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The Lancet, Volume 366, Issue 9487, Page 689, 27 August 2005
doi:10.1016/S0140-6736(05)67148-6Cite or Link Using DOI

Can Russia cope with avian influenza?

The Lancet
European leaders are running scared. Avian influenza, which for the past few weeks has been spreading through central Asia, has now reached the Ural Mountains in Russia, sparking fears that the virus will continue its march west into Europe. The Dutch Government, mindful of its 2003 brush with avian influenza, which left a quarter of its poultry population (and one veterinarian) dead, was first to buckle under the pressure, ordering its farmers to keep all free-range poultry indoors. German politicians are currently mulling over a similar strategy. Other European countries have stockpiled antiviral drugs and placed orders for new vaccines. But is this concern justified? Animal health experts continue to assert that the risk of the virus spreading to Europe's poultry population remains small. They have held back from recommending large-scale protection measures. However, for human health, the risk is not necessarily dependent on geographical spread. Even without the virus moving further west, widespread infection in Russia and Asia makes human transmission more likely. And if Russia's ailing health system is to be the front line of defence against a possible pandemic, Europe's leaders are right to feel afraid.
Despite laudable public-health achievements during the Soviet era in Russia, the health situation in the country is now dire—and getting worse. Since the break up of the Soviet Union, Russia has seen surges in previously controlled communicable diseases. Rates of HIV/AIDS, an infection that was barely seen in the country a decade ago, have soared, and life expectancy has fallen steadily. The latest estimate from Russia's federal statistics service, Rosstat, puts mean life expectancy for Russia's men at 58·8 years—lower than any country in Europe, and almost 5 years less than in Ukraine.
Social upheaval resulting from the collapse of the Soviet system was the initial cause of Russia's health crisis. But the reasons behind the continued worsening of health status are more complex. Whereas most central European countries that experienced similar upheaval during the early 1990s have managed to control HIV, Russia has failed. Pitifully low investment in health and widespread use of outdated equipment are contributing factors, but the main problem for Russia is its inability to adopt modern disease-control measures, which involve employing fewer, more highly trained, staff, use of increasingly technological disease-detection methods, and a shift towards primary-care-led health promotion to help curb lifestyle-related disease.
An inevitable consequence of Russia's neglect of its health system is that the country remains ill-prepared for emerging threats to human health, despite a reasonably efficient reaction to the identification of avian influenza in birds. And while the Government's rhetorical response to the human-health risk has been along the right lines—earlier this month, the Russian health minister assured international observers that the country will continue surveillance and report any disease developments; and last week, the country's chief public-health official announced plans to step up coordination between federal bodies—the historical lessons from Russia's practical problems with its burgeoning epidemics of HIV and tuberculosis hint at the likely difficulties of counteracting a new outbreak.
Pandemic control requires prompt detection of cases and targeted interventions for the first clusters. But it remains doubtful whether Russia has the necessary capacity. The country's huge size is an obstacle to those services that do function well. With more than 140 million people spread over 17 million km2, getting health care to the population is a monumental task. There are more than 80 oblasts (administrative regions), with varying degrees of autonomy, differing health infrastructure, and diverse standards. Although some achievements in HIV and tuberculosis control have been made in densely populated areas such as Moscow and St Petersburg, treating those in need in the most sparsely populated oblasts depends on how sustainable and well equipped the health system is to deliver the necessary medicines. In these areas, standards are generally poor on both counts.
So western Europe is right to be scared. Importantly, though, rather than prompting protectionist policies, this fear is pushing the EU to look beyond its borders and tackle the risk posed by frail health systems in neighbouring countries. The fledgling European Centre for Disease Prevention and Control (ECDC) is leading this effort and, by showing that it can support WHO-EURO in fields where it has been historically weak (dealing with zoonoses is one example), ECDC has already proved its worth as an international health agency.
Europe's community actions may help protect it from the consequences of Russia's health problems. But who will protect Russia from itself?
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