A Disappearing Country

AMY DAVIDSON: You’ve previously written for The New Yorker about the AIDS crisis in Africa and in India; this week, you look at AIDS in Russia. What makes the situation different there?

MICHAEL SPECTER: It takes an average of ten years before somebody who is infected with H.I.V. shows the signs of AIDS; the epidemic hit much of Africa before anybody on earth knew that it existed. In addition, the poverty in Africa is acute. In India, much of the population is desperately poor, diseases like malaria are epidemic, and millions are illiterate. Russia had the special advantage of avoiding the earliest waves of the AIDS epidemic. It is a highly literate country. Yet the Russian government has done almost nothing to capitalize on that advantage. It seems a special shame for an epidemic to be spreading in a country that is not poor, and at a time when so much is known about how to prevent infections.

The starkest part of your story has to do with the general health of Russians since the fall of Communism: life expectancy has dropped precipitously, young people aren’t having children, and the population has declined by millions. Is Russia dying?

Perhaps not, but it is certainly atrophying. By 2050, there will be a third fewer Russians than there were just fifteen years ago—that is an optimistic government estimate. No industrialized or advanced country has ever had such a reversal of general health (except during wartime), and what it implies for the future of Russia cannot be good.

How have—or haven’t—Russians dealt with that reality?

The government has acknowledged demographic realities in words but not in actions; President Vladimir Putin has even spoken about it. But very little has been done to improve the public health or to make people want to have families at all, let alone large families. It’s hard to convince people to have more children in a society where people feel they are getting poorer and where opportunity seems to be shrinking, not growing.

How do other health and social problems interact with AIDS? Is AIDS just another blow, or does it act as a force multiplier, compounding other problems?

The incidence of AIDS and the way it is treated is often a mirror of the public-health system itself. In one way, it is just another, serious blow, but it is tied up with the epidemic of tuberculosis, and each feeds on the other. People with AIDS are still often treated like criminals; most Russians believe that it is solely a problem for people who use drugs. That was once true but is less so every year. And as the AIDS epidemic grows, it will siphon funds away from other health priorities in a country that already spends far too little on public welfare.

You write that in Russia Putin is viewed as a poryadochny chelovek—a man of order and discipline. Is that what’s needed for Russia to fight AIDS?

No. What is needed is openness. In Uganda, one of the worst and earliest hit African countries, President Yoweri Museveni has made it a policy to mention AIDS in speeches, and so does every member of his cabinet. In Russia, you cannot find an ad, a television talk show, or a government-sponsored panel about the epidemic. If Putin led on the subject, then his forcefulness could be useful. But until the severity of the epidemic is acknowledged, it doesn’t matter what type of leader Russia has.

There’s a tendency to view an open, democratic society as a part of the antidote for any number of ills—that was the implicit message behind the American AIDS activists’“silence equals death” slogan. How relevant is democratization in Russia to both the AIDS crisis and the larger breakdown in public health?

I’m not sure. China is doing a better job than Russia of addressing AIDS, and that government is the furthest thing from democratic. In America, it helped that some of the earliest of those affected were gay men in New York and San Francisco. They were relatively affluent, media savvy, and connected. And they got results. As to the breakdown of public health in Russia, the end of the Soviet Union has brought stress and confusion. But primarily, the government simply has not devoted enough of its resources to the welfare of the people—and that started years ago.

You’ve written in the past about the AIDS activist Larry Kramer. Is there a comparable Russian figure?

Not really. There are a few activists, but you need media to get attention, and the media is controlled by the government. A Russian Larry Kramer could chain himself to Lenin’s Tomb for weeks and I doubt that you would see mention of it on the state television networks.

You write that the response to AIDS is wrapped up in questions of national pride—Russia wants to be compared to the U.S., not to, say, Ghana. Is Russia still a superpower? 

If you believe that a superpower is a country that has a lot of nuclear weapons, then, yes, it is. If a superpower is a country that leads intellectually, in the global economy and with human capital, I don’t think anyone could consider Russia to be one.

Is AIDS having an effect on Russia’s military? [сколько в этом вопросе неподдельного гуманизма!]

Russia wants a big army; it has always had one. But draftees are increasingly testing H.I.V. positive. The country is already suffering through a shrinking pool of eligible soldiers, and that will soon get worse. If those who are available are sick, there is very little choice for the Russian military but to reduce its forces.

You visited Irkutsk, a bleak city that seems to be emerging as an AIDS capital. A young woman you spoke to there said that everyone she knew used or had used drugs. How thoroughly demoralized are young people in Russia?

Sadly, I wouldn’t call Irkutsk an AIDS capital. It’s just one of many demoralized, depressed cities I have seen. Some young people in Moscow and St. Petersburg are energized by the new freedom and the entrepreneurial spirit that exists today. In most other cities, though, such opportunity does not exist, and the young, who once had free education and guaranteed jobs, have neither now. Nor do they have much of an alternative.

In Moscow, however, you saw enormous wealth, concentrated among the so-called oligarchs. Is any sort of philanthropic principle developing in Russia?

Slowly. There are some people who give money, and if they were encouraged they might give more. 

You’ve written about the problem of dividing resources between treatment and prevention in the fight against AIDS. Could you talk a little bit about that, and about whether the choices in Russia may be different than in India or in Africa?

It’s always hard to convince leaders to spend money on prevention when other diseases are already visible and they need treatment. Yet prevention costs so much less and is so effective. In Russia, the choices are different than in Africa or in India, because, for one thing, the country has a lot more money. It’s not rich, but it can afford to spend tens of millions of dollars on prevention and education campaigns (and that would save tens of billions of dollars on treatment and related costs later). Yet this year Russia will spend far less than ten million dollars on every aspect of AIDS combined: treatment, prevention, education, care. 

Let me ask you the question that you say you posed to nearly everyone you met in Russia: When are they going to do something?

When it becomes impossible to ignore the epidemic. When people are dying in large numbers—and, tragically, that will be too late for millions of people who, if they were educated now, could avoid this horrible disease altogether.