part two of New Yorker article

[Michael Denner]

I was even told, by Aleksandr Goliusov, of the Ministry of Health, that the infection rate in Russia wasn't nearly as bad as Western experts have asserted, and he implied that the West was simply trying to humiliate Russia by inflating the figures and comparing them to Africa's. He was not the only person to say this to me. "Isn't much of this coming from your C.I.A.?'' he asked, with some justification. The American intelligence community has for several years been openly concerned about the security threat that a rampant epidemic in Russia would pose; it is hardly a controversial assessment, though, since Russia maintains an enormous arsenal of nuclear weapons. "I can only work with the numbers we have,'' Goliusov said. "We receive requests for service and medication based on those numbers. The C.I.A. has issued a report saying that from three to five million people are infected with H.I.V. in Russia. That simply is ridiculous. I can agree that not every case is reported or counted properly. But the number that foreign observers say need medicine now is fifty thousand. That is just wrong. What the international organizations do is they apply mathematical models, and they said if there are seven hundred and fifty thousand infected you should have fifty thousand who are sick. But that is theory, and reality is what I get coming into hospitals and clinics.''

 

Russia is one of the world's best-educated nations-the literacy rate is above ninety-nine per cent. But, in a poll conducted last year, two-thirds of the respondents who knew that AIDS is caused by H.I.V. also believed that it can be contracted through kissing; a majority of Russians think you can get AIDS from a cough; and three-quarters believe that the virus can be transmitted by mosquitoes. None of that, of course, is true. While I was in Moscow, two acquaintances of mine-both successful professionals with access to people at the highest levels of the Kremlin and of Russian life-were astonished to learn that it takes many years for a person to become sick after being infected with H.I.V. That the virus goes about its business silently, destroying the human immune system without warning, is one of its defining characteristics. If there were no time lag between infection and illness, AIDS would not have been so insidious, and so difficult to understand. One Russian woman I have known for years, a prominent liberal, said, "AIDS might be a good thing, in a way, because it is killing people who only destroy the country anyway.''

She was talking about drug addicts. The Russian government has been particularly unwilling to treat substance abusers as citizens in need of help instead of as criminals. A highly critical report by Human Rights Watch noted earlier this year that H.I.V.-infected addicts are often barred from the type of education and outreach programs designed to help them. Even in prison, which itself is a notorious incubator for H.I.V. and for tuberculosis, inmates rarely have access to treatment. The report argues persuasively that the government has made the epidemic far worse by routinely mistreating and victimizing those who are infected. The attitude toward drug use is so uniformly harsh that the people at the Red Cross in Irkutsk were reluctant to send me into neighborhoods where heroin is bought and sold. They consider it dangerous, and, one of them told me honestly, the city has been receiving bad publicity. Nonetheless, I was introduced to Misha and Alyosha, both former heroin addicts in their thirties who travel frequently to Trety Posyolok, the neighborhood where heroin is sold openly. They were willing to let me tag along when they delivered clean needles to a friend who distributes them there.

We flagged a taxi. The driver raised an eyebrow when he heard the destination. But money is money, so he nodded and we piled in. As we talked, the driver immediately jumped into the conversation. "One day," he said, "I had a guy come in and he wanted to buy drugs. So I said O.K. and I took him up the hill.'' The driver fell silent, then continued, "He went into a house to buy his stuff and then he came out, and before I could say a word he had a needle in his arm and he was shooting up in my taxi." This was a couple of years ago, he recalled, at a time when the heroin sweeping into the area was particularly potent. The passenger overdosed and started to choke. "He was dying right in the back of my car,'' he said. "I had to rush him to the hospital and explain what happened. I am lucky they didn't throw me in jail.'' We asked if the man had lived. "I don't know,'' the driver said. It was clear that he didn't care. We drove across the Angara River, and soon we passed a line of cabs. "Heroin taxis," he said. "These are the cars willing to take people to Trety Posyolok." He told us that most cabs didn't want to bother, and that since his near-death incident a couple of years earlier he hadn't been back. 

Trety Posyolok is not much more than a collection of wooden houses, muddy, half-paved roads, and seedy kiosks scattered along the southern edge of Irkutsk. The Posyolok-the word means "settlement"-is part of the city now, but it was created in the nineteen-sixties as a separate village, the third in a row of identical places all thrown together to house workers assigned to build the power station that still dominates the area. Few of the streets have names. Almost everyone who ventures there knows where he is going and why: it's the best place in the city to buy heroin and to pick up a fresh dvoushka, one of the two-millimetre syringes favored by Irkutsk drug addicts. 

We drove down a narrow, shabby street. Garbage was strewn everywhere. Gypsy touts and homeless women stood on the corners rubbing their hands together to keep from freezing. The moment we parked, a toothless man wearing a Los Angeles Lakers sweatshirt approached. "You want it?'' he asked. "A hundred rubles. Very clean." Drug deals are done both on the streets and in the houses. Each location has its dangers; the main street leads to a hill, and at its end is the regional police academy. We watched as, every few minutes, fresh-faced recruits, none more than eighteen years old, walked awkwardly down the hill, guns strapped tightly to their hips, as they pretended not to see what was happening all around them. Misha and Alyosha took me to a rickety old house halfway up the street. Two large but seemingly docile dogs responded to the doorbell. They were quickly followed by their owner, a thin, hawk-faced man with a ponytail and a cigarette dangling from his lips. The man's name was Volodya, and he is the most effective preventive weapon against AIDS in the neighborhood, because each week he hands out clean needles to anyone who asks. 

Distributing clean needles occupies a gray area in Russian law. Most people assume that it encourages drug use, and many officials oppose it for that reason. (In fact, the participants in a major AIDS conference held in St. Petersburg this May took a stand against distributing clean needles.) In some cities, including St. Petersburg and Irkutsk, AIDS organizations have made efforts to explain to the police why they are beneficial. Volodya says that he isn't hassled much anymore, though police in Irkutsk are certainly not eager to talk about their approach to needle exchange or narcotics. (I tried to meet with narcotics-squad officers while I was there. They told me that they could speak only with the permission of Moscow, which I had not obtained. I then called the head of the local police. He also refused to see me.) Volodya was hardly surprised to hear this. "All we have to do is pay some bribes,'' he said with a shrug. "Sometimes it's just give them condoms and other times money. But if people come to my house to get needles and they have drugs they can be busted, and so can I.'' There was a knock on the door. Two men stood silently on the stoop. Volodya pulled out a shoebox full of neatly packaged two-millimetre syringes. Then he took a few individually wrapped alcohol swabs from his pocket. The men took them, nodded sullenly, and were gone. The entire transaction lasted less than thirty seconds. 

Volodya has used drugs for years, but his main interest in life is heavy-metal music. He has nearly a thousand records, and he plays them day and night. He showed me the cover of the album that was currently rattling the windows of the house, "1000 Percent Metal Ballads.'' He talked at great length about the relative merits of Metallica, Megadeth, and Aerosmith before mentioning that he had travelled to Moscow in 1995 to see a performance by Deep Purple-his favorite group by far. "It was worth every minute and all the costs,'' he said with a smile of the deepest possible satisfaction. 

Volodya is available all day to pass out clean needles to anyone who knocks. "Why?" I asked, waving away a thick cloud of cigarette smoke. "Clearly, it's dangerous. Why bother?"

He looked mystified. "I can deal with the police," he said. "I have lots of friends, they all use drugs, and I would like them to stay alive.''

The next afternoon, I drove to the Irkutsk Infectious Disease Hospital. The complex is far from the center of the city and is difficult to reach. It was nearly deserted. Every significant city in Russia has an AIDS center. Moscow's is a crumbling shack situated near the back of the Second Hospital for Infectious Diseases, the main hospital for H.I.V. in the capital. It was marked by a small plaque. Irkutsk's center was in better shape, but it is tucked away on the grounds of the hospital complex, behind a large building, and is marked by the smallest imaginable sign, written in white paint on the side of a red brick building that almost nobody ever sees. The writing looks like graffiti (except that nobody writes graffiti that small): "Tsentr SPID"-SPID being the Russian acronym for AIDS. I had come to see the chief of the region's AIDS unit, Dr. Boris Tsvetkov. He was a pleasant middle-aged man, and he welcomed me with the type of hospitality that was common among mid-level Soviet officials: he made tea, took a box of chocolates from his desk, tore off the cellophane, and insisted that I eat. 

Tsvetkov told me that the severity of the problem in Irkutsk was often exaggerated. "All the responsible parties, from the police to health organizations, work together to fight the virus," he said. "We coöperate." I asked why the police refused to talk about the relationship between drug use and AIDS. He shrugged. "That's a difficult issue,'' he said, but he would not elaborate. He acknowledged that in Irkutsk, as in many other parts of Russia, a fundamental shift is now under way, with the epidemic moving from its base among drug users to people who are infected through heterosexual contact. Statistics are collected in a haphazard way, but they tell a story that isn't hard to understand: in 1999, more than ninety per cent of those who tested positive for H.I.V. in the region were intravenous drug users. Today, that number is sixty-five per cent. "And I know that we are able to catch at most only half of the infected people,'' Tsvetkov said. He added that doctors were treating fewer than two dozen people in the region with antiretroviral drugs. "It just hasn't become that big an issue yet,'' he said. I asked how, in a city of more than half a million, with one of the country's highest AIDS-case rates, there could be so few people on antiretroviral drugs. "We treat those who come to us with the appropriate diagnoses," Tsvetkov said. "The number right now is sixteen. I know that it will change soon and that we'll need money from the government. But in the last two years the number of infections has gone down.'' He shrugged. "It's meant that it has been hard to get money from the central government. There is a feeling in many places that the problem is going away. We know very well that is not true." He said he was aware that Irkutsk was gaining a reputation as a center of the AIDS epidemic in Russia. He was not pleased. "We do acknowledge the problem," he went on. "Still, we are experiencing nothing more and nothing less than what the rest of the country experiences. It's not easy now, and it's only going to get harder. In two or three years, I know, it will take our entire health budget just to treat people for H.I.V. And when that happens I am not sure, really, what we are going to do.''

 

The man who for decades has paid the closest attention to the Russian population crisis is not even Russian; his name is Murray Feshbach, and he works in Washington, D.C. Feshbach, a scholar of Russia, statistics, and lies, started telling people in the nineteen-seventies that the Soviet Union was so frail that it was in danger of falling apart. Nobody wanted to listen. The Soviets lied about health statistics, and during the Cold War few American leaders were willing to believe that their mighty adversary in the great battle for ideological and physical supremacy could actually be sickly and weak. But Feshbach-first while working for the U.S. Census Bureau, then as a professor at Georgetown University, and now as a senior scholar at the Woodrow Wilson International Center-has spent his life plowing through obscure data in otherwise unread files. He has never wavered from his view that disease and the effects of environmental poisons are the biggest threats that Russia faces. His books-"Ecocide in the U.S.S.R.,'' about the horrendous environmental damage done by the Soviets, and a recent volume on Russia's demographic crisis-are impossibly grim. Eventually, though, American leaders, and then many of the Russians who had once mocked him, began to admit that Feshbach was right. 

I went to see him one day not long ago, just a week before he was scheduled to fly to St. Petersburg, where he was to receive an award for his work. Feshbach is a heavy man with thick glasses who looks like an owl and seems to possess a copy of every number or population statistic that exists. His workspace at the Wilson Center was strewn with arcane monographs, charts, and books like "Infections and Inequalities: The Modern Plagues," "Pathologies of Power," and "The Wellbeing of Nations." There were stacks of data sitting on his desk and a pile of the articles and studies that he was most interested in at the moment; they ranged from the demographics of Bulgaria to the economic impact of sexually transmitted diseases in Central Asia.

"What do you think it's going to take before Russia starts to respond to AIDS seriously?'' he asked me, then quickly answered his own question. "More deaths. Many more deaths. Not enough have died yet." He began to recite statistics. "The demographic is moving, it's moving right now,'' he said, meaning that the epidemic was switching from one primarily among drug users to one with a significant base in the wider population. "You can see it in pregnant women. As officially recorded, the number of infected children born to women who were not drug users is seventy-five hundred. But seventy-five per cent of them were born in the past two years.'' The military will be hit particularly hard. Although the Russian government has said that it intends to maintain armed forces of a million men for many more years, it is unlikely to succeed. After 2005, the number of seventeen- and eighteen-year-olds eligible for military duty will decline sharply, the result of the baby bust of the late nineteen-eighties and early nineties. Soldiers are at much higher risk for H.I.V. than other members of society: young men are prone to risky sexual behavior, often relying upon prostitutes during long tours of duty away from home, and drug use is common. In 2002, only eleven per cent of the men called to serve were considered fit for duty; five thousand draftees tested positive for H.I.V. and were turned away. In fact, in the past five years the number of draftees with H.I.V. has increased twenty-five-fold. Last year, a quarter of those who entered the armed services during the spring draft had less than nine years of education, which means that they could not be trained to use the advanced equipment that is central to the success of a modern army.

"The military is a complete disaster area-prosto koshmar,'' Feshbach said, using the Russian words that mean "simply a nightmare." Russian defense planners have even floated the idea of creating a foreign legion for Russia. In the coming decade, it may be the only way to maintain the Army. "The situation is awful, horrendous, terrifying-any word you want to use," Feshbach said. "Russia badly wants a modern military, but you have to have a certain skill level to do something more than just run and stop and shoot. And when there are fewer soldiers what will the generals rely on?" Shaking his head, he answered the question. "Nuclear weapons, biological weapons, and chemical weapons," he said. "That is what scares me the most. Russia has a view of itself as a superpower, and this is the only way it can support that view. The country can only become more unstable as it becomes sicker, but its leaders cling to their view of Russia as it existed when there was a Soviet Union. They want to be compared with us, not with Ghana. AIDS will not permit them to do that much longer. This epidemic will alter the way families are formed, and change the labor force completely, not to mention the way cities are built and populated.'' Feshbach added, "It's going to be an epochal reshaping of that part of the world.''

As the number of people in the working population shrinks, so, naturally, will the gross domestic product. Russia may lose as much as eight per cent of its annual income, but experience from other countries demonstrates that the repercussions from H.I.V. are far larger than what one would expect simply by subtracting the money earned by those who are sick. People have to be fed, clothed, and taken care of, and that hurts productivity as well. If your best friend is dying of H.I.V., you are less likely to concentrate at the workplace and less likely to volunteer for the night shift, and, more than that, if your son or mother is dying you don't go to work at all. AIDS also changes the way a society thinks. In most countries, the principle of saving is easy to understand: if you put money aside today, somebody will use that money to produce shoes or a computer or to build a house tomorrow. In Russia, people will die too soon to take advantage of any of that, so they are not likely to consider investment or saving for the future to be worth the effort. In countries where AIDS has taken a large toll, people quickly learn to consume what they have. The savings rate plummets, and the economy suffers badly. 

"I think Russia will get desperate,'' Feshbach said. "People will eventually see where they are going, and they will get desperate. There are people who say Russia will die. I don't know. But it will be weak and unstable. How can it not? Right now, the state is doing nothing, and if the state doesn't address this basic problem what does it address? I have heard every excuse for the lack of initiative: fate, that the Russians don't care if they live or die, that they don't understand life, that AIDS is too much of a stigma. I have heard that it's just about these promiscuous people, that it's bad stuff coming from the West, that it's the wrong crowd." He concluded, "Who cares what the reason is? Who cares? What is happening in Russia right now is going to define, to a large degree, the future of the AIDS epidemic globally. Yes, the country escaped for twenty years, but now it is confronted with possibly a disaster. And the impact, the size of the population, and the geography mean that it will have a direct influence on what will happen in Europe, in Central Asia, even in China and India. And that will have an impact on us. It's hard to imagine a more critical country at a more critical moment."

 

How many fact-finding tours of southern Africa, of India, and of various countries in Eastern Europe will Russian officials take before they see the implications of the epidemic that is now spreading rapidly within their borders? Why does Brazil, with a comparable population and a slightly lower per-capita income, spend nearly a billion dollars on AIDS each year when Russia doesn't spend even a tenth that? It can't be poverty; Russia is not rich, but it has eighty-five billion dollars in its financial reserves. The Kremlin is certainly capable of spending money when it wants to: last year, for example, the lavish three-hundredth-birthday party for the city of St. Petersburg-Vladimir Putin's home town-cost $1.3 billion. There are more billionaires in Russia today than in any other country-at times, they seem to be buying everything that is not nailed to the ground, from yachts and British soccer clubs to Malcolm Forbes's collection of Fabergé eggs. "Do you think for one minute that if Putin called these people into a room and said we have a crisis and we need to come up with some money for AIDS they would say no?'' a senior international health official asked me. "Do you think that anyone in Russia can begin to justify spending just a few million dollars on AIDS each year? There are people there who spend that maintaining their private jets."

The Kremlin demands to be taken seriously as a world power and as an active member of the Group of Eight industrial nations. The country's leaders often mention AIDS in public at international gatherings, acting as if Russia still had an empire to control. At home, though, the story is different. "Russia went ahead and made a decision to contribute money to the Global Fund,'' Christof Rühl, who was until recently the World Bank's chief economist in Russia, told me. The Global Fund to Fight AIDS was set up by the U.N. to provide money for those countries which cannot on their own defeat AIDS, tuberculosis, or malaria. I talked to Rühl one day when I was in Moscow. He was taking a break from a conference on Western investment, held at the Radisson SAS Slavyanskaya Hotel. Men in Valentino suits were talking on cell phones and smoking huge cigars. Their drivers and bodyguards, all clad in thick black leather, stood smoking cigarettes patiently by the coatroom. 

Russia invested just over four million dollars in 2003 in its federal AIDS program, but it committed twenty million to the Global Fund to Fight AIDS. Two years ago, the Kremlin's protracted negotiations effectively delayed a hundred-and-fifty-million-dollar loan offer by the World Bank on the ground that it did not wish to incur further foreign debt. "If you watch," Rühl said, "you will see the President and all the ministers and the economic advisers going out and saying to the world, with great pride, 'Russia is a donor country. We are one of you. We are going to help solve this health crisis for these poor nations.' It is cheap and cynical. It has not been about H.I.V. at all. It was to say, 'We are a country that helps; we don't need handouts, like Africa.' But the truth is that the government is so disorganized and so removed from the needs of its own people that it could not even help get one application filed for the first round of this Global Fund. 

"The people just don't care. On a very broad scale, it's a country where people care about their family and their friends. Their clan. But not their society. Yet they have this attitude that we are a great power. A donor nation. What does that really mean? It means you pay a few million dollars to the world AIDS fund even though you are too stupid to attempt to profit from it when your own citizens are dying.''

 

 

()()()()()()()()()()()()()()()()

Dr. Michael A. Denner

Russian Studies Program

Director, Honors Program

Stetson University

Campus Box 8361

DeLand, FL 32724

386.822.7381 (department)

386.822.7265 (direct line)

386.822.7380 (fax)

http://www.stetson.edu/~mdenner

 


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