minister set foot in a pharmacy being besieged by patients sick and desperate for medicine.

The advertised goal of these policy projects is to raise the quality of life. But to do that, the existing reality first needs to properly assessed. It's a bit like raising a ship that has foundered. To ensure success the salvage team needs to know just how far down the vessel has sunk. If Medvedev were to spend just an hour in such a prescription line he might get some useful ideas out of it, if only to fork out more cash for anti-cancer drugs. He would be forced to confront the hollow and false glossy image of Russia’s public health system that he and the government routinely promote on TV. If Medvedev wants the truth, that is.

Yesterday, we reported on how Russia leads the world in smoking and the adverse health consequences resulting therefrom. Today, we report on the other side of Russia's double whammy, namely booze. Paul Goble reports:

Russian adults, according to Moscow officials, currently consume some 30 liters of pure alcohol every year, a figure that is more than three times what the World Health Organization says is dangerous and one that is eight times the amount Americans drink. But because this official figure measures only officially registered distilled spirits and does not include additional liters of pure alcohol from illegally produced samogon (Russian for “moonshine”) or from what Russians call alcohol “surrogates,” the actual among of alcohol consumption among Russian adults may a third or more again higher. As a result, as members of the Duma were told this week, such high rates of alcohol consumption now play a direct or indirect role in nearly one-third of all Russian deaths and thus constitute a threat not only to popular well being but also to that country’s national security. During the course of a roundtable earlier this week, members of the Duma not only listened to reports about this general state of affairs but had their attention directed both at its specific features and what they might do to try to correct this situation.

According to the state statistical administration, something over 40,000 Russians die from alcoholism or alcohol poisoning each year, but the real impact of their heavy drinking on the country’s death rate is far larger, if not always understood or acknowledged. Sustained heavy drinking leads to a variety of illness, murders and suicides, automobile and other accidents, and the disintegration of families, and all those things in turn are behind 550,000 to 700,000 of the 2.2 million deaths recorded in the Russian Federation on average in recent years. But two additional elements to this story, the Duma deputies were told, make it especially tragic. On the one hand, Russians legally purchase 80 percent more alcohol than the country produces through their purchase of the large volume of alcoholic beverages now flooding into the country. And on the other, they drink each year “not less than 600 million liters” of samogon, according to the Interior Ministry which is able to seize only about one percent of this amount, as well as unknown amounts of other surrogates like perfume or industrial fluids not intended for human consumption.

In relatively well-off Moscow, Russian experts say, illegally produced samogon and surrogates of one kind or another probably account for only about one-quarter of total amount offered for sale, but in poorer and more isolated regions of the country, that figure may now have reached the far more dangerous level of 40 or even 50 percent. Although this does not appear to have been mentioned at the Duma meeting, that pattern is behind one slightly more optimistic prediction: As Russians become relatively better off because of higher oil prices, they drink more vodka but less samogon and surrogates, and thus they are less likely to die as a result. That conclusion was first advanced by Russian demographers in the so-called Izhevsk study last year and reinforced by the subsequent experience of Pskov oblast.

Despite the comment of one participant at the roundtable that “laws do not work” in this sphere in Russia, the parliamentarians discussed what they might do legislatively. Among their ideas: raising the drinking age to 21, banning alcohol advertising, forced treatment of alcoholism, and a state monopoly on alcohol production. Both individually and collectively these measures would have some impact on the amount of alcohol Russians consume and thus on the health of that nation, but many of the problems Russia faces now as in the past are the result of efforts by individual drinkers to get around just such laws, be they tsarist, Soviet or Russian. And there is even the danger that such legislation, however attractive its staated purposes may be, could in fact make the situation worse by driving even more Russians away from officially produced and in smaller amounts relatively safe distilled spirits and toward more dangerous samogon and surrogates.

Robert Amsterdam points to an article in Kommersant which reports that Russia is now the #1 smoking nation on the planet. Way to go, Russia! Another category (like fraud, violence, pollution) where you lead the world! There's no stopping Russia under KGB rule! What wise folks those Russians are!

Russia is the country, where the habit of smoking is most popular. Some 65 percent of men and 30 percent of women smoke here. Of them, 80 percent and 50 percent respectively started smoking before getting 18 years old, signaled statistics of Rospotrebnadzor timed to the World No Tobacco Day.

Over 3 million teens, 2.5 million boys and 0.5 million girls, smoke in Russia. The trend is that smoking is becoming more popular with youth, and regular smokers are younger now. In the age group of 20 years old to 29 years old, the share of smoking women is 10 fold above the share registered for the women older than 60 years.

According to Rospotrebnadzor, exactly tobacco is the cause of mortality from lung cancer (90 percent of all cases), bronchitis and emphysema (75 percent), heart disease (25 percent). Some 25 percent of regular smokers die prematurely.

In the world, around 5 million annually die from smoking tobacco.

At the same time, the prices for tobacco are the lowest in Russia today. “The wide price range and reduction in cigarette price vs. other consumer goods ensure economic accessibility of cigarettes for all groups of the population,” representatives of Rospotrebnadzor said.

The Moscow Times reports:

Russia's failure to provide adequate treatment for drug addiction is leaving addicts "virtually to their own devices" to battle substance abuse and putting users at an increased risk for serious diseases, an international human rights group said Thursday. The effectiveness of drug addiction treatment in Russia "is so low as to be negligible," Human Rights Watch said in a summary of a 110-page report on Russian drug-dependence treatment. "This leaves [drug abusers] vulnerable to HIV infection, other drug-related health conditions, and death by overdose," Diederik Lohman, senior researcher in Human Rights Watch's HIV/AIDS and Human Rights Program, said in the report. Exacerbating the problem, the report said, are short treatment periods, few state rehabilitation centers and the fact that addicts are hesitant to seek help because their names are entered into a registry of alcoholics and drug addicts. Furthermore, it said, Russian bans the use of methadone and buprenorphine in treating people addicted to opiates -- such as heroin -- despite evidence of their effectiveness in other countries. Yelena Sokolchik, a senior drug addiction official in City Hall, dismissed several of the report's claims. "All patients whom we manage to persuade to undergo rehabilitation are treated for at least a year," she said. Federal health officials had no immediate comment.

Scholar Paul Goble exposes yet another outrageous incidence of the Kremlin's total disregard for the well-being of the people it purports to govern:

Despite dramatic increases in the incidence of diabetes in the Russian Federation, that country still lacks a domestic producer of insulin and has not been willing or able to purchase sufficient supplies abroad to meet domestic requirements, according to two Moscow investigators who have examined this situation. As a result, Boris Mironov and Vladimir Chertovich say in an article posted online this week, many Russian diabetics are not getting the medicines they need, a shortcoming in Russian pubic health that often produces other illnesses and premature deaths. To a large extent, of course, the story of Russia’s insulin shortage is part of broader problems there: the reduction of state subsidies for medications, the collapse of the health delivery system in certain regions, and even the inability of many Russians to get to drug outlets because of Russia’s diminished system of public transport. But these problems have been compounded by new reports suggesting that a decision the Russian health ministry made last February when it directed public hospitals and clinics to screen guestworkers for disease and then to those needing it at low cost. That decree, recent reports suggest, has led to a sharp rise in the number of immigrants who come to Russia not to work but rather to obtain inexpensive medical treatment and also to anger among many Russians who conclude that their government appears to be discriminating in favor of immigrants and against Russian citizens.

What makes the insulin situation especially infuriating, Mironov and Chertovich say, is that the Russian government has allocated millions of rubles to remedy it, steps health ministry officials have pointed to with pride, but so far, these funds have not helped any diabetics but rather enriched corrupt officials and businessmen. The two journalists describe how the health ministry has repeatedly given large sums of money to Russian and foreign companies to manufacture insulin even after these companies have failed to deliver on their promises. Only recently, when some of these funds ended up in the U.S., did prosecutors charge anyone with corruption or fraud. Such charges represent a useful first step, Mironov and Chertovich admit, but they argue that what has really occurred in this case is “not theft and not corruption” alone. Rather, they write, it is something much worse: “the intentional murder of the nation” by depriving its citizens of needed medicines. And they conclude in anger that when it comes to the lack of insulin for diabetics and the deaths that have and will result, “the murderers are the power structures of Russia” who allowed this to happen, even though they have sought to present themselves as the guardian of the country.

Science Daily reports:

Hundreds of thousands of birds at a poultry farm in Russia's southern Krasnodar Terroritory are being destroyed following an outbreak of bird flu. Russia's agricultural watchdog says the lethal HRN1 avian flu virus was discovered after some 500 chickens died on September 4, RIA Novosti reported Monday. The day after the infection was confirmed, 22,000 birds were slaughtered. Officials say by the time the operation ends, 248,000 chickens will be culled in an effort to prevent the outbreak from spreading. So far, no human deaths from bird flu have been reported in Russia. In 2006, more than a million birds were culled, slightly less than the number recorded in 2005. Officials consider Russia's Krasnodar Territory at higher risk for bird flu because it is on the route migrating birds take. However, the World Health Organization says most of the spread of bird flu is through poultry and the poultry trade.

The Moscow Times reports that not only is Putin's Russia's blood supply egregiously tainted, it's running out of even that shoddy supply. More proof that Russia is a backwards, third-world state that doesn't belong on the G-8 or UN Security Council.

The country does not have enough blood to meet its emergency needs, while blood donated in the country is up to 1,000 times more likely to pass on diseases than in the European Union, according to a leaked federal health inspection service memo.

Russia is not prepared for "civil and military emergency situations requiring donated blood," and the risks of HIV/AIDS, hepatitis and other infections transmitted through transfusions is from 500 to 1,000 times higher than in the EU, said the memo from the Federal Health and Social Development Inspection Service, which was obtained by Kommersant.

Russians donate blood at a rate half that of Europeans, and the number of names on the country's donor register has fallen from 4 million to 1.8 million over the last 10 years. Over the same period, there have been 65 cases of HIV infection from blood transfusions, the document said.

Inspection service spokesman Alexei Sapkin said he could not comment on internal memos, but that the situation was critical and the entire blood transfusion system needed to be brought up to international standards. The problem is less a lack of donors than the general state of medicine in the country, said Yevgeny Zhiburt, chief blood therapist at the National Surgery Center. He said 24 units of blood were used per 1,000 people in Russia, compared with a figure of 109 per 1,000 in the United States, indicated that many more complicated surgical procedures are being performed there. The system for distribution of blood and different blood components is also a problem. Zhiburt said 20 percent of all red blood cell units end up going unused. Alexei Maschan, head of the Hematology Department of the Russian Children's Clinical Hospital, said this was largely because there was no centralized database allowing blood to be used more effectively. "There is no logical system of blood preparation and usage in the country," he said. The lack of a centralized system also contributes to the problem of blood safety. In the Netherlands, for example, there is one central laboratory that tests blood for diseases. Zhiburt said the number in Russia was 600, and many of these laboratories were still working with obsolete equipment.

Axcess News reports on wealthy, healthy Russia, a paradise under Vladimir Putin
. . . except of course for small matters like being ravaged by tuberculosis at a rate more than twenty times higher than in the United States, the 11th highest rate in the entire world.

Russia's high rate of tuberculosis will decline when living conditions improve, experts on health issues said Tuesday during a discussion at the Woodrow Wilson Center. The experts said the main reasons for the TB problem in Russia are that people don't eat properly and don't have an appropriate system of health care to diagnose TB. They said it is less possible to overcome this disease without normal nutrition and living conditions. In Russia, high rates of alcoholism and drug addiction also add to the problem, experts said during the discussion. The experts recommended Russians should know more about the problem of TB and its treatment.

In Russia in 2002, according to statistics presented at the conference, 113 of every 100,000 people had TB. In the U.S., five people per 100,000 had the disease. Russia ranks 11th in TB rates in the world after African and Asian countries, according to the 2005 report of the World Health Organization. About 73 Russians die every day because of TB, according to Russian state statistics. Mortality due to TB is three times higher among men than among women in Russia, according to the WHO report.

People with TB suffer from constant coughing, usually with high fever. As they cough, infected people transfer more TB bacteria to those around them. Specialists say that anyone with health problems is susceptible to TB infection. Those with HIV and pregnant women are more likely to become infected. According to the WHO statistics, the rate of TB in Russia remains the same as it was during Soviet Union times. Russia has several state programs to support ill people, but the experts said the system of diagnosis and treatment needs modernization and more money from the state budget. Salmaan Keshavjee, an associate physician at the Brigham and Women's Hospital in Boston, headed a project in the central Russian province of Tomskaya Oblast to support sick people with medication and diagnostics. In 2001, nearly 40 percent of the population of the province had TB, he said. His group worked with about 250 people. At the end of the project, 188 people were cured and 12 died, Keshavjii said. Their patients' main problems were poverty and alcoholism, he said. Keshavjee said prisons house the most people with TB. There, the rate of sick people is 30 times higher than among civilians. The main reasons for that, Keshavjee said are bad conditions and that the prisons are usually overcrowded.

Most forms of TB can be treated with a variety of drugs. The conference was part of the Wilson Center's Global Health Initiative, which provides an interdisciplinary forum for examining health issues

Russian dictator Vladimir Putin is doing a wonderful job supplying the Iranians with nuclear power and the Venezuelans with weapons. How is he doing supplying healthcare services to sicks Russians? The International Herald Tribune reports:

When Karen Papiyants lost his leg in a road accident last year, his medical nightmare was only beginning. Although like any Russian he was entitled to free treatment, he says the doctors strongly suggested he pay $4,500 (€3,500) into their St. Petersburg hospital's bank account, or be deprived proper care — and perhaps not even survive. Faced with that choice, the 37-year-old truck driver's relatives scrambled to scrape together the money. But Papiyants said that didn't stop the nursing staff from leaving him unattended for most of the night and giving him painkillers only after he screamed in agony. "It's nothing but blackmail and extortion on the part of doctors," Papiyants said.

In theory Russians are supposed to receive free basic medical care. But patients and experts say doctors, nurses and surgeons routinely demand payments — even bribes — from those they treat. And critics say the practice persists despite Russia's booming economy and its decision to spend billions to improve the health care system. Medical care in Russia is among the worst in the industrialized world. A 2000 World Health Organization report ranked Russia's health system 130th out of 191 countries, on a par with nations such as Peru and Honduras.

This is one of the few nations in the world where life expectancy has declined sharply in the past 15 years. The average Russian can expect to live only to age 66 — at least a decade less than in most Western democracies, according to a 2005 World Bank report. For men, the figure is closer to 59 — meaning many Russian men don't live long enough to start collecting their pension at age 60. Compounded by alcoholism, heart disease claims proportionately more lives than in most of the rest of the world. Death rates from homicide, suicide, auto accidents and cancer are also especially high.

Russia's population has dropped precipitously in the past 15 years, to below 143 million in what President Vladimir Putin calls "the most acute problem of contemporary Russia." In 2004, according to the Organization for Economic Cooperation and Development, Russia spent $441 per capita on health care, about a fifth of what the EU spends. Over the past two years the government has more than doubled health care spending to some $7 billion (€5.2 billion), but that still works out to only about 3.4 percent of all government spending, and the World Health Organization recommends at least 5 percent.

Experts here say new spending does little if it fails to tackle corruption. The state covers all Russians under a standardized medical insurance package, while well-heeled citizens can buy extra insurance and be treated privately. In the Soviet era, patients occasionally rewarded doctors with money or gifts, but were largely guaranteed free treatment. The Soviet Union's public health system was, for a time at least, considered among the world's best. But the system failed to keep up with Western medicine, and after the Soviet collapse, went into decline. Today, many who can't afford to pay or bribe — especially those in remote provinces — may never receive proper care.

Some experts say this has helped drive up death rates. "Corruption in health care is a threat to Russia's national security in the broadest sense of the word," said Yelena Panfilova, head the Russian branch of Transparency International, a global corruption watchdog. According to a summer 2006 study commissioned by the group, 13 percent of 1,502 respondents who had sought medical help during the previous year had to pay an average of $90 under the table, out of wages averaging $480 a month. The poll had a margin of error of 2.6 percentage points. Panfilova also said medical and pharmaceutical companies routinely bribe health officials so that hospitals buy their equipment and medicines, even though their quality is often not the best. Kirill Danishevsky, a health researcher with the Russian Academy of Sciences' Open Health Institute, has estimated that up to 35 percent of money spent on health care consists of under-the-table payments. At the Dzhanelidze Emergencies Institute where Papiyants was treated, spokesman Vadim Stozharov denied that doctors refused to provide free care. But he conceded the hospital has received so many similar complaints it set up a hot line to deal with them. The Health Ministry declined to comment on the bribery allegations. But Galina Lavrishcheva, the top health official in Stupino, an industrial town in the Moscow region, acknowledged that health care workers sometimes demand payoffs. "Yes, it is true, I am not going to hide it — extortion takes place," Lavrishcheva said. The Stupino regional hospital is at the forefront of government reform efforts. Officials have fought overcrowding by cutting the number of beds from 800 to 625, have set up an outpatient clinic and have installed new equipment, including ultrasound and electrocardiogram machines.

Overspecialization, a legacy of the Soviet era, is a big problem because patients are shuttled from one narrowly focused specialist to another. Meanwhile, no physician generally takes responsibility for their state of health. Dozens of Stupino's specialists have been retrained as general practitioners and their salaries raised to reduce the lure of bribes and create incentives for more doctors to become GPs. Yelena Filippova, a freshly retrained GP, now treats some 2,000 patients and earns $700 (€515) a month, more than double her previous salary. Filippova, 27, says the system is more efficient. Her patients like it as well. "It's professional, it's high quality, it's quick and convenient — you don't have to stand in lines," said Viktor Lenok, a 60-year-old retiree, whom Filippova treats for asthma. But critics say these changes are no substitute for radical change — just a high-profile way of spending the country's oil-driven wealth in an election year. They insist the reform does not address bribe-taking by emergency health care providers and medical specialists. "A huge heap of money is being pumped into the same health care system — but why invest into something that doesn't work?" said health researcher Danishevsky. "The very system needs to be reformed."