The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities: Workshop Summary (2006)

Andrey K. Demin, M.D., Doctor of Political Sciences, Candidate of Medical Sciences²

This research is based on variety of disciplinary perspectives, including political, social, and public health science, and attempts to add new approaches to and better understanding of global public health policy and governance at the national and international levels. The research methodology includes monitoring of public health and social security and relevant socioeconomic aspects, including activities implemented by the Russian Public Health Association, and comparative analysis of socioeconomic aspects of public health challenges. Some of the research materials were obtained by means of direct contacts with public health officials and experts and political scientists.³ A search of available publications, including those on the Internet, was followed by structuring and analysis of the collected information and data.

This paper addresses in turn Russia in a globalizing world; public health theory and practice in Russia; public health challenges in Russia; political, economic, and social factors related to public health challenges in Russia; and the role of various political actors in public health. The final section presents conclusions.

Since the 1990s, globalization has become dominant in the world arena.⁴ Globalization is an objective reality in international relations, with an attendant political model, leaders, logic, and institutional system (Dakhin, 2001). The place of Russia in the changing political and economic world order is an important issue. Dissolution of the USSR and the Soviet bloc proved that the previous political, social, and economic systems were exhausted. Responses to the challenges of the postindustrial era were inadequate because of political and information secrecy, state control of information, and the absence of markets. These obstacles were removed in post-Soviet Russia after 1991. Since then, the country has been in search of a new paradigm of progress and development that involves joining the globalized economy, as well as internal stability and development.

Efforts aimed at preservation of the post–World War II world order, proclaiming post-Soviet Russia as successor to the former superpower, proved to be futile. According to the National Security Concept of the Russian Federation, adopted in January 2000 (Concept of National Security of Russian Federation, 2000), in the postbipolar period, the national interest in the international sphere is in ensuring sovereignty and strengthening Russia’s position as a great power—one of the influential centers of the multipolar world. However, there is also a countertrend toward construction of a unipolar world dominated by developed western countries, with U.S. leadership in the international community, and envisaging unilat-

eral, military-first solutions of the key issues of world politics and circumventing the basic norms of international law.

Russian scholars (Dakhin, 2001) argue that the latter trend prevails, and that economic globalization has become an instrument in the construction of such a unipolar model of world order, in which sovereignty is limited. This political model has thus far failed to encompass the whole world. Domination of financial markets and recurrent financial crises may compromise the neoliberal approach promoted by national governments and international financial institutions such as the World Trade Organization (WTO), the International Monetary Fund, and The World Bank, and the world economy may turn to greater use of state regulation (Kargalitsky, 2001).

Russian experts (Fedotova, 2001) claim that after the dissolution of the USSR, countries leading the globalization process became indifferent to the social quality of non-Western societies unless it threatened relevant interests. The goals of integration into the global economy were separated from the goals of internal development.

The negative impact of the current pattern of globalization is becoming more pronounced in a number of countries, including developed ones (Bezruchka, 2000), as a result of environmental decline; marginalization of specific regions and social groups, such as youth, the aged, and employees of declining branches of the economy; and liberalization of social policy. In response to the unipolar political model, antiglobalist sentiment takes the form of social clashes, extremism, and terrorism (Dakhin, 2001). Inequalities in development are generating tension in international relations.

One of the features of transnational social organization is the freedom of movement of individuals beyond national borders. Thus issues of health and social security become international and necessitate the development of transnational and global health policy and governance (Kickbusch and Buse, 2001; Kickbusch and de Leeuw, 1999; Lee, 1999). Public health challenges become a basic element in the stability of international political systems. This is important from the point of view of the prevention and control of infectious disease (IOM, 1997).

Many of the critical issues related to global health⁵ and increasing global interdependence are represented in post-Soviet Russia, and globalization can provide keys to some solutions. It is a positive movement to-

ward economic and social progress (Matveevskiy) including public health advancement. Globalization can help overcome the negative aspects of development. It is impossible for any state to develop in isolation. However, a political model of globalization should serve the broader interests of the global community, primarily those related to environmental, social security, and public health challenges. Global policy and governance in the interests of all states and nations, based on relevant institutional and legal components, is needed in the era of global interdependence, when “Everyone is responsible to everyone for everything.”⁶

It should be noted that post-Soviet Russia emerged at the peak of a political, socioeconomic, and public heath crisis, and since then has been an object rather than a subject of globalization (Dakhin, 2001). The choice of a neomodernization model by the ruling elite in the era of globalization, along with economic weakness and other factors, brought the country to the periphery of the globalizing world (Fedotova, 2001).

In the 1990s, a radical approach to change aimed at transfer of the Western institutional model was combined with demodernization as a result of the inappropriateness of the selected model of development to the culture of the population. In brief, Russia “returned” to obsolete or nonexistent values as a result of the dominance of demodernization with elements of Westernization. As a result, in the 1990s there developed in Russia a form of “crony” or “wild” capitalism different from the Western model, lacking a labor basis and the ethics of entrepreneurship. Neomodernism was discredited. The challenge of internal social development was further complicated in Russia by recurrent debate on the Eurasian concept.

An important factor is that until recently, the majority of Russian politicians and scholars overlooked and misinterpreted globalization. Attitudes toward globalization have been dominated by black-and-white sentiments, an approach traditional for the Russian social sciences. Globalization has often been understood ideally, as a global conspiracy against the USSR and Russia, the forced opening of the country, the loss of its global role, the destruction of national “goods,” and the importation of global “bads.” With a few exceptions (Russian Federation, 2000), discussion of globalization and Russia has centered on WTO accession and its impact on the economic interests of specific narrow groups.

The unprecedented economic openness of post-Soviet Russia does not imply its integration into the globalized economy, for several reasons. The first is economic weakness and the decline of research. The USSR and its

allies made up a powerful single unit of economic space and a part of the world economy. That space was split after the dissolution of the USSR. Post-Soviet Russia does not possess an economic complex; rather, it is a geoeconomic vacuum without an autonomous identity in the world (Dakhin, 2001). Currently the country’s share of global trade is small, and it is dominated by raw materials. Russia’s prospects are compromised by a huge international debt, considerable uncontrolled outflow of capital, and weak regional integration.

Views on Russia entering the globalized economy vary from optimistic to pessimistic. Yet this is an urgent challenge, and breakthrough strategies as well as adequate internal development are needed. Nationalist sentiments and further social disintegration or a social explosion after a period of apathy are possible in the current circumstances. However, a post-modernist option is still possible for Russia.

Russia might be considered an ideal place for the development of ideologies that could serve as an alternative to globalism because the latter does not possess a social basis, the old ideology has been destroyed, and a new one has not emerged. However, continuing systemic crises promote antiglobalist protest (Dakhin, 2001).

A number of projects for the future development of Russia have been put forward by representatives of the elite. However, isolation of the elite has always been typical for Russia. The Russian elite is challenged to determine the character of the Russian state as a new entity with new political and economic systems, values, and ideology, or as an “echo” of the USSR. On that basis, the system of national interests and their hierarchy according to political and economic realities should be developed, ideologically based, and protected if Russia is to secure a sound place in the changing world, including participation in the development of new approaches for a global world order, public health policy, and governance.

Analysis of the development of public health theory and practice in Russia, closely related to the political, economic, and social changes in the country, is also important for understanding the country’s public health challenges and response.

From the 1917 Socialist Revolution until the late 1920s, the theoretical approach taken was termed “social hygiene.” It was highly political and directly connected to revolutionary practice and the construction of a new society and state, and it combined Marxism, hygiene, sociology, and prerevolution achievements in population health (Field, 1992; Kazan, 1998).

Soviet social hygiene provided a basis for the development of a new system of health protection and improvement. It was also used as a means

for increasing the loyalty of health professionals, incorporating education in Marxist philosophy and related social sciences. Enrollment of new medical students increased considerably. However, a “class approach” was practiced in the training of medical professionals.⁷ Soviet social hygiene claimed that diseases and premature mortality are the product of a “sick” capitalist social system, social habits, and institutions, and that population health would be improved with the advent of “healthy” socialism and ultimately communism through the transformation of society and the education of the population.

From the late 1920s, Soviet social hygiene was suppressed by the ruling political elite. Communist Party decisions to implement industrialization under a forced draft and collectivization of agriculture on the basis of administrative-and-command management further exacerbated social conditions, and the former official approach to population health became inappropriate. Public health theory and the health care system were shifted toward the classic clinical approach. Information on many population health indices was suppressed, as was international collaboration in public health. In 1929 the “class approach” was proclaimed as a principle of health care.

From 1941 until the mid-1960s, public health science was further reduced and officially termed the “organization of health care.” It had to execute command and administrative decisions and to prepare dogmatic, unsubstantiated recommendations (Kazan, 1998).⁸ Foreign public health research and practice were largely ignored or criticized as irrelevant to the Soviet system.

A postwar campaign to control cosmopolitism, eradicate bourgeois influence, and prove the universal priority of domestic and Soviet science included debates among specialists on social hygiene versus organization of health care. Social hygiene was viewed by many as “the Western, reformist, cosmopolitan and bourgeois science.” Many distinguished specialists were repressed.

In the early 1950s, a dogmatic attitude toward health care as the “non-productive” sphere in the national economy emerged. In 1966, the official term for public health science was changed to “social hygiene and organization of health care.”

Soviet public health theory and practice were increasingly unable to address the unfolding epidemic of noncommunicable diseases and relevant risk factors, as well as “social” diseases, including abuse of psychoactive substances (tobacco, alcohol, and drugs) and sexually transmitted diseases (STDs) (e.g., HIV/AIDS). Informed discussion of public health challenges as a basis for developing policy response was impossible for specialists, the media, or concerned citizens. Neglect of public health theory and research, as well as of the social costs of political and economic decision making, continued.

Extensive development of the health care system was undertaken. The numbers of hospital beds and physicians were increased, despite shortages of resources, without due consideration for quality of care. The health system was characterized by neglect of economic incentives in health care, medicalization of care, and use of administrative and command approaches to handling public health issues and did not meet promises of universal free care. Salaries of medical professionals as state employees were kept low, and they were deprived of the right to establish independent associations. Women came to represent the majority (70 percent) of the profession (except the administrative elite).

Among the historical successes of Soviet public health theory and practice is the invention of the state model of the health care system in 1919; its principles and practices were later used in many countries. The Soviet system proved to be effective in the prevention and control of infectious disease. During the Great Patriotic War (1941–1945), the health system returned to military duty more than 72 percent of the wounded and 90 percent of ill soldiers and officers. By 1940, provision of beds and physicians was close to that in the economically developed world, and it has further improved since then. By the mid-1960s, Russia’s public health profile was comparable to that of many Western countries. The comprehensive health and social security of the Soviet citizen was considered by many to be an international “yardstick.”

However, public health theory and practice failed to prevent the decline of many public health indicators, experienced in Soviet Russia after 1964, with a short period of relative improvement in 1985–1987 with the advent of “perestroika.” This decline can be explained largely by the sacrificing of social to military concerns during the cold war (Field and Twigg, 2000).⁹

It should be noted that loss of life and health in the country was profound after 1917. The impact of World War I (1914–1918); the radical changes in the Russian political, social, and economic systems; dissolution of the Russian Empire; and the transition to socialism resulted in a demographic disaster.¹⁰ The human toll of industrialization and collectivization was great.¹¹ Repressive political regimes increased the losses.¹² About 27 million died during the Great Patriotic War (1941–1945).

During the post-Soviet period, substantial changes took place in public health theory and practice. Health information was declassified in 1993; modern research became possible, international collaboration began to develop, and activities of international players in Russia commenced.

Attempts to modernize public health theory and practice according to Western approaches began. Since the introduction of health insurance in 1991, however, the economic model for medical care provision and administrative issues has been the focus of attention of reformers. As a result of a decline in funding of science and education, a “gold fence” succeeded an “iron fence” in the development of public health theory and practice.

Public health science became politicized. Positive and negative impacts of globalization on public health were not considered adequately. The approach to public health in social policy reduced health to survival; the importance of the absence of disease and subjective individual satisfaction with or control over factors influencing health were overlooked. A “multi-layer” health care system developed, compromising social justice. The decline was further exacerbated after 1991, with a short period of improvement in 1995–1998.

In 2000, the challenge of depopulation and inadequate social security, including health care, was positioned as a priority at the highest political level by the President of the Russian Federation, Vladimir Putin. The official term for public health science was changed to “public health and health care,” and attempts to modernize the approach continued. Thus Russia is

able to participate in the development of global public health policy and governance by the global public health community on a common theoretical and practical basis.

The public health decline after 1991 exacerbated the long-term trend that emerged in 1964. Among major public health challenges in Russia are depopulation, high mortality, low birth rates, intensive migration (including illegal), increasing morbidity, and the rise of infectious diseases such as tuberculosis (TB) and AIDS. The global importance of these public health challenges should be emphasized. They can change the geopolitical landscape dramatically in a relatively short period of time (CIA, 2001). Indeed, some alarmist forecasts question the existence of the Russian nation in the next century.

The increase in mortality from 1988–1994 was the beginning of a long-term negative trend. As noted, a short period of improvement was confined to 1995–1998. The global trend among the majority of developed countries toward falling fertility and aging is combined in Russia with high mortality, resulting in population decline.

The death rate is 1.7 times the birth rate. The excess of deaths over births in 1992–2000 reached 6.8 million, and the total population in 2001 had decreased to 145 million. Depopulation has become a national challenge. However, the phenomenon should be confirmed by the population census of October 2002 because of inadequate data on immigration during the period after the 1989 census (immigration may have compensated for the excess of deaths over births).

The birth rate decreased by a factor of 1.6 in 1990–2000, down to 8.7 per 1,000. The death rate had increased to 15.3 per 1,000 by 2000. The average life expectancy in 2000 was only 59.0 years among men and 72.2 among women (Government of the Russian Federation, 2001a). There has been a considerable decline in fertility. In 1988–1998, the net reproduction rate and the total fertility rate fell by 42 percent, leading to a sharp population decline (Ellmann, 2000). About 20 percent of couples suffer from infertility.

Fitness for military service among conscripts has declined (Gerasimenko, 1997). Abuse of psychoactive substances (tobacco, alcohol, and narcotics) has increased. In 1987–1999, the proportion of smokers among men in the age group 30–39 increased from 51 to 71 percent. The number of 15- to 17-year-old teenagers registered at narcotics dispensaries as drug users increased 12 times.

Demographic challenges are more qualitive than quantitive in nature. There are many indicators of decline:

• Declines in somatic and mental health are accompanied by increases in TB, syphilis, and AIDS.

• According to expert assessment, 70 percent of the population experiences long-term psychoemotional and social stress, resulting in increases in depression, reactive psychoses, and neurotic disorders.

• Social ill health is characterized by high levels of alcohol abuse, drug abuse, and suicide.

Especially distressing is the decline in maternal and child health. Health problems have increasingly shifted from the elderly to children and youth. Each succeeding generation possesses worse health and lower life expectancy. Ill generations fail to produce healthy offspring, and this may imply a long-term decline in the human potential of the nation. In spite of their higher life expectancy relative to men, women’s individual health potential is lower than men’s. Poor health of women results in the birth of unhealthy children. In 1996, over one-third of pregnant women suffered from anemia, and one-third of children were born unhealthy. Only 10 percent of children finishing school are healthy, and only one-third of conscripts are fit for military service.

The role of infectious disease in declining living standards and other social factors, especially poverty, is rising. TB, responsible for over 80 percent of deaths from infectious and parasitic diseases, caused 29,600 thousand deaths in 2000. The incidence of TB stabilized at 87.3 per 100,000 in 2001. Among inmates, its incidence is 35 times higher, and mortality from the disease is much higher as well. STDs have also increased. For example, in 1990–1997 the incidence of syphilis increased 64 times, up to 277.7 per 100,000, although it had decreased by 40 percent by 2000. Hospital infections are also on the rise. The incidence of HIV is high as well; more than 55,000 new cases were registered in 2000. Viral hepatitis, especially hepatitis B, is also increasing (Government of the Russian Federation, 2001a). In the early 1990s, there was an epidemic of diphtheria due to a decline in immunizations in 1990–1991; it was brought under control by 1995.

Migration has become a very important issue for Russia. The total number of migrants in Russia according to the United Nations is 13 million. Only in the United States is the number of foreign migrants higher with 35 million migrants (United Nations, 2002). There is a considerable inflow of migrants from the states of the former USSR. This migration is not monitored or controlled from an epidemiological point of view because of a lack of funds and is thereby posing a threat.

According to some forecasts, by 2010 the number of illegal migrants into Russia could increase to 19 million, representing 15 percent of the total population. The current number of illegal migrants according to various

estimates is 5.5–12 million (Korich, 2002). Illegal migration from China, Afghanistan, Iran, Iraq, and other countries takes place. Many migrants come from countries with unfavorable sanitary–epidemiological profiles. Temporary work accounted for 300,000 migrants in 2001. The majority of these migrants are employed in production and transportation, and many do not pay taxes.

Since 1990, 1000,000 individuals have emigrated from the country for permanent residence abroad each year (Government of the Russian Federation, 2001a). Finally, in 2001 Russia was visited by 21.5 million foreigners, including 7.4 million tourists.

In Soviet Russia, state social programs were the sole provider of safety nets for the population. These programs, as well as the economy and industry, were fueled until 1992 largely by state exports of natural resources, not manufacturing. Thus in principle, the labor force was of secondary importance for the satisfactory functioning of the Soviet model. Nevertheless, the social security of Soviet citizens (setting aside its quantity and quality) was more comprehensive compared with developed welfare states according to the “Soviet social contract.”

The dissolution of the USSR and the shift away from a bipolar world compromised “Soviet civilization” as a global phenomenon, with profound repercussions for public health. A change in the model of political and socioeconomic development necessitated new approaches to addressing public health issues. However, the ruling elite failed to meet this challenge. In accordance with the neoliberal approach, the state deserted the social policy arena. “Shock therapy” wiped out savings. Privatization and the market failed to substitute for Soviet state safety nets destroyed by the “two nations” reform project. The bulk of the population was deprived of economic power and thus became “excessive” at this stage of post-Soviet reform. Russia is a highly urbanized and relatively cold country (40 percent of the total area consists of permafrost regions); thus a considerable portion of households could not switch to private gardening as the basis for their subsistence.

Rhetoric aside, the practical indifference of the post-Soviet Russian elite and the state toward social policy and public health issues in 1991–1999 might be explained by the emphasis on the redistribution of state property inherited from the USSR, the control over flows of funds generated in the sphere of natural resource use, the allocation of budgetary funds and foreign loans, and adaptation to changes in the place of Russia in the world. As noted, the importance of population for the elite and for the acceptable functioning of the state bureaucracy further diminished during that period: final product represented less than nine percent of Russia’s

total exports. Another argument supporting this point is the lack of effective action of the state until 2000 on collecting taxes, as well as later introduction of a 13 percent flat-rate income tax. The population demonstrated high tolerance to hardships and the level of protest was low, despite the fact that the structure of the country’s gross national product might imply the right of every individual to receive considerable benefits based on the fact of citizenship alone. A decline in production, abolition of the state monopoly on foreign trade, natural resources, and alcohol turnover, and biased privatization of state property created a small, deindustrialized, raw material export–oriented economy beneficial for a small segment of the population and promoting outflow of capital.

Currently, Russia is in rather a geoeconomic vacuum. Its gross domestic product (GDP) is less than two percent of the world GDP. External debt stands at $US 138.1 billion. A considerable portion of the state budget is allocated to servicing this debt. Internal debt is high. Foreign investment in Russia in 1992–1998 totaled $US 15.9 billion (Russian Federation, 2000), comparable to an outflow of capital in one year (2001) of $US 17 billion.

Positive changes took place in post-Soviet Russia, related to ensuring political freedoms, opening up the society, effecting political and administrative reform, and developing market relations. The availability and variety of consumer goods and services increased as a result of price and trade liberalization. Cultural, economic, and recreational benefits were derived from increased foreign travel. The variety of media increased, and the Internet became accessible. Opportunities for legal self-employment and entrepreneurship increased and were seized by millions of people (Ellmann, 2000; Rimashevskaya, 1998a).

Public health challenges develop in parallel with, though lag behind, changes in the economy and social security. This was illustrated by a decline in public health in 1992–1994 and after the August 17, 1998, economic crisis in Russia; the latter resulted in a four-fold devaluation of the national currency. A considerable portion of the Russian population became involved in the vicious circle of poverty, disease, and premature death.

One of the first results of the post-Soviet changes was rapid impoverishment: from 1987–1988 to 1993–1995, the total number of poor increased from 2.2 to 57.8 million; 10 percent of the impoverished are considered the social “bottom” and are rejected by the society (Rimashevskaya, 1998b). According to official statistics, the share of population with incomes less than the living minimum is approximately 30 percent (Ellmann, 2000). In 1992–1996, the highest incidence of poverty was among children under six.¹³ There are at least one million neglected and homeless children. Impoverishment has resulted in

large-scale undernourishment (Rimashevskaya, 1998b) and increasing morbidity and mortality.

In 1990–1999, formal-sector employment fell sharply (UNECE, 2000a). The result was a decline in individual and family income, social exclusion, and declining life opportunities for children. Official employment was characterized by a large-scale failure to pay wages regularly in money and in full.¹⁴ Registered unemployment increased in 1994–1999 from 7.5 to 12.3 percent (Goskomstat estimates according to the International Labor Organization definition) (UNECE, 2000b).

Morbidity and mortality from diseases associated with poverty and unemployment increased. The greatest decline in fertility was seen in regions of the “rust belt,” which also experienced the greatest fall in industrial production and the highest unemployment, suggesting that the worsening economic circumstances since 1989 forced people not to have children. This point is further confirmed by a decline in the mean age of childbearing (Ellmann, 2000).

The increase in mortality was highest among men of working age, and was sometimes related to alcohol abuse (Shkolnikov and Nemtsov, 1997). Increased alcohol consumption is explained by a decline in its relative price and unrestricted accessibility. State and social control of alcohol use deteriorated in 1987 after the anti-alcohol campaign ended. The state alcohol monopoly was abolished in post-Soviet Russia at the end of 1991 by neoliberal ministers, sacrificing public health and state tax income to market interests. State officials also created opportunities for the penetration of the transnational tobacco, alcohol, and beer industries into the country. It should be noted that abuse of alcohol and other psychoactive substances is a traditional “escape from reality” when a response to intensive stress is needed (Bezruchka, 2000).

Inequality in wealth is leading to an increasing inequality in health. By 1995 the average income of the richest 20 percent was 8.5 times higher than that of the poorest 20 percent of the population (Rimashevskaya, 1998a).¹⁵

The winners in the process of change are those who are young, in good health, well educated, flexible, entrepreneurial, and mobile, and those who have privileged access to enterprise assets. The social groups that have borne the social costs of the change process are industrial workers and budget-sector employees, children, women, refugees, and persons displaced because of social and military conflicts. Men constitute the majority among both the beneficiaries and victims of change. Lifestyle factors have promoted gender gaps in mortality and life expectancy (Ellmann, 2000).

After the breakup of the USSR, about 25 million Russians remained in the New Independent States outside Russia. Their status was reduced to that of ethnic minority, and in many states they were deprived of basic rights and discriminated against. Some emigrated to Russia.

A very inexpensive or free network of public services (e.g., medical care, education, sport, public housing, public transport, garbage collection, preschool child care, cinemas, theaters) ceased to exist because of budget cuts or privatization. This development negatively affected a large proportion of the poor, especially pensioners, the disabled, and orphans.¹⁶

Scholars emphasize the important role of stress related to the failure of the state in Russia’s increased mortality. This stress results from the destruction of behavioral stereotypes and adaptation to changed roles and circumstances, reduced incomes, the loss of safety nets, and so on (Field and Twigg, 2000; Shapiro, 1995).

Post-Soviet changes led to increases in socioeconomic pathologies: corruption; criminalization; and alcohol, tobacco, and drug abuse. The criminalization of society has prevented social and economic development. Close links among the criminal, political, and business worlds have developed. Growth in corruption, including bribes and theft of public money, resulted from state failure, the rotation of elites, and the inadequate introduction and enforcement of legal and cultural norms and values. This in turn affected efficiency, policies, distribution, incentives, and the political system (Ellmann, 2000).

In 2001 there were two million inmates in Russia, and three million criminal offences were registered.^17,18 Each year 30,000 individuals are reported lost. Russia ranks second in the world in homicide incidence, after South Africa. According to Transparency International, in 2001 Russia was 79^th among 91 groups of countries on the corruption perception index, the degree to which corruption is perceived to exist among public officials and politicians.¹⁹ Moreover, post-Soviet armed conflicts resulted in loss of life, injuries, migration, and damage to property.

It is obvious that the hasty opening of the country to globalization processes during a crisis in social development has been one of the key factors in public health changes. Examples of these agents of change are

shifts in social values; outflow of capital; intensified migration; internationalization of crime; devaluation of the national currency in 1998; and large-scale imports of falsified food, alcoholic beverages, pharmaceuticals, toys, and other goods. Transnational producers of global “bads” such as tobacco, alcohol, and “junk food” penetrated Russia after 1991, using the window of opportunity provided by globalization processes. Currently, transnational companies control about 65 percent of local tobacco production. Tobacco production increased in 1990–2001 from 150.5 to 398 billion cigarettes (Gerasimenko and Demin, 2002). Beer consumption has been increasing by 25–30 percent annually. The world center of illegal drugs has moved closer to Russia, to Afghanistan.

Four actors shape public health policy in the era of globalization: the state, private enterprises, civil society, and international players.

Development of state public health policy in post-Soviet Russia can be divided into two periods. The first is Boris Yeltzin’s presidency in 1992–1999. A law introducing compulsory and obligatory medical insurance was adopted in 1991. It was proclaimed that the state health care system should be changed to a public one.

Advisers to the President in the spheres of health and environment and women, family, and children were nominated and functioned in 1991–1994. They were active in public health issues, emphasizing the need to control high mortality and preserve the environment.

The first state public health report was commissioned by the President in 1992, presented by the President to the National Parliament, and published. A presidential decree prescribed preparation of the report on an annual basis. A recommendation for the administrative territories to prepare similar reports was issued.

In 1993, health information was declassified by the Federal Law of State Secrets. A national security concept (Concept of National Security of Russian Federation, 2000) was adopted, incorporating social security and public health issues. The bases of legislation of the Russian Federation on protection of the health of citizens were approved, including revised principles of health care. In December 1993, after a conflict among federal branches of power, a new constitution was adopted.²⁰

During this first period, however, a broad crisis characterized by political changes, economic hardships, security issues, and the conflict in Chechnya drew the attention of individuals, the society, and the state, and public health concerns were overshadowed and reduced to health care reform. The latter emphasized the introduction of medical insurance. That shift resulted in such problems as the neglect of public health, disease prevention, and health promotion, as well as inappropriate use of health funds. Despite constitutional guarantees, a several-tier health care system has become firmly established. Drug supplies and access to expensive quality health care became a matter for public concern.

The response to public health challenges, even the depopulation threat, was inadequate. Some experts and scholars even referred to depopulation as a trait of developed societies, which Russia aspired to be. The financial crisis of August 17, 1998, exacerbated the political, economic, social, and public health crisis, and resulted in modification of the path forward.

The second period began in 2000, when Vladimir Putin was elected president. At that time, the overall crisis and depopulation were continuing.

Russia’s new leadership became increasingly aware of the need to prevent depopulation, particularly in Siberia and the Far East, to ensure the survival and stability of the country. Russia’s global security role (beyond issues of weapons of mass destruction), acknowledged by its membership in the Group of Eight (G8), also necessitates alleviation of public health problems.

In his first Address to the National Parliament on July 8, 2000 (Rossiyskaya Federatsiya, 2000), President Putin reviewed the most pressing issues Russia is facing, citing a forecast of population decline. In his words, in 15 years the country’s population could decrease by 22 million, and the survival of the nation would be endangered if this trend were to persist. A closely related public health priority for the new administration is effective management of migration. The policy response includes instituting pronatalist and health-promoting policies and/or revising immigration policy. In any case, the role of the federal government is central as sponsor and market regulator. This is illustrated by the experience of the developed world, especially Western Europe and Japan.

In September 2001, the concept of demographic development of the Russian Federation (Government of the Russian Federation, 2001b) was promulgated by the federal government. For the first time in Russian his-

tory, the state started to articulate the interests of society in the demographic sphere. The concept is a concise 11-page document and is not obligatory, nor does it include funding decisions or specify the optimal number and characteristics of population for the country. Three approaches to control of depopulation have been proposed, each entailing political, economic, and social costs.

The first is to promote pronatalist policies. Such policies promise long-term solutions. Analysis of the Soviet experience when additional benefits were provided to families having children suggests that such programs may encourage families to have children sooner than they would otherwise. Even if successful, these programs take a long time to show a significant effect on dependency ratios and can also lead to decreased participation by women in the workforce. Some politicians in Russia have suggested introducing a ban on abortions, recalling that such a measure was adopted in the USSR after World War II until 1955 and helped restore and then increase population numbers.

The second approach is to prevent premature mortality by means of health promotion and disease prevention. However, if this approach is to succeed, the social security system and informal safety nets, already strained in Russia, need to be strengthened to serve the increased numbers of aged with poor health that would survive.

The third approach is to promote immigration. This is a common practice in many developed countries, notably the United States. The Russian government is exploring replacement migration as a way to improve support ratios (Demin, 2002). Relevant legislation would have to be developed. However, this strategy could be ineffective and politically unacceptable because of the extraordinarily large numbers of immigrants that would be required. From 2000 to 2050, the net total number of migrants needed to maintain the size of the working-age population in Russia would be 32 million (nearly 650,000 per year), according to the United Nations forecasts. Promotion of large-scale immigration would thus require major cultural changes in Russia, including effective programs promoting tolerance and preventing xenophobia. Currently the number of resident aliens is small.

Moreover, control of illegal immigration has become one of the main tasks for law-enforcement bodies within the Federal Ministry of Interior. Many illegal immigrants are criminal offenders or are targets of criminal groups. The majority are involved in illegal commerce and do not pay taxes (Korich, 2002).

The strategic priority of the current Russian federal government is ensuring an increase in the revenues of households, controlling poverty, and protecting socially disadvantaged groups. The 2002 census is expected to

provide additional information for public health policy development. Private enterprise in Russia thus far has proved to be socially irresponsible, with some minor exceptions.

Civil society started to develop in Russia in the 1990s. Since 1996, political parties have included public health issues, related mainly to the nation’s health care model, in their electoral platforms. The Communist Party is the main opposition power; it attempted to impeach President Boris Yeltsin, and one of the issues put forward during the impeachment procedure was “genocide” of the nation. However, this party is responsible for the accumulation of public health problems during the Soviet period.

Only 10 percent of the population have adapted to the changed economic environment. About 20 percent believe there has been some improvement, and one-third do not accept the new reality and are ready to protest against it (Rimashevskaya, 1998b). The population continues to expect medical care to be a right of citizenship and believes in the idea of universal though not necessarily equal entitlement.

There has been strikingly little political protest, despite the considerable social costs of change. The political stability is explained by the legacy of the USSR regime, such as the absence of large inequalities and long-term poverty, the provision of welfare services, and compromised trade unions, as well as by the structural and institutional consequences of the neoliberal measures implemented, including increased unemployment, a decline in trade union membership, growth of the private sector, an increase in employment insecurity, and the opportunity to protest by voting the government out. Neoliberalism has enhanced possibilities for expressing discontent by means of “exit” strategies, which include informalization (earning money in the informal sector) and emigration, despite that fact that both are economic pathologies resulting from the implemented policies (Ellmann, 2000). Emigration, a direct impact of globalization, has led to the loss of large numbers of young, well-qualified, healthy, educated potential workers.

The World Health Organization (WHO) office (Moscow) for the Special Representative of the Director General was established in December 1998. Core funding is provided by a voluntary donation from the five Nordic countries. Among the office’s tasks are assisting Russian health authorities in activities against TB and HIV/AIDS and addressing structural issues related to essential drugs (WHO, 2005). The threat of the spread of drug-resistant TB strains beyond national borders has attracted international attention, and relevant programs have been launched. The World Bank considers AIDS and TB to be major problems for Russia, and for several years has consulted with the Russian federal government on a $US 150 million project for control of these diseases.

Russia’s public health challenge is unique, though it mirrors many global and regional public health trends in both developed and developing countries.

Historical developments in the twentieth century—including dissolution of the Russian Empire in 1917 and of the USSR in 1991; two radical transitions, to socialism in the late 1920s to 1991 and to a civilized market economy from 1991 to the present; an internal repressive regime (1929–1953); and the Great Patriotic War (1941–1945)—had great social and public health costs. The costs of recent post-Soviet changes in Russia to the population have thus far been greater than the benefits. Changes in Russia triggered by the dissolution of the USSR and the opening of the country to globalization took place without due consideration of their social and public health impacts by any of the political actors involved: the state, private business, civil society, and international players. Adaptation of the population to new social relations, as well as social, mental, somatic, and even biological aspects of human well-being, has been unsatisfactory. Until 2000, social policy in Russia was aimed at survival while demodernization and declining employment were shifting social development toward the corrosion of society due to social instability.

The availability of natural resources and an educated population and opening up to globalization processes cannot guarantee a country’s integration into the global economy or its internal social stability if social security and public health are not a priority in global and national political, social, and economic changes. Social security and public health can decline very rapidly if their importance is underestimated by the ruling elite, with profound repercussions for national security, the economy, and survival at the national level and beyond, to the regional and global levels. With the decline of social security, public issues already resolved can return at a new level.

There is a need to overcome a gap between the reality and the image of post-Soviet changes in Russia among many political actors, as well as among international players. Programs based on irrelevant standards and developed for other types of society and stages and levels of development cannot be sustainable in Russia and collapse when external support and funding is exhausted.

The state will have to play a central role in breaking the vicious circle of poverty, inequality, disease, premature death, and depopulation during the next stage of post-Soviet reform. The approach to public health challenges should be changed. Not only the quantity but also the quality of population matters. Democratization, more private responsibility, and less state paternalism should be combined with strong state regulation.

Support to civil society and incentives for the private sector should be

legislated, along with redistribution of revenues from exports and competitive sectors of the economy toward employment, raising the incomes of households, and social security. Social policy should move from sustaining acceptable living standards toward creating a comprehensive system for developing and educating individuals. Care for neglected children and strengthening of migration service are priorities, along with education, health care, and science.

More use of the positive opportunities provided by globalization—for example, telemedicine, the Internet, access to information—is needed. Discussion of globalization and public health issues should be expanded in Russia. A new paradigm of global health is needed among Russian public health leaders.

Public education is needed because an antiglobalist front, as well as xenophobia, is developing rapidly in Russia. The role of international players should be modified, especially in relation to the planned WTO accession of Russia. These players should pay more attention to the social and public health aspects of the policies pursued; otherwise, negative impacts will have a regional and global spillover effect. Peculiarities of public health theory and practice in Russia, both successes and failures, should be taken into account in the development of global public health policy and governance, with the participation of Russia. Adequate participation of Russia in global governance will depend on its success in the public health sphere.

A single system of global governance based on unification will require improved standards of national governance, with an emphasis on humanitarian issues, as well as the closing of gaps in governance and development among countries and prevention of the marginalization of whole countries and regions. Incentives for national and international players should be designed to ensure positive developments. International law on poverty might be among the first steps, as the historical development of social security in various nations suggests.

The political model of globalization should be amended. Trade interests should be subordinated to public health interests. Public health and globalization issues should be incorporated into intergovernmental cooperation programs between Russia and other countries.

A transnational research agenda in public health and globalization should be developed, especially addressing migration and infectious disease control. There are experts in Russia capable of participating in relevant activities within international collaborative programs. Russia possesses unique experience in the protection of its territory from extremely dangerous infections through its so-called counterplague service, and this experience could be useful for other countries. Russia could play a leading role in the prevention and control of HIV/AIDS and other infectious diseases in the Commonwealth of Independent States and Eastern Europe. Russian experts

could work on the problem of bioterrorism prevention and control, as well as prevention of the spread of infectious diseases beyond national borders as a result of migration.

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