A patient sleeps in a ward set aside for heroin users and those infected with HIV in a tuberculosis hospital in the Russian town of Tver. (Diana Markosian/Reuters)

Russia considers itself a robust member of the global community, keeping pace with heavyweights such as the United States and China. But when it comes to health, the world’s largest country is more in the company of Botswana.

A global health study that compares the health toll of various diseases with 1990 data reports that in 2010, HIV/AIDS was the third-largest cause of premature death in Russia, where the number of cases has been growing rapidly. In a measure of years of life lost (with deaths among younger people given more weight in the calculation than deaths among older ones), Russia is faring similarly to Gabon and Bot­swana, although Russia’s top two killers remain heart disease and stroke, just as they were in 1990.

“If you look at the story of Russia, particularly for Russian males, the profile of disease is dramatically different than in other developed countries,” said Christopher J.L. Murray, who led the recently completed Global Burden of Disease Study 2010.

When the study grouped countries by income, Russia was compared to 14 others, including the Baltics, Lebanon, Libya, Mexico and Botswana. On many measures, Botswana did better than Russia, but they were close on premature deaths from HIV/AIDS and tuberculosis and on life expectancy — 68.9 in Russia in 2010 and 71 in Botswana.

“When you put together the leading causes, it’s remarkable that HIV/AIDS is third,” said Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington in Seattle. In the United States, it is No. 23.

Causes of premature death in Russia

Russian President Vladimir Putin has ordered his government to make improving health and life expectancy a priority, and campaigns have been started to encourage people to cut down on tobacco and alcohol — a formidable enough challenge in a country where 60 percent of men smoke and, until recently, beer was classified as food.

The battle against HIV/AIDS and tuberculosis is far more daunting. Russia had 471,676 registered cases of HIV/AIDS in 2008, according to the Russian Federal AIDS Center, and 703,781 by November 2012. That figure is considered far short of the real one. Officials here estimate that about 1.2 million people are HIV-
positive but that many are not counted because they have not been tested. Activists say the real number may be twice as large.

“Most people are stigmatized and are afraid to go to the hospital,” said Anya Sarang, president of the Andrey Rylkov Foundation for Health and Social Justice, a nongovernmental organization dedicated to helping HIV/AIDS patients.

“Doctors say by the time people get into the medical system, they already have advanced stages of HIV and tuberculosis,” she said.

Grim statistics

Until 2008, Sarang said, 80 percent of HIV infections were connected to intravenous drug use. “Now the main route is heterosexual transmission among drug users and their partners,” she said.

Other countries try to prevent HIV infection by providing needle exchanges to reduce harm and getting users off drugs by relying on substitutes such as methadone. But here, methadone is illegal. Russia’s “narcologists” — experts in addiction — insist that substitutes will only perpetuate dependency and disease.

Vadim Pokrovsky, head of Russia’s Federal AIDS Center, said he is hopeful that eventually minds will change here.

“HIV prevention should be a priority,” he said. “The threat is very high, so whatever works must be done.”

The optimism, however, seems misplaced. Last year, the Rylkov Foundation’s Web site was shut down after drug-control officials accused it of spreading drug propaganda by publishing scientific papers about the use of methadone. The site moved to a foreign server.

HIV started spreading in Russia in the late 1990s, later than in the United States and encouraged by drug use. “More have died in the United States,” Pokrovsky said, “but in Russia the future is worse.”

Russia no longer accepts help from UNAIDS and other international organizations because it sees itself as a donor rather than a recipient of help, but programs once supported by those agencies have not been financed by the government.

“We might succeed in medical treatment,” Pokrovsky said, “but this will not be enough. We need prevention.”

Tuberculosis, which kills the majority of HIV/AIDS patients here, brings another complication. The World Health Organization lists Russia as one of the 22 countries where TB takes the heaviest toll. Most alarming, Russia, China, India and South Africa have almost 60 percent of the world’s multi-drug-resistant TB, which is difficult and expensive to treat.

Global health agencies consider the incidence of TB much higher than Russian figures show. And it is deadly. Murray Feshbach, a senior scholar at the Woodrow Wilson Center in Washington who has studied Russian health and population trends for years, notes that the United States, with a population of 314 million, has 500 to 600 TB deaths a year. Russia, with 143 million people, has more than 20,000.

Olga Nechaeva, head of Russia’s federal TB monitoring center, said that the country is making progress on TB but that it will take years to control the disease. According to her figures, the TB rate was 34.2 cases per 100,000 in 1990, 90.4 in 2000 and 68.9 last year.

Impact of Soviets’ fall

Nechaeva, a doctor who worked on tuberculosis for 20 years in the Sverdlovsk region, is the daughter of doctors who specialized in TB.
A picture of her 91-year-old mother hangs on the wall behind her desk. She said the Soviet Union had just managed to bring TB rates down when the social and political crises of the 1990s undid the work.

“There was a decrease in income,” she said, “and there were no regulations on how to treat TB, and no coordination between the federal and local level. They stopped giving chest X-rays. No equipment was bought.”

Treatment was haphazard, Nechaeva said, and drug-resistant forms of TB took hold. The WHO estimates that 20 percent of new TB cases in Russia are multi-drug-resistant, along with 46 percent of previously treated cases. By 2020, Nechaeva estimates, 80 percent of TB patients will have multi-drug-resistant TB.

The Global Burden of Disease Study was compiled by 488 scientists in 50 countries and supervised by seven institutions, including the Johns Hopkins Bloomberg School of Public Health and Murray’s institute in Seattle. The country profiles were published this month, and Murray said they are meant to provide the kind of information and analysis that would prompt discussion and guide policy. The report is full of charts, graphs and visual presentations that make it easy to grasp what diseases are killing a nation. Russians, particularly, need to start talking, he said.

“It’s extraordinary to me how little social response there is to a level of health that is so bad,” he said. “There should be a profound level of concern. If it keeps going the way it is, we’re talking about a place where the population will be declining and where they’re not enjoying the benefits of the 21st century and longer, healthier life.”