Western versus post-Soviet medicine: Fighting tuberculosis and HIV in north-west Russia and the Baltic states

Journal of Communist Studies and Transition Politics

Volumn 21, Issue 3, 2005, Pages 395-415

  Hønneland, Geir ^a   Rowe, Lars ^a  

^a FRIDTJOF NANSEN INSTITUTE   (Norway)

Author keywords

[No Author keywords available]

Indexed keywords

DISEASE CONTROL; HUMAN IMMUNODEFICIENCY VIRUS; MEDICINE; TUBERCULOSIS;

BALTIC STATES; EASTERN HEMISPHERE; EURASIA; EUROPE; NORTHERN EUROPE; WORLD;

EID: 25444432610     PISSN: 13523279     EISSN: None     Source Type: Journal    
DOI: 10.1080/13523270500183561     Document Type: Article

References (53)

1. From 2000 to 2004, Geir Hønneland and Lars Rowe conducted the so-called contextual evaluation of the Task Force on Communicable Disease Control in the Baltic Sea Region. The study resulted in the book Health as International Politics: Combating Communicable Diseases in the Baltic Sea Region (Aldershot: Ashgate, 2004).
2. In 2002, Geir Hønneland and Arild Moe produced Evaluation of the Barents Health Programme - Project selection and implementation, FNI-report 7/2002 (Lysaker: Fridtjof Nansen Institute, 2002).
3. Interviews were conducted in Moscow in December 2002 and November 2003; Tallin, Riga and Vilnius in March 2003; St. Petersburg in June 2003; Murmansk and Arkhangelsk in June 2002 and September 2003; and Petrozavodsk in November 2003. Most interviews were carried out at the workplace of the interviewee and lasted from 60 to 90 minutes. All interviews were conducted without interpreter; most importantly, all interviews with Russians were conducted in Russian. We chose not to reveal the identity of our interviewees, but indicate their position and location (for example, 'civil servant from the Republic of Karelia').
4. 'Medicine' is here understood in a broad sense, as the entire organization of the country's healthcare services. No separate presentation of the Soviet healthcare sector is given; particular principles and structures of the Soviet era are referred to in the context in which they happen to appear (that is, in the encounter with Western principles). For overviews of Soviet medicine, see M.G. Field, Soviet Socialized Medicine: An Introduction (New York and London: The Free Press/Collier-Macmillan, 1967);
5. and Michael Kaser, Health Care in the Soviet Union and Eastern Europe (London: Croom Helm, 1976).
6. For a discussion of the impact of the old controversy between the Westernizers and the Slavophiles on post-Soviet Russian international politics, see I.B. Neumann, Russia and the Idea of Europe: A Study in Identity and International Relations (London and New York: Routledge, 1996).
7. A Western critique of the reforms inspired by the West is found in Stephen Cohen, Failed Crusade: America and the Tragedy of Post-Communist Russia (New York and London: W.W. Norton, 2000). Cohen coined the term 'Cold Peace' in an article first published in 1992.
8. N. Krementsov, Stalinist Science (Princeton, NJ: Princeton University Press, 1997), pp. 140ff.
9. The most infamous response to this policy was agronomist Trofim Lysenko's attack on Western (or 'unpatriotic') genetics. In line with the official view that a new breed of humans - the 'Soviet man' - could be created, he argued that acquired characteristics in a species could be inherited.
10. Krementsov, Stalinist Science, pp.287ff, argues that the direction Soviet science took in the late Stalin era was largely a result of the Cold War and remained in force until swept away by the political reforms of the 1980s.
11. Ibid., p.298.
12. R.J. Coker, B. Dimitrova, F. Drobniewski, Y. Samyshkin, Y. Balabanova, S. Kuznetsov, I. Fedorin, A. Melentsiev, G. Marchenko, A. Zakharova and R. Atun, 'Tuberculosis Control in Samara Oblast, Russia: Institutional and Regulatory Environment', International Journal of Tuberculosis and Lung Disease, Vol.7 (2003), pp.920-32 (p.920).
13. P. Spradling, E. Nemtsova, T. Aptekar, M. Shulgina, L. Rybka, C. Wells, G. Aquino, H. Kluge, W. Jakubowiak, N. Binkin and B. Kazeonny, 'Anti-Tuberculosis Drug Resistance in Community and Prison Patients, Orel Oblast, Russian Federation', International Journal of Tuberculosis and Lung Disease, Vol.6 (2002), pp.757-62 (p.757).
14. Coker et al., 'Tuberculosis Control', p.920.
15. A. Kochi, 'Tuberculosis Control: Is DOTS the Health Breakthrough of the 1990s?', World Health Forum: An International Journal of Health Development, Vol.18 (1997), pp.225-32 (pp.225-6).
16. C. Dye, G.P. Garnett, K. Sleeman and B.G. Williams, 'Prospects for Worldwide Tuberculosis Control under the WHO DOTS Strategy', Lancet, Vol.352 (1998), pp.1886-91 (p.1886).
17. Kochi, 'Tuberculosis Control', p.228.
18. I b i d.
19. World Health Organization, DOTS-Plus & Green Light Committee: Improving Access to Second-Line Anti-TB Drugs, WHO/CDS/TB/2000.283 (Geneva: World Health Organization, 2000), p.1.
20. P. Farmer and J.Y. Kim, 'Community Based Approaches to the Control of Multidrug Resistant Tuberculosis: Introducing "DOTS-Plus"', British Medical Journal, Vol.317 (1998), pp.671-4 (p.674).
21. , accessed 28 Oct. 2003.
22. M.I. Perelman, 'Tuberculosis in Russia', International Journal of Tuberculosis and Lung Disease, Vol.4 (2000), pp.1097-1103.
23. C. Mawer, N.V. Ignatenko, D.F. Wares, A.K. Strelis, V.T. Golubchikova, G.V. Yanova, T.V. Lyagoshina, O.E. Sharaburova and N. Banatvala, 'Comparison of the Effectiveness of WHO Short-Course Chemotherapy and Standard Russian Antituberculosis Regimens in Tomsk, Western Siberia', Lancet, Vol.358 (2001), pp.445-9 (p.445).
24. M.E. Kimerling, 'The Russian Equation: An Evolving Paradigm in Tuberculosis Control', International Journal of Tuberculosis and Lung Disease, Vol.4 (2000), pp.S160-S167 (p.S161).
25. Ibid., p.S162.
26. Coker et al., 'Tuberculosis Control', p.927.
27. According to ibid., p.930, tuberculosis dispensaries in Samara oblast receive 6,987 roubles for uncomplicated tuberculosis cases treated non-surgically, and from 10,361 to 24,189 roubles for cases treated surgically.
28. R. Coker, 'Control of Tuberculosis in Russia', Lancet, Vol.358 (2001), p.435.
29. Mawer et al., 'Comparison of the Effectiveness', pp.445-6.
30. World Health Organization, Global Tuberculosis Control: Surveillance, Planning, Financing, WHO/CDS/TB/2003.316 (Geneva: World Health Organization, 2003), p.105.
31. I b i d.
32. I b i d.
33. N. Banatvala, 'Deal Struck for Russians with Tuberculosis', Lancet, Vol.354 (1999), p.54.
34. N. Banatvala, S. Matic, M. Kimerling, P. Farmer and A. Goldfarb, 'Authors' Reply', Lancet, Vol.354 (1999), p.1036.
35. , accessed 28 Oct. 2003.
36. World Health Organization, Global Tuberculosis Control, p.171.
37. , accessed 28 Oct. 2003.
38. World Health Organization, Report on the WHO European Region Interagency Coordinating Committee (ICC): 2nd Meeting Focusing on Tuberculosis. Report on a WHO Meeting, Copenhagen, Denmark, 19-20 February 2003 (Copenhagen: World Health Organization, Regional Office for Europe, 2003), p.3.
39. No overview exists of tuberculosis-control funding at the regional level, but the total sums spent by Russia's 89 federal subjects surely exceed federal funding by a large margin. One estimate is that nearly 80 per cent comes from the regional level, 20 per cent from the federal level and a small percentage from the local level: ibid., p.4.
40. P. Webster, 'World Bank Approves Loan to Help Russia Tackle HIV/AIDS and Tuberculosis', Lancet, Vol.361 (2003), p.1355. The World Bank insists that the loan be closely tied to a control strategy based on recent outcomes from 19 pilot projects introducing DOTS in Russia.
41. World Health Organization, Global Tuberculosis Control, p.105.
42. Perelman, 'Tuberculosis in Russia'.
43. Ibid., p.1101.
44. Ibid., p.1102.
45. Ibid., p.1098.
46. This is reflected in our interview with an employee of the Moscow office of WHO: 'We cannot compromise on DOTS. For us, this is a political matter'.
47. It should be observed that this 'arrogance' refers back to the late 1990s when WHO first started its efforts to introduce DOTS in Russia; we have no evidence that this is the general perception of WHO today.
48. There are methodological challenges associated with statements like this, which will not be explored here since we focus on the more problematic areas of collaboration; suffice it to say that project participants might wish to appear 'polite' to two interviewers from a major Western donor country.
49. He was not referring to Russian statistics as such - 'we have the most accurate statistics in the world' - but to the tendency to argue that official statistics show just 'the tip of the iceberg'. However, it is unclear what exactly he meant by 'our statistics'. Russia has a long tradition of producing one set of 'official' statistics and one set of 'departmental' (vedomstvennaya) statistics for internal use. Russian 'hyper-diagnosis' of communicable diseases was also mentioned by other Russian interviewees, primarily in connection with the difficulty of making a correct diagnosis with outdated technology.
50. This is a well-known fact in East - West co-operation in northern Europe after the Cold War. For instance, Finland has particularly close historical and cultural ties with the Republic of Karelia in Russia and focuses therefore efforts on this federal subject. Norway, for its part, shares borders with Murmansk oblast and is hence most interested in that region. Likewise, the Western countries around the Baltic Sea have tended to have 'their own' Baltic state, with which contacts have been particularly close.
51. Interviewees indicated related problems in the US: 'Sexually transmitted diseases are a huge problem in the United States. Syphilis is rampant among women and children there'. Implicitly: 'Why are you so interested in us when problems are huge also in the West?'
52. Again, it should be emphasized that these problems are not representative of the situation more generally. Our interviews left us with the impression that problems with needle-exchange programmes were most intense in their early phases, but that some sort of settlement with the police was reached in most cases.
53. This story was told to us by an informant who had no direct involvement in this particular project. When we later interviewed the Russian manager of the project in question, we hoped to have him confirm this information. However, as he seemed extremely eager to emphasize the good things about his project and play down any problems, we did not press him on this issue. All attempts to approach the episode in conversation met with an insistence that 'we have a very good co-operation with the police'. We assumed he was afraid that talking about implementation problems might reduce the chances of further project financing.