Russia’s Health Care System, Demographics Present Unique Advantages, Disadvantages in Fighting COVID-19
The coronavirus hit Russia late, but is now gathering steam. This week, identified cases have been increasing by around 6,000 daily. As elsewhere, we can assume that unidentified infections are spreading much faster. How has Russia reacted? Among other things Russia has responded by drawing on some of its useful experience controlling tuberculosis since the collapse of the Soviet Union, by suffering from the weaknesses of an imperfectly reformed health system and by seeing control efforts undercut by a legacy of inadequate and unevenly distributed medical facilities.
Russia has been testing aggressively—over 3.49 million tests had been run as of April 30, which represents about 2.4 percent of the population. This is roughly equal to testing rates in Ukraine, lower than those of the Baltics and significantly higher than the rest of the post-Soviet space, Poland and Hungary. (For comparison, consider that the United States testing rate is 1.9 percent; the top tester is Iceland with 13.9 percent, and a hard-hit country like Italy has a testing rate of about 3.2 percent.)
In addition, Russia’s longstanding experience with tuberculosis, both during and after the Soviet Union, may give it an edge in setting up systems to test, treat and contain the spread of the virus. The collapse of the Soviet Union led to a spike in TB cases that remains an issue today, particularly as far as multiple drug resistant TB (MDR-TB) is concerned. To deal with the problem, Russia re-introduced a regime of extensive testing and monitoring of patients. Some regions also introduced highly effective community outreach programs that provided better contact tracing. Unlike COVID-19, TB is concentrated in vulnerable populations like the homeless. However, both COVID-19 and TB are highly infectious diseases that spread through the air, and Russia’s experience in bringing down TB rates by 5-6 percent per year suggests that the country has the capacity to tackle a highly infectious disease.
Russia and other Eurasian (and Asian) countries may also have another TB-related advantage: they continue to vaccinate their populations with the BCG vaccine that is effective against severe cases of childhood tuberculosis. Although the World Health Organization (WHO) reported in April that BCG doesn’t appear to offer protection against coronavirus infection, some scientists hypothesize that the lower than expected number of cases in Asia and Africa might be a side-effect of comprehensive BCG vaccination programs. This theory will have to be tested over time by comparing the incidence of COVID-19 in vaccinated and unvaccinated populations across the pandemic.
Another advantage that Russia enjoys according to some of its Western peers in fighting the disease, which disproportionally kills older people, is the younger age of its population The average age in Russia is 38 compared to 40 in the U.S. and 47 in Italy. Especially in Moscow, Russian COVID-19 cases are skewing younger than we have seen elsewhere. This may be explained by the fact that it is easier to access public or private testing in the capital, but it also reflects Russia’s younger population. It may also be the result of the fact that self-isolation has not been possible for construction workers, employees in isolated work sites in the far north and east, prisoners and doctors (including in the Komi Republic, St. Petersburg and Ekaterinburg); these groups have been at the heart of a number of COVID-19 clusters, and tend to be of working age. Moreover, given that Russian men have significantly lower life expectancy than women (67 years versus 77 years) and that men appear to succumb more readily to the coronavirus, Russia’s unfavorable demographics may play in its favor when it comes to the pandemic.
At the moment, the epicenter of the Russian coronavirus crisis is in Moscow, which as of April 30 had about 53,700, or roughly half, of Russia’s 106,500 cases. But the disease is rapidly making its way out to the regions where the populations may be, demographically-speaking, more vulnerable if they get infected. As in other countries, COVID-19 started in the largest cities, and then began to seep out to rural areas where the populations are older, as are the medical facilities. In addition, as Judy Twigg has noted, the chronic diseases that disproportionately afflict many Russians (and especially men)—diabetes, heart disease and chronic obstructive pulmonary disease— are those that are associated with coronavirus victims who require more intensive care. Some 40 percent of Russians suffer from multiple chronic diseases.
In addition to disparities in regions’ demographic characteristics and the prevalence of underlying conditions that can make the virus more deadly, Russia faces two more major problems in its fight with the coronavirus. First, seven years of “optimizing” the health care system have significantly reduced not only inefficiencies, but also the capacity of the system to deal with the current crisis. The number of Russian epidemiologists has fallen from 33,300 in 1990 to 13,300 in 2018, while the number of beds for infectious diseases fell from 140,000 to 59,000. All that being said, Russia still has an impressive number of doctors and hospital beds—479 doctors and 797 beds per 100,000 people (Germany has 430 and 800, respectively; the United States has 280 and 277. Tatiana Golikova, the vice premier for health, has said that 94,000 total beds are ready for coronavirus patients.) The neoliberal call to reduce the size of the public sector was not fully implemented in Russia, despite repeated calls from Western advisors.
Second, these resources are not evenly distributed across the country. The number of epidemiologists per 100,000 residents varies from 26 in Altai and the Chukotskiy AO to one in Chechnya. Available ventilators per 1,000 residents varies greatly across regions, but reported statistics should be read as an indication of regional variation, not as reliable data. This is clear from the anecdotal story of a medic in the hospital in Kalach-on-Don. She complained they had only 2.5 ventilators—2 already being used by patients and one with a broken compressor. She was then interrogated by police while the hospital rounded up their hand-pumped ventilators and some other older, nonworking units to bring up their total number of ventilators to 13.
Moscow has the money to build emergency field hospitals, like it just did in Voronovskoe. However, Russian regional governments, which bear the primary responsibility for funding health care, will not be able to afford personal protective equipment for medical staff, let alone new facilities. Only 41 percent of Russian medical facilities have access to the internet and 10 percent of Russian medical facilities need significant upgrades: half of these have no hot water, and a third lack indoor toilets.
The Political Fallout
Russian President Vladimir Putin has, for the most part, been sitting out the pandemic and working remotely. His public speeches have been increasingly stern, but governors and mayors have been left to deal with the crisis as best they can—ideally without outshining the president. In Moscow, Mayor Sergey Sobyanin has emerged as the man in charge, which may come back to haunt him. Other regional leaders have followed his lead, for example, announcing that they too would introduce a digital pass system for residents who want to travel from their apartments.
The coronavirus may have weakened the Kremlin’s domestic power, but its strength may always have been somewhat illusory. Yes, there is a vertical of power and the federal government has consolidated control over the past twenty years. But the Ministry of Health is like the American Centers for Disease Control—it issues guidance, and then it’s up to the regions to implement. The Italian and American epidemics revealed the extent to which regional leadership can make a difference, for better or worse. Unfortunately, it’s now Russia’s turn to experience this revelation, which was anticipated by Russian author and doctor Mikhail Bulgakov in The White Guard (1926), “For twenty years people have been engaged activities like, for example, reading Roman law, and on the twenty-first, it suddenly turns out that Roman law has nothing to do with anything…”
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The opinions expressed in this commentary are solely those of the author.