Slipping into critical condition Russian health system: Ordinary neglect has allowed infectious diseases that once were all but wiped out to return with a vengeance.

THE BALTIMORE SUN

DMITROVGRAD, Russia -- This pleasant, tree-lined city had a nasty visitor recently: a dysentery outbreak that sickened almost 1,900 people and left residents wondering whether they could trust their tap water.

It is a problem that no longer is a rarity. With basic sanitation and water treatment facilities deteriorating in cities across Russia, the incidence of dysentery, which is spread by fecal contamination in water or food, is up 26 percent over the past year. In the first half of 1995, 17 people died in Moscow of this easily curable malady.

As Russia's health system slips into critical condition, infectious diseases that had been nearly extinguished have returned with a vengeance.

Measles, rubella and whooping cough are now ravaging the country, and vanquished plagues such as cholera have reignited. Malaria has reappeared in areas where mosquito extermination programs have been abandoned as too costly. Tuberculosis is endemic -- and is 17 times more likely to prove fatal than in the United States. Mass food poisonings have become routine.

In a particularly horrifying development, 137 children in the southern Russian republic of Chechnya have contracted polio since March. Seven have died; the other victims, most of them younger than 2, might end up permanently disabled because of an entirely preventable disease.

Some victims were never vaccinated against polio, a scourge that was all but wiped out in the West after the development of the Salk vaccine in the 1950s. Other children were injected but probably received vaccine rendered useless by improper handling and storage.

"We have one 16-year-old girl who didn't feel well on a Saturday. She woke up the next day and couldn't move her leg," says Ailsa Denney, a nurse with the London-based medical relief group Merlin, which is helping the Chechen Health Ministry conduct an emergency immunization program. "She was vaccinated seven times."

A nation that was considered to have an effective -- albeit rudimentary -- system of public health five years ago, Russia is now slipping into the sickly ranks of the Third World.

Between 1991 and 1994, the death rate from infectious and parasitic diseases jumped 67 percent. That means 11,700 more Russians died last year than three years earlier from diseases that can be easily prevented by water and sewage treatment, basic hygiene and systematic vaccinations.

Unlike residents of underdeveloped countries, Russians are still

far more likely to die from cardiovascular disease, cancer, accidents and other hazards of industrialized society than from communicable diseases. But the abrupt resurgence of so many infectious diseases, together with an unprecedented decline in life expectancy, is a worrisome indicator of how far public health standards in Russia have fallen.

For millions, private treatment or a bribe to ensure that they are cared for decently is an unaffordable luxury.

By the government's own count, 27 percent of Russians live below the official poverty line, earning less than $67 a month. A sharp decline in living standards for the majority of Russians has meant that more people are poorly nourished and, hence, more vulnerable to disease. Fruits and vegetables in winter are beyond the means of many. Mothers complain that they do not have the money to buy vitamins for their children.

And those children are less likely to be vaccinated than ever. Factories and schools no longer receive orders from the Communist Party to vaccinate everyone within a week -- or else.

"Under the totalitarian system, we pressured people to get vaccinated," says Yuri M. Fyodorov, deputy head of the Health Ministry's infectious diseases unit. "If you didn't get your kid vaccinated, you couldn't enroll him in school."

But the system was far from perfect. Even before the demise of the Soviet Union, immunization rates were dropping. Improper vaccine storage meant that some people received useless shots, while the poor quality of some vaccines caused a high rate of allergic reactions and complications in children who were inoculated.

By the mid-1980s, leading immunologists were advising parents to shun the shots.

Despite well-publicized warnings, many well-educated Russians are still vaccination-shy. Sergei Zakharov, a demographer at Moscow's prestigious Center for Demography and Human Ecology, says his 13-year-old daughter has yet to be vaccinated against childhood diseases.

"We must do it, of course," says Mr. Zakharov, a former medical school instructor. "But I would go to a doctor I know. I would not take my child to the local clinic. I don't trust the health care system."

In Chechnya, routine childhood vaccinations apparently ceased in 1992, when rebel leaders declared the area independent.

"We asked the doctor for the vaccine, but they didn't have any," says Aminat Ulubava, 19, whose 3-year-old daughter, Markha, is now stricken with polio. She is in a children's hospital in Grozny, the Chechen capital, where polio victims lie five to an unheated room, together with their mothers, who sleep on cots and tend to them as best they can.

Polio victims can be helped through physical therapy, says Ms. Denney, the Merlin nurse, but "it's too cold for them to do the therapy, too cold to take off their clothes."

Ms. Denney says it is unclear what caused this epidemic of polio, which can be contracted through the respiratory system -- for example, among refugees crowded together in unhealthy conditions -- or by fecal contamination.

"The worrying thing about this is that 17 percent of the children who are getting it have been vaccinated," she says.

Russian officials tried valiantly last summer to prevent a major outbreak of cholera, which is ravaging Ukraine, Moldova, Belarus and Tajikistan, the Health Ministry's Mr. Fyodorov says. Eight cases have been reported in Russia, two of them fatal; Chechnya is considered a high risk.

"The hospitals have been bombed," Mr. Fyodorov says. "People don't have water. The sewer system doesn't work. In Grozny, dysentery and hepatitis are going up."

But it doesn't take a war to start an epidemic; ordinary neglect will do.

In Dmitrovgrad, where more than 1 percent of the 130,000 residents contracted dysentery last summer, the outbreak began in an area of the city that draws drinking water from the polluted Cheremshan River, a tributary of the Volga. There is no water treatment plant, only a gravity-powered system that filters the river water through soil and sand before it reaches an underground reservoir.

"The water in the Cheremshan River is totally unsuitable for use as running tap water," says Yuri F. Solovyev of the Moscow oversight committee investigating the outbreak. The level of E coli, a bacterium found in the human intestine, exceeds 200,000 per liter. The standard for drinking water is three per liter; tap-water sources should contain no more than 1,000.

"It's just dreadful," says Murray Feshbach, an American who documented the catastrophic Soviet environmental legacy as co-author of the book "Ecocide in the USSR."

In the United States, an E coli count of 200,000 "would be a scandal of the first order," he says. "But they just shrug their shoulders and say, 'If you don't die of this, you'll die of something else.' "

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