THE DEATH OF A NATION

Drug Abuse, HIV And Tuberculosis, Combined With The Old
Scourge Of Alcoholism, Are Lowering Russia's Population

In his 20 years on this earth, Dima has seen a lifetime of abuse. At
16 he shot his first heroin, and in the years since he has lived on
and off the streets of St. Petersburg. What life is left for him is
likely to be brutal and short. "I can't say this is how I hoped to
die," he says. "But at least I'll have plenty of company where I'm
going."

Dima's humor may be black, but sadly, his prediction may be right. Something
terrible is happening in Dostoyevsky's old city. Doctors believe that as
many as
40,000 young people in St. Petersburg, mostly addicts, were infected with HIV
last year. Five time zones to the east, in the Siberian outpost of Irkutsk, the
toll is rising with equal ferocity. The same in Tolyatti, a grim city of
automobile workers on the Volga in Russia's heartland. Moscow leads the nation
with as many as 100 new HIV cases registered each day. In fact, virtually no
place in Russia has been spared. Says Irina Savchenko, the head HIV specialist
at the Ministry of Health: "By now wherever you look, from Kaliningrad to
Kamchatka, from Grozny to Murmansk, HIV is not only there, it is moving faster
and faster."

After a false lull for most of the first post-Soviet decade, HIV is
now sweeping across Russia faster than almost anywhere else in the
world. In the last year alone, the number of registered cases of HIV
has more than quadrupled, from 15,652 to 80,300. Experts believe the
actual number is 10 times higher. "It will not be long before we have
1 million Russians infected with HIV," says Dr. Vadim Pokrovsky, who
has directed the country's federal center for the fight against AIDS
since 1985.

Vladimir Putin describes Russia as "a great power with unlimited
potential." But given the rise of HIV, tuberculosis (see box) and
other diseases, Putin's Russia is in danger of becoming known as a
land of unending affliction. Even the most ardent patriots concede
that their country is dying. Fewer and fewer Russians are able to
escape the clutches of the old scourge of alcoholism, and the new one,
drug abuse. In the past decade, the death rate has risen by a third,
while the birthrate has fallen precipitously. Last year alone, the
population dropped by about 750,000. Hepatitis B and C rage, while old
world diseases largely extinct in the West--measles, typhoid and
diphtheria, to name a few--are staging a comeback. But HIV poses the
greatest danger. "The HIV epidemic is a tragedy in itself," says
Pokrovsky. "Far worse will be the eventual depopulation of the
country. Not only will those with AIDS die, but they will not have
children."

On one recent frigid night in St. Petersburg, near a metro stop on the
city's desolate southern edge, two dozen teenagers gather outside a
retrofitted bus. They are there to get clean needles, free condoms
and, for many, their first HIV test. In the first 10 months of last
year, St. Petersburg registered 3,652 new cases of HIV, compared with
400 in 1999. "From 13-year-olds to over-30-year-olds, they come to
us," says Sergei, a former addict on the Medecins du Monde team that
has been providing anonymous HIV tests and psychological
counseling--something the state does not offer--since 1998. In recent
months, the crew has seen the HIV rate skyrocket. "Nearly one out of
four kids we test is positive," says Dr. Vladimir Musatov, the team's
medical coordinator and deputy head of St. Petersburg's AIDS clinic.
"The epidemic is growing faster than anyone dared imagine."

Tolyatti, home to the giant AvtoVAZ car plant, offers a terrifying
example of the epidemic's speed. The city has 3,250 registered cases
of HIV. A year ago, it had 11. "We are waking up late," admits Dr.
Larisa Mikhailova, head of the city's drug treatment clinic. "We
should have started working with the addicts years ago. Now for
thousands it's too late."

Tolyatti also reveals the economic and social forces behind the rise
of HIV in Russia. The trouble is drugs--to be precise, heroin. Nearly
every registered case of HIV in the city stems from a shared needle,
primed with $ 2 worth of smack. "If we didn't have heroin," proclaims
Mikhailova, "we would not have HIV."

The tragedy is born of prosperity. "We're a young city, and we're a
well-off city," says Mikhail Khoutorskoy, head of the local health
department. Once a boon, that combination is now lethal. Jobs at the
car plant pay well by Russian standards. And nearly one out of five
residents is under 16 years old. "These are the kids who wanted to
live free," says Alexander Ablamonov, a weary doctor who nightly
crisscrosses Tolyatti's most populous region--"Car Factory
District"--answering SOS calls in one of the city's 44 ambulances.
"They've got freedom now, and this is what they do with it." One
recent night, Ablamonov and his crew responded to seven calls. Four
were drug overdoses.

The Ministry of Health--whose AIDS department comprises a staff of
three--cannot cope. It cannot even keep an accurate tally of the HIV
cases registered. The federal statistics lag far behind the numbers
reported in the provinces. In Irkutsk, the Siberian city that thanks
to a sudden flood of Central Asian heroin witnessed an HIV explosion
in 1999, seven out of 10 addicts tested are infected with HIV. "The
numbers grow by thousands each week," Savchenko concedes, while the
federal funds budgeted for all AIDS programs in 2000 was a scant $
1.75 million. "We need more than an education campaign," says
Pokrovsky, the federal AIDS center director. "Putin must see this as a
national security threat. He must declare war on HIV."

As grim as the epidemic is now, the prognosis is worse. Unlike the
early stages of the AIDS crisis in the West, HIV in Russia is spread
among the country's burgeoning population of intravenous drug
users--an estimated 2 to 3 million nationally. "Today the infected are
mostly addicts, but addicts are sexually active and addicts also
become prostitutes," says Dr. Yevgeny Voronin, who heads a clinic in
St. Petersburg that is Russia's largest facility for mothers and
children with HIV. As the virus spreads through sexual contact,
experts foresee a heterosexual HIV boom in three to five years.
Condoms, once scarce in the U.S.S.R, are now in every pharmacy. But
they are rarely used.

The virus moves swiftly but invisibly. Only 741 Russians are known to
have died of AIDS to date. "It's hidden because we haven't yet had one
known case of AIDS in our city," says Mikhailova in Tolyatti. "But in
a few years, the plague will appear before our eyes." Pokrovsky
explains: "Treatment today costs $ 10,000 a year, and in eight years
we are likely to have a million people with AIDS. And so the state
would have to spend at least $ 10 billion on treatment. The question
'To treat or not to treat' will arise, and given our federal budget, I
think I know the answer we'll hear."

Still, those on the front lines have hope. More and more Russian
cities are launching prevention programs, like those in St.
Petersburg, Irkutsk and Tolyatti, where former addicts have teamed up
with doctors to stem the HIV tide. Not all understand the urgency of
the cause. In Irkutsk, local officials have thwarted attempts to
distribute clean needles, but in Tolyatti two needle exchange points
opened last fall. "It may be a small step," says Mikhailova, "but it's
a big one psychologically." She notes that the city even funded the
program, giving a grand total of $ 28,571.

"No one can save us except ourselves," says Aleksei Surikov, a
25-year-old former addict who works in a fledgling Irkutsk detox
center that has helped more than 50 young addicts go clean. "If we do
nothing, we'll lose every addict here. They believe in nothing. Not
the state, not the church, not school, not their parents. But if we
can reach them, something changes. We can help them change their lives."

These street warriors know well they face a Sisyphean struggle.
Russia's health care system is antiquated, worn-out and desperately
underfunded. The World Bank is expected to lend Russia $ 50 million
for HIV and AIDS prevention and $ 100 million for TB treatment.
"Russia still has a window," says Jean-Jacques de Saint Antoine, head
of the World Bank's Russian health program. "The virus has barely
entered the mainstream population." But from the country's head AIDS
doctor to the prevention activists on the St. Petersburg bus, people
involved in the HIV fight know that the funds, spread out over five
years, will not suffice. They complain above all of the silence in the
Kremlin. "It comes down to economics and a political will," says
Voronin, the young doctor in St. Petersburg. "Putin must make HIV his
top priority. Never mind Chechnya. This is our future and we are losing it."

Late last year the author and Nobel laureate Aleksander Solzhenitsyn
described the crisis bluntly, questioning the urgency of Putin's campaign for a
new state hymn and flag. "You cannot save a dying country with symbols," the
writer chided. "When men are dying without any hope in the prime of their
lives,
it makes no difference what hymn is sung over their heads." Adds Mikhailova in
Tolyatti: "Attention must be paid, and something must be done." The politicians
may not like it, but as more and more young Russians succumb to HIV, it will
become harder to hide the obvious: Russia stands to lose a generation.