(Un)Civil Societies Report: August 27, 2003

27 August 2003, Volume 4, Number 21

IN FOCUS

ONLY 20 PERCENT OF RUSSIANS HEALTHY; 60 PERCENT OF CHILDREN SICK. Russians are constantly subjected to media reports of scary health statistics -- surely enough to have a negative effect on their mental as well as physical health. "Only about 20 percent of the population is healthy," Health Minister Yurii Sevchenko said, "Rossiiskaya gazeta" and other media reported on 8 August. It was a typically blanket statement, long on shock value and short on specifics or breakdowns by region. Citing poor lifestyle habits, Sevchenko said, "the main culprits in Russia's health crisis are nicotine and alcohol." He also blamed foreign tobacco companies, breweries, and fast-food franchises for worsening the already grim picture, which has led to a decrease in life expectancy and a decline in population. The message was clear -- Russians shape up, and foreigners watch out.

While populations are generally aging and declining across Europe, the sickening and dying process provokes nowhere near the angst it does as in Russia, where population drops have been more precipitous. Russians often speak in despair of the depletion of the "genafund," or genetic pool as they dub their nation's stock, and its loss has a psychological and political as much as a demographic dimension. The shortfall is also a catalyst for health campaigns, such as those recently launched with a new organization, the National Health League.

The Russian population has reportedly already dipped from the 145 million at the last census in 2002, to over 144 million. To be sure, the birthrate has nudged up a bit to 9.8 births per 1,000 last year from 9.1 the year before, but it is still not at the replacement rate, that is, not exceeding the death rate, and the population is expected to decline. Male life expectancy stands at 58 years, 10 years less than it was a decade ago; female life expectancy is 72, with the discrepancy between the two among the widest in the world, Russian demographers say.

Although adults face their own crisis, the statistics reported about children are even more unsettling. Every few weeks, some health official is sure to deliver some bad news to journalists, who then wheel out the stories of drug-addicted schoolchildren, and then forget about the topic while they focus on the latest political assassination or terrorist bombing. The number of healthy children in Russia over the past 10 years dropped from 45.5 percent to 33.9 percent, and the number of disabled children doubled, according to the epidemiology section of the Health Ministry, RosBalt reported on 6 August -- surely cause for national alarm.

Curiously, in the Health Ministry's announcement this time, despite past lurid media accounts, childhood illness wasn't blamed on alcoholic parents creating substandard health environments, or increasing drug abuse, or sexually transmitted diseases among young teenagers, or even smoking and fast food but surprisingly, on an increase in the school workload and an ensuing greater amount of time without fresh air and exercise. A whopping "up to 75 percent of children" were said to be suffering from high blood pressure and related conditions, a statement that was difficult to assess, since such a high number of children truly suffering from serious hypertonia would have led to greater numbers of deaths.

In another worrisome report, about one-third of Russia's children have been discovered to be born out of wedlock, the government minister overseeing nationalities policy, Vladimir Zorin, told a news conference on 7 August, citing information gathered from the 2002 census, which asked new questions about ethnicity, marital status, and other personal data. Zorin did not specifically link the illegitimate birthrate with poverty, but as in other countries where the connection has already been well-established, the issue will be one to watch when the government publishes further census studies in December. This will create a clearer picture of the Russian family, pravda.ru reported 7 August.

Few Russians question such alarming pronouncements, usually delivered in terse lectures from public officials and covered in short wire-service reports. They are already steeped in a culture of acute anxiety about the next generation. Indeed, the topics of the paucity of babies in Russia and the plight of the young are themselves a kind of metaphor for all the angst that post-Soviet citizens feel about the traumatic upheavals of market reforms, the ruble devaluation, job loss, dislocation, and war. It is difficult under these conditions to sort out what "sick" really means, and what to do about it at a practical level, given certain cultural norms.

Long before reforms, Westerners were bewildered when they saw Russian grannies wheeling babies wrapped in multiple layers like little mummies even in springtime, or when Russian friends told them with alarm that their merely colicky infants were destined to a life of horrible disability. Russian parents seem to hold the necks of their newborns far longer than Westerners, for example, do not like to let babies practice sitting up for fear they will damage their spine, and generally avoid letting their young explorers touch the ground. Prospective foreign parents seeking to adopt from Russia have found a perplexing phenomenon, where on the one hand, many babies have been labeled disabled for no apparent reason, often under catch-all terms not used in the West (such as "oligophrenia") or, conversely, have not had even simple interventions to prevent lifelong disabilities. In Russia, excessive anxiety about children appears side-by-side with woeful neglect.

When some Russian reporters use the word "congenital" about children's sicknesses as if to signify something permanent such as "birth defect," they surely must be exaggerated. While individual studies on different diseases have been done here and there, i.e. the affect of Chornobyl on children's thyroid cancer, comprehensive, detailed studies on the real health state of Russian children if done, are not widely published or examined in depth by the media. The preferred mode for addressing the topic is the panic bulletins of the type of "60 percent born ill" (in fact, the number is closer to 66 percent if the Health Ministry's statistics are taken at face value.)

Sickness at birth can mean mild conditions like a cold or jaundice -- conditions not considered terribly serious in the West, where they rapidly resolve in a few days with good health care. Or it could mean perinatal heart conditions easily fixed by medication and operations not so readily available in Russia. When doctors make the claims of "60 percent" (contrasting with the 80 percent of the entire population said to be sick), journalists don't seem to ask what they mean -- they take it on faith, and never wonder why other countries do not periodically produce such formulations.

Judging from reports on various Russian websites that have sprung up to meet the demand for health information, anxious parents frequently try to decipher complicated diagnoses attached to their infants at birth -- indeed, some students of the Russian infant-care system have concluded that babies are declared sick until proven healthy, and all possible conditions ruled out. Quite often, inquiring parents who take home babies they thought were healthy later learn of traumas during the birthing process, unspecified "damage to the central nervous system," labor complications, and poor Apgar scores (i.e. on color, breathing, vision, etc.) indicating that "sickness at birth" could be preventable.

Carelessness and unsanitary conditions in the delivery room seem to echo a negligence about safety in other areas of life. The UN's Children's Fund (UNICEF) has reported, for example, that children suffer many more preventable accidents in Eastern Europe and the former Soviet Union than in other developed areas of the world. Safety measures like seatbelts, bicycle helmets, or waiting a half hour after eating before swimming are not practiced. In fact, ignorance is not the only issue, as resistance to such notions of public safety is often explained by equal and opposite ardently held beliefs -- that a seatbelt will prevent someone from getting out of car safely in an accident, that a bicycle helmet will block peripheral vision, that a child on the beach must immediately bathe or face heat prostration.

Improvements in public education and public confidence in a reformed health-care system may enable people to keep their children healthier, but in Russia, with many different climates and cultural practices, as well as the separate problems of a crumbling public education system, it will be difficult to standardize and disseminate the message. Whether the numbers given out by health ministers are exaggerated or do not reflect only serious diseases, the fact is Russian parents perceive their children as chronically ill and behave accordingly.

RUSSIA

WHY WOMEN DON'T HAVE BABIES. Alarmed at the shrinking population, the government has looked for ways to boost the birthrate and curb abortions. With increasing availability of more reliable birth-control methods, and the help of various international agencies concerned about reproductive health, the high abortion rate, which was seen as mainly exemplifying the need for more-accessible birth control, has been brought down in recent years from a high of 4.6 million per year in 1988 to 1.7 million last year, "The New York Times" reported on 23 August. Reversing nearly 50 years of liberal practice regarding abortion (a ban imposed by Stalin was removed in 1955), under a new law, government officials as well as health-care agencies who believe the rate is still too high will now attempt to involve themselves more closely in women's lives in an effort to reverse the trend.

Prime Minister Mikhail Kasyanov signed a decree on 11 August reducing the number of circumstances under which women can legally get late-term abortions, gazeta.ru reported on 18 August (see "RFE/RL Newsline," 19 August 2003). The document came into force on 15 August when it was published in "Rossiiskaya gazeta." The majority of women will no longer be able get late-term abortions, as 22 weeks' gestation will be the cut-off point under the new rules (in the U.S., the point of viability is established at 24 weeks). Furthermore, between 12 and 22 weeks, abortions will be legal only if certain medical and social indicators are met -- concepts open to subjective interpretation as well as abuse.

Whether for reasons of demography, perceived as an essential component of a great power, or on religious or moral grounds, with the new law the government has dropped its traditional socially oriented linkage between viable pregnancies, healthy children, and good economic circumstances. The 13 reasons that could be previously cited for pregnancy termination under past law included poverty, unemployment, unsure job prospects, or poor housing -- these could all be invoked easily and interpreted broadly. Russian women will still be able to seek early abortions freely through the 12th week of gestation, but then subsequently will have to demonstrate that they fit under one of four categories, including rape, death or disability of a husband, and loss of parental rights -- itself a court procedure used quite frequently in Russia to punish women found guilty of crimes or determined to be drug-addicted or mentally ill.

Women's rights groups and health associations do not appear to have reacted yet very strongly to the government's new decision. Doctors have somewhat more publicly resisted the move to restrict abortions, when prodded by reporters, saying they fear a return to septic back-alley practices, and are already indicating that they are likely to broadly interpret the categories for their patients privately. They face the reality that, according to the Health Ministry, 60 percent of pregnancies in Russia still end in abortion or miscarriage. Compare this figure with that in the U.S., where, with double the population and improved health care, according to statistics for 2000 issued by the Centers for Disease Control, at least 60 percent of pregnancies ended in childbirth, even if some are unwanted. Like other areas of public life in Russia, a strict new law is more likely to evoke indifference and noncompliance and a new avenue for bribe taking rather than achieve the stated goal.

Looking beyond the government's constant fretting about the drop in population growth, "Argumenty i fakty" dug deeper, asking the question "Why don't Russian women want to have babies" in an article of that title on 23 July. The reasons they uncover give some inkling that Russia's demographic shortfall is unlikely to remain unsolved even with zealous application of the new antiabortion legislation. First, some 5 million-6 million Russian women are simply unable to have children, Health Ministry officials told the newspaper, due to their own or a partner's infertility. Those officials claim that only 10 percent of pregnancies ended in miscarriage, curiously low given the poor health-care system (by contrast, in the U.S., 20 percent of conceptions end in miscarriage, considered a natural occurrence). That may be explained by the fact that Russian women seek abortions more frequently, but may have found that they would suffer a miscarriage in any event. Due to the heavy use of abortions as a form of birth control, and many women reporting multiple abortions throughout their reproductive lives, infertility can be a serious problem.

Second, of the 60 percent of those pregnant who opted to have abortions, "Argumenty i fakty" said, almost half selected the procedure due to immediate financial difficulties; another 20 percent said they did not see how they could secure their children's future in Russia. The figures indicate a high degree of likelihood that women would seek abortions under the old economic "social indicators" of past legislation, and will be forced either to seek earlier abortions or attempt to fit their stories to the new, more limited criteria under the new law -- or have their babies. Although the newspaper did not ask about the remaining 20 percent, presumably rape, the mother's health, or deformities of the fetus were the reasons leading others to seek to terminate pregnancies.

But long before contemplating the plunge into parenthood, couples were putting off children indefinitely for what they viewed as serious financial difficulties just to produce a live birth, "Argumenty i fakty" reported. Deterred by overcrowded and poorly staffed state clinics, especially those in the rising middle class tend to make decisions on what private options are available to them. In private clinics, prenatal care from conception until delivery costs $800-$1000 in Moscow, in regional centers $200-$400, in the provinces, about $100-$160, according to the paper. The government provides a one-time payment of only 300 rubles ($10) for the first 12 weeks. The actual childbirth and stay in the hospital is an additional cost.

Polled about their reasons for avoiding pregnancy, women often cited their previous bad experience in attempting to get and stay pregnant and bring a healthy baby to term, given the rigors of the poor health-care system. Mothers recounted that they met with indifference or outright hostility and skepticism when they went to neighborhood clinics, and sometimes suffered appalling mistakes -- such as orders to have an abortion when a routine infection test came back positive, rather than doctors agreeing to order repeats of the test, which are widely mistaken in underequipped laboratories, or trying antibiotics.

If the women could manage to keep their pregnancies going, they would face the cost and the ordeal of going to one of the notorious Russian birthing homes, where in many parts of Russia, just as in the Soviet era, women labor in groups in unsanitary conditions without anesthetics, in some remote areas even without running water. Once they leave their homes, they encounter the obstacle of finding adequate baby formula to feed their infants -- some 30 percent-40 percent of infants are immediately put on bottles, say doctors. There is a widespread misbelief that many mothers are unable to nurse, due to a lack of lactation training for both nurses and patients.

While websites established in recent years like mama.ru and doktor.ru have moved to fill the gap in the public's health knowledge, there are indications that much more sophisticated and broader educational efforts are needed, backed by law. For example, a patient contemplating conception asked the resident obstetrician serving mama.ru if she could continue to drink the generous shots of "vodka infusion" she was using to treat an ulcer if she wanted to get pregnant -- and was told to find an alternative while pregnant, without much comment on the inappropriateness of liquor as a salve for ulcers or the real dangers of drinking. Yet another woman, alarmed to discover she was pregnant after drinking heavily, was told that if the alcohol was going to damage the fetus, she would have already had a miscarriage. If the pregnancy continued, then "no harm has occurred," said the doctor reassuringly, although recent U.S. studies link the consumption of even one or two drinks in early pregnancy with fetal alcohol syndrome, leading to mental retardation.

Only a small portion of the Russian health-care system is privatized, a factor that would seem to indicate that lack of access to at least minimal health care was not a major factor in women's health. Given the inadequacies of the public system, privatization has meant that those with a few hundred to a few thousand dollars, depending on the region, now have a better shot at having a healthier baby. In private clinics, costs of $10 a visit are out of reach for those with the average salary of $180 a month, RIA-Novosti reported on 7 August. Still, there are costs involved even in the public health-care system -- there are always extras needed (sometimes patients must supply food, medicine, and even sheets) and "presents" to be made to poorly paid doctors.

If a woman can get her infant through the risk-prone first year --in the Soviet tradition, deaths are still not reported before that milestone, meaning infant deaths are underreported -- then she must help her child weather the childhood years of infectious diseases and accidents. If she does not have a good job or is divorced, she is out of luck. Aid to children of low-income families is only 70 rubles ($2.3) a month, according to the Ministry of Labor and Social Development. Officials told "Argumenty i fakty" they were aware that was insufficient and were attempting to double the amount.

The issue of employment for mothers going back to work is critical, especially as cultural customs have not evolved to produce many stay-at-home dads. Women say that they are having increased difficulties getting their jobs back at the same level of pay after maternal leave -- which is far shorter than in the Soviet period. "Argumenty i fakty" drew the connection between the lack of funding and priorities set for prenatal care, child health care and women's employment, and the demographic crisis, ultimately focusing on the government's responsibilities for securing better conditions for pregnancy, childbirth, and health care rather than on women's compliance with new restrictions on abortions.

STUDY CORRELATES CHILDREN'S HEALTH AND ECONOMIC CONDITIONS. Scholars argue heatedly over the reason for Russia's ills in health care and other areas -- is it the devastating and lingering after-effects of the Soviet system with its poor services and environmental destruction and oppression, continuing to create shocks for the next generations? Or is the rigors of market transition that have depleted the nation's resources, destroyed the minimal safety net for jobs and health care, and caused a general breakdown in public services? Or some of both?

One study using econometrics, published by researchers David Sahn and Leonid Fedorov at Cornell University in June, has attempted to get a grip on the actual connection between the upheavals of market transition and children's health statistics (see "Socio-Economic Determinants of Children's Health in Russia: Estimating a Dynamic Health Production Function," http://people.cornell.edu/pages/des16/sahn/wp135.pdf). The work is more about developing the tools to further analyze economic and demographic data than a definitive health study, but it contains some useful information that indicate the need for changes in public policies.

Sahn and Fedorov found that parental education, household income, locality, quality of infrastructure, and variables such as prices of major food items and overall economic conditions "have significant effects on height of children in Russia" -- and that height was lagging. Children's height is taken as an indication of health status. From other studies, they had learned that stunting of growth and wasting were not large compared to developing nations, but a sign of malnutrition as a serious problem in Russia, and worsening within the last decade. They made use of the Russia Longitudinal Monitoring Survey designed and implemented by the Carolina Population Center of the University of North Carolina at Chapel Hill with the assistance of the World Bank and the Russian government.

The study tracking economic conditions and height was conducted in dozens of Russian regions, reaching thousands of households. Using complicated formulas for calculating various demographic factors, the scientists found what many ordinary people already know from experience -- that the mother's level of education affects the health of her children because she is the primary caregiver. Where women have more access to education and are able to manage their lives more autonomously and get better jobs, their children are fewer, but healthier.

For those seeking to prove definitely that market transition ruins health, the results of the study are not so clear-cut because there are so many variables and values in Russia. For example, rural children, who might be expected to be poorer due to market transition, and therefore less healthy with less access to health services and with parents having less education and resources, are in fact healthier than their urban counterparts because "they are more physically active, eat more home-produced food, have cleaner air and live in a generally less stressful environment," Sahn and Fedorov wrote.

Children in the North Caucasus were found to be less healthy, possibly due to their proximity to the war in Chechnya and the neglect of health care that occurs with massive displacement, but also possibly due to a tendency to have large families, which produces a "quantity-quality" trade-off, the researchers say. Availability of hospitals was another strong positive factor for children's heights, and communities with all paved roads had taller children.

The availability of foodstuffs and the cost of food was another indicator, although the researchers found that the high price of potatoes in some regions had a positive, while not significant effect on children's growth. This could be explained by the likely fact that their families were growing the potatoes on their home plots, and then selling them at the higher prices, which significantly improved their economic lot. "Mother's education and prices of major food staples are found to have especially large effects" on children's growth, they concluded in the report. "We also made an alarming discovery that children in politically unstable North Caucasus regions are 3 to 4 cm shorter than children living in other regions of Russia," they said. One piece of good news found in the Cornell study is that children with less than average height need not face permanent growth retardation -- but presumably better nutrition would have to come into play.

If they wish to boost the population, Russian government officials face the need to make some tough decisions when grappling with such grim statistics as 60 percent of pregnancies not reaching live births, and more than 60 percent of all children being deemed "sick." These will involve more investment in prenatal and postnatal care, education campaigns, and far greater support for families facing divorce and other disruptions, more treatment programs for alcohol and drug abuse among adults as well as children, and an end to the displacement from war.