Post-Soviet Russia Slips Into Third World’s Sickly Ranks : Health: As sanitation and water treatment worsen, infections spread. And trust in the government weakens. : GRIM PROGNOSIS, <i> Disease, Death Ravage New Russia</i> . Last of two parts

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 can ever trust their tap water again.

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% over the past year. In the first half of 1995, 17 people died in Moscow alone of this easily curable malady.

As the underfunded public health system here slips into critical condition, infectious diseases that had been nearly extinguished by the now-defunct Soviet Union have returned with a vengeance.

Measles, rubella and whooping cough are now ravaging Russia, 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. The incidence of scabies, a skin disease caused by a burrowing mite whose presence is usually associated with poor hygiene, is up threefold since 1985.

A diphtheria epidemic across the former Soviet Union has prompted the World Health Organization to declare an international health emergency. Because of the risk of the epidemic spreading further, Western doctors are now being urged to ensure that adults from the United States and Europe who travel in the region receive booster vaccinations that have often been ignored.

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, may end up paralyzed or 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 impotent 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,” said 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 vast nation that was considered to have an effective--albeit rugged--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%. That means 11,700 more Russians died last year than three years earlier from diseases that can be easily prevented by rudimentary 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 here have fallen.

A Host of Culprits

Scholars and health officials blame: poverty; mass migration of refugees from hot spots around the former Soviet Union; a sudden rise in the number of homeless people; chronic underfunding of the sanitary and medical infrastructure in Russia, and unabated environmental destruction, as well as indifference, neglect, greed and ignorance.

While the West has primarily used economic indicators to track Russia’s march toward capitalism, Russians are more inclined to judge the success of post-Communist reforms by progress in areas such as housing, education and health care--and to find their government wanting.

For 70 years, the Communist social contract held that Soviet citizens might be poor--and might have to wait decades for an apartment or a car--but that if they fell ill, the socialist workers’ state would look after them. Now, with the national budget for health care shrinking and doctors often earning as little as $75 a month, ordinary Russians are discovering that medical care they considered a birthright costs them dearly.

For millions, private treatment or bribes to ensure that they are cared for decently are unaffordable luxuries.

By the government’s own count, 27% of Russians live below the official poverty line, earning less than $67 a month. Critics put that figure even higher. 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 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,” said Yuri M. Fyodorov, deputy head of the infectious diseases unit of the Health Ministry. “If you didn’t get your kid vaccinated, you couldn’t enroll him in school.”

The system was far from perfect, however. And 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.

Vaccinations Shunned

By the mid-1980s, leading immunologists openly advised parents to shun the shots.

Meanwhile, an outbreak of pediatric AIDS--spread by a hospital that reused its needles--led panicked parents to refuse vaccinations en masse. Some reportedly even bribed doctors to issue false vaccination certificates so their children could enter school.

By 1993, more than 20% of children had not been inoculated against diphtheria; in some areas the rate was 40%. Adults also stopped getting the boosters required every 10 years to maintain immunity. Little surprise that the diphtheria epidemic that began in 1990 has flourished and proven deadly.

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, said his 13-year-old daughter, who has allergies, has yet to be vaccinated against diphtheria, scarlet fever or whooping cough.

“We must do it, of course,” said Zakharov, a former medical school instructor. He would have no problem obtaining Western vaccine and disposable needles for the job. “But I would go to a doctor I know,” he said. “I would not take my child to the local clinic. I don’t trust the health care system.”

Zakharov argues that his widely shared mistrust of the medical system is justified because the Soviet Union’s finest doctors were concentrated in special clinics in Moscow while rural clinics suffered from primitive conditions, acute shortages of medicine and poorly trained doctors. Sick Russians may have called the doctor--but only to get a prescription and a certificate excusing them from work.

“The average Soviet person did not expect a doctor to help him--and the doctor in fact couldn’t do much for him,” he said. “People go to the hospital only when they already have a very serious illness--and they know it.”

Meanwhile, Russia still does not vaccinate for one of the most dangerous infectious diseases, rubella. Better known as German measles, it can cause birth defects through prenatal exposure.

“I keep yelling at people there: ‘It’s your kids! It’s your grandkids!’ ” said Georgetown University demographer Murray Feshbach. An expert in Soviet health, Feshbach calculates that rubella causes about 5,500 preventable birth defects in Russian children each year.

“To this day, it’s not on their immunization calendar,” he said. “One of the leading medical epidemiologists in the country has said, ‘We’re thinking about it now.’ That’s their attitude toward their own people.”

In a sign of new openness at the Health Ministry, however, Russian officials have at last responded to such criticism. Last month, the Health Ministry announced that rubella vaccinations will be introduced as of Jan. 1, and authorities hope to make them standard as soon as possible, Fyodorov said.

But in Chechnya, routine childhood vaccinations apparently ceased entirely after rebel President Dzhokar M. Dudayev declared independence from Russia in 1992.

“We asked the doctor for the vaccine, but they didn’t have any,” said Aminat Ulubava, 19, whose 3-year-old daughter, Markha, is now stricken with polio. Markha is in a children’s hospital in Grozny, the Chechen capital, where tiny 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, said Merlin nurse Denney, but “it’s too cold for them to do the therapy, too cold to take off their clothes.” The relief agency is now trying to raise money to open a rehabilitation center for the victims.

Denney said 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 via fecal contamination.

“The worrying thing about this [epidemic] is that 17% of the children who are getting it have been vaccinated,” she said. “The patients are very angry, very upset.”

Ulubava and other Chechen mothers said they believe Russians deliberately infected their children as part of the effort to subdue the rebellious republic. “We caught the polio from Russian chemical weapons that were used by the troops,” Ulubava said.

The Russian Health Ministry has launched an emergency campaign that has already vaccinated 141,000 Chechen children, Fyodorov said, but renewed fighting has made it difficult to reach some areas where the vaccine is needed. Merlin has been working to introduce a “cold chain” to ensure that the vaccine remains potent during transport from Russian to Chechnya to each patient.

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

“The hospitals have been bombed,” Fyodorov said. “People don’t have water. The sewer system doesn’t work. In Grozny, dysentery and hepatitis are going up.”

Effect of Neglect

But it doesn’t take a war to start an epidemic; ordinary neglect will do. In Dmitrovgrad, where more than 1% 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,” said Yuri F. Solovyev of the Moscow oversight committee investigating the outbreak. The level of E coli, a bacteria found in the human intestine, exceeds 200,000 per liter, he said. The standard for drinking water is three per liter, and tap-water sources should contain no more than 1,000.

“It’s just dreadful,” said Feshbach, who documented the catastrophic Soviet environmental legacy as co-author of the book “Ecocide in the USSR.” An E coli count of “200,000 in this country [America] would be a scandal of the first order. But they just shrug their shoulders and say, ‘If you don’t die of this, you’ll die of something else.’ ”

Dirty or polluted water is cited as one factor in an overall decline in the health of Russian children and teen-agers. In various areas, contaminated water has also been blamed for viral hepatitis and a variety of other intestinal ailments, kidney diseases, urinary tract infections, miscarriages and other health problems.

The Russian Environment Ministry concluded in a recent report that half of all Russians are forced to rely on substandard drinking water. Pollution of water sources with everything from radioactive waste to oil products to fertilizer and pesticides has worsened in the last five years. Up to three-quarters of reservoirs do not meet safety standards; in about a third, microbe levels are “tens to hundreds of times higher than safe levels,” the ministry report said.

Lack of money to maintain water treatment facilities--or even change the water filters--is blamed for many intestinal diseases that often go unreported. In the Volga River basin, 80% of all drinking water sources have no treatment systems at all, the report found.

The prescription for Dmitrovgrad’s dysentery problem is simple: Tap-water pipes must be thoroughly flushed and chlorinated and a filtration system must be constructed immediately, said Solovyev. But “money is always the problem,” he complained. “If the situation is not drastically changed, we could deal with far more Dmitrovgrads next year.”

Local authorities in Dmitrovgrad have been slow to inform residents about the causes of the outbreak. In the absence of information, suspicion, alienation and despair have spread as fast as malicious microbes.

As in Chechnya, where chemical weapons were blamed for the polio epidemic, a popular theory in Dmitrovgrad is that radioactive contamination from the buried wastes of a local nuclear research institute caused the dysentery epidemic.

“I think it’s all coming from the atomic plant,” said a young man who gave his name as Sergei. “I think they released a nuclear cloud and it’s spreading through the air. Of course, they write in the newspaper that there were no emissions before or after the outbreak, but we don’t believe them.”

Such suspicions, however far-fetched, will be hard to put to rest, born as they are of deep mistrust of Russian public health officialdom, the notorious Soviet cover-up after the 1986 Chernobyl nuclear accident and a widespread belief that the state cares not a whit for citizens’ well-being.

“They haven’t given us a concrete explanation of what is causing it,” Maria Leontiyeva, the mother of a 9-year-old, said of the outbreak here. “Some people talk about radiation, about the water. They just don’t tell us.

“Before, they used to care about the health of the workers,” she added. “Now, [the bosses] say, ‘Well, as long as I’m healthy . . .’ Of course everybody is frightened.”

Victims say they felt there was little they could do to protect their family’s health.

“We gave her only boiled water,” said Sergei A. Osokin, 35, a truck driver who had spent five days in the isolation ward nursing his sick 2-year-old daughter, Tatyana. “Maybe she got sick from the fruit?

“I am just a simple citizen,” Osokin said with the stoic resignation that Russians summon when facing disease, death or their government. “What can I do about it?”

Adding insult to illness, the deputy mayor told the local newspaper that dysentery would not be a problem if only residents would wash their hands more. But the very water is dangerously polluted, and the city’s overall sanitation is primitive. Like roughly half of all Russian hospitals, even the infectious disease ward in Dmitrovgrad’s hospital has no hot running water.

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GRIM PROGNOSIS: DISEASE, DEATH RAVAGE NEW RUSSIA

Deaths from Infectious Diseases. Per 100,000 population

1992: 13.1

1993: 17.3

1994: 19.8

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Disease Rates

Though Russia has made progress in beating back some infectious diseases, rates of many maladies have risen sharply since 1990. Cases per 100,000 population:

*--*

% increase U. S. 1985 1990 1994 from 90-94 1993 Diphtheria 0.8 0.8 27 3,275% 0 Measles 130.5 12 19.5 54% 0.12 Rubella 301.5 193 247 28% 0.07 Tuberculosis 45 34 48 41% 9.82 Whooping cough 29 17 33 94% 2.55 Syphilis (men) 11 6 92 1,433% 39.7* Syphilis (women) 9 5 80 1,500% - Gonorrhea (men) 167 158 270 71% 172.4* Gonorrhea (women) 132 103 145 41% -

*--*

* Both sexes

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Health Care Spending

Russian Federation spending on health care and physical education was $8.86 billion in 1994. But health spending has fallen since 1970 as a percentage of the entire federal budget. Health and physical education spending as a percentage of federal budget.

1970: 12.4%

1990: 9.7%

1992: 7.8%

1994: 8.4%

Sources: V. Shkolnikov, Russian Federation State Statistics Committee, U.S. Centers for Disease Control