- ST. PETERSBURG, Russia AT THE LENINGRAD
Republican Infectious Disease Hospital, located in the countryside near
this city of 4.5 million, many of the dynamics - and much of the history
- driving the HIV explosion in Russia can be seen at once at a Salvation
Army prayer meeting.
- A 10-year-old girl demurely bows her
head, a large pink bow in her hair as she prays. Beside her, a 9-year-old
girl, her hair filled with carefully entwined artificial flowers, shifts
impatiently in her seat. And across from them, two tough-looking men in
their mid-20s nibble on the free meal, only half-listening to an ongoing
- In all, nearly 30 people sit around a
large lunch table. Ranging in age from 6 to 50, they represent a cross
section of Russian society. And they're all infected with the human immunodeficiency
- "See little Misha over there? The
12-year-old boy?" whispers Svetlana, a 32-year-old Salvation Army
volunteer, who is also HIV-positive. "He says, `It's okay, I'll get
married when I grow up, and my HIV will go away."'
- Some of the adults in the room, like
Svetlana, got HIV through heterosexual intercourse. Others - probably the
majority - were infected through contaminated needles they shared with
fellow opium users. And one, Nikolai, got the virus through homosexual
- But the children were all infected in
Russian hospitals in a series of transmissions known within the health-care
system as the "Elista incident."
- "Aren't they charming?" Svetlana
- Yes, and tragic.
- They have grown up cut off from society
by the government, surrounded most of time not by their families but by
the well-intentioned medical personnel of the Republican Hospital. And
their sad story remains key to how many Russians - and, indeed, citizens
in many of the countries that once made up the Union of Soviet Socialist
Republics - view a health care system barely surviving the change from
big brother authoritarianism to a favorite uncle-type democracy.
- While drug-related HIV can be blamed
on gangsters and the region's growing pains, the tragedy that occurred
in the city of Elista signifies for many a substantial rip in the fabric
of basic health care. In conversations over several months in Russia, Georgia
and Ukraine, many people spoke vehemently of avoiding minor surgery and
dental visits because they feared getting AIDS via reused or contaminated
instruments. And physicians told of the dangers they fear in caring for
- The chain of tragic events known as the
Elista incident began around 1982, when a Russian sailor who had worked
in Africa unknowingly acquired HIV. He passed it on to his wife, and she,
in turn, unknowingly infected her fetus.
- In May, 1988, the child was admitted
to Elista's pediatric hospital with a variety of intractable infections,
all with no apparent causes. The baby died soon afterward, still undiagnosed.
Meanwhile, the baby's mother, by now 23, began to develop the same type
of unusual infections.
- The mother went to Moscow for treatment,
where she ran into a woman with similar symptoms, who also had lost a child
at Elista. When the two mothers compared notes, they determined that their
children had been in the neonatal ward at the same time and had suffered
the same type of infections.
- The result? Doctors finally added up
the coincidences and gave both an HIV test, determining that one of the
country's first HIV outbreaks was under way. A joint Russian/UN probe later
determined that by the time the last mother and child in the chain were
infected in 1994, about 250 cases had occurred - the children infected
through hospital injections with recycled syringes and catheters, the mothers
via bites from breast-feeding babies.
- And follow-up investigations determined
that the problems at Elista were not unique: Pediatric practices in hospitals,
clinics and doctors' offices throughout Russia were astonishingly backward.
- Healthy babies, or those suffering minor
ailments, routinely received up to 300 injections yearly of vitamins and
antibiotics that were given with needles used on one patient after another
all day long. And babies who were very sick routinely received implants
of recycled, poorly sterilized catheters.
- "There was just one case to begin
with," said Dr. Saladin Osmanov of the UNAIDS agency. "But the
terrible medical practices were enough to create an outbreak."
- And the outbreak didn't end at Elista,
investigators said. Some of the HIV-positive babies were shipped to other
hospitals in the Russian cities of Rostov-on-Don, Volgograd and Stavropol
before their diagnoses were clear. And doctors in those facilities, repeating
the same health care practices, passed the virus around their pediatric
facilities, as well.
- How was the outbreak tracked? It proved
easy, Osmanov said: Everyone connected to the outbreak was infected with
the same strain of HIV, an unusual strain, known as subtype G, which had
never previously made its way out of East Africa.
- After Elista, Soviet authorities panicked,
stepping up mandatory HIV testing to levels unheard of elsewhere, and allowing
doctors to screen patients without consent. But experts on world health
say this policy was a mixed blessing historically.
- They could, indeed, use the testing to
isolate individual infections. But since the rate of infection remained
tiny, the Russians felt no pressure to follow up with an expensive infection-control
effort that would have ensured adequate supplies of sterile syringes and
protective equipment, not to mention extensive retraining of caregivers.
And that, the experts agree, did nothing to prepare the country for the
maelstrom it now faces.
- At a clinic in Kiev, Alexander, a television
repairman by trade, sits in the converted 17th-Century Ukrainian monastery
that serves as that country's primary AIDS hospital. The 46-year-old father
of three speaks of his room as his "cage," but says he appreciates
the kindness of the staff.
- One of the nurses - a woman who has treated
HIV patients for more than two years - rolls up Alexander's sleeve and
begins to take a blood sample. Although she is not wearing protective latex
gloves, she uses her forefinger to apply pressure on the site of injection
after she removes the needle. Then, still bare-handed, she injects the
blood into a test tube, manually removing the needle from the syringe.
- When her supervisor, Dr. Alla Vouk, is
questioned about the incident later, she flatly denies that any of her
staff ever performs blood-related procedures without appropriate precautions.
Her denial is unaltered by a reporter's insistence that these events were
witnessed and photographed.
- And in Odessa, where abortions are the
preferred form of birth control, doctors make extra cash by performing
the procedures outside the hospitals. "In that case, the physician
doesn't know that [the patients] are HIV-positive," prominent obstetrician
Igor Boychenko said. "And she may well be treated with the same tools
and instruments as the next woman."
- Throughout areas of the former Soviet
Union witnessing a surge in HIV, health providers seem woefully behind
the times. While concerned about their own safety, many were seen routinely
- without protective attire - performing procedures that put them in direct
contact with patient blood.
- Meanwhile, some continue to demand the
right to decrease their personal risk by insisting on performing HIV tests
even without patient approval, and refusing care to those who are infected.
It is a discussion painfully familiar to American nurses, physicians and
dentists who collectively confronted the same issues more than a decade
- "If I operate on an HIV patient,
I'm taking risks! It would be great if we could screen our entire population,"
argues Vitaly Pushkaryov, a white-haired surgeon who directs the enormous
Novosibirsk Oblast Hospital in Russia.
- "That's a typical surgical attitude,"
responds Evgeny Bocharov, an infectious-disease specialist. "You want
clean patients, not sick ones."
- The surgeon, though seated, towers over
Bocharov, both physically and in his status within the hospital hierarchy.
Yet, the fiesty Bocharov holds his ground during a joint meeting with an
American reporter, arguing for better infection control throughout the
hospital. The intensity of the debate, they admit, is heightened by the
appearance this year of a new HIV outbreak within this Siberian city, 3,343
kilometers from Moscow.
- "Why should I take risks? I'm not
insured," the director says. "So my family gets 20 million rubles
to pay for my funeral? I want 100 percent screening for everyone."
- "We will never be able to test every
patient," Bocharov notes. "It's impossible. And what about the
- "That oath is forgotten," Pushkaryov
says dismissively. "We discuss now a doctor's code. I may take a risk,
but I have to be ready. Not with latex gloves, with iron gloves!"
- In 1995 the Russian Federation changed
its HIV-testing laws, eliminating most circumstances under which police
and nonmedical personnel can compel individuals to be tested against their
will. But many physicians said they still give tests to patients without
their permission, or sometimes their knowledge.
- "There are no compulsory AIDS tests
in the new law except for blood donors," Dr. Mikhail Narkevich, who
heads AIDS policy for the Ministry of Health, said. "The rest are
recommended. But you can view `recommended' from different angles. One
can be very insistent on an individual having a test. We [Russian doctors]
made 4.5 million tests for `clinical reasons' in 1996, 388 of which were
- The major group pushing for continued
large-scale screening of the populations of the former Soviet Union are
the physicians - especially surgeons - Narkevich said. But even when such
tests are done, and results known, surgeons haven't necessarily been trained
to pay attention, and often don't.
- One crisp June morning in St. Petersburg,
Dr. Aza Rakhmanova, chief "infectionist" for the city, rushed
between the numerous buildings of Botkin Infectious Diseases Hospital,
heading for the Neurosurgery Institute. The month before, the short, plump
woman recalled breathlessly, "surgeons did brain surgery and afterwards
realized the patient was an HIV-positive drug user from Kaliningrad. And
the surgeons weren't wearing gloves! They claim that the brain is a fine
structure and gloves impede their work. I told them it's a crime!"
- Rakhmanova disappears into the neurosurgery
building to deliver the sorry message that first-round testing had turned
up tentative HIV-positive results in six of the surgeons and nurses who
were in that operating room. The tests will have to be repeated several
times over coming months.
- Ironically, Rakhmanova has just come
from her AIDS ward, where she dispensed therapy that would be sophisticated
even in New York City, epicenter of the North American epidemic. To 28-year-old
Kosta she suggested adding anabolic steroids to his protease-inhibitor
combination therapy to enhance the man's metabolism.
- "It makes sense," she says
brusquely. The patient is left wondering how he will pay for still more
drugs, as Rakhmanova strolls next door to the room of a long-haired, bearded
man who is sitting on the edge of his bed slowly and tentatively spooning
food into his mouth.
- "How is the invirase [a drug] going
down?" Rakhmanova asks. Timour Novikov looks up, his eyes fixing on
a spot a few inches shy of the doctor's position. As he carefully slides
his borscht soup aside, Novikov smiles and says, "I can swallow the
pills - it's not too difficult."
- Novikov, an artist, lost his eyesight
recently when an opportunistic viral infection invaded his brain, causing
encephalitis. Now he sells his paintings to pay for the protease inhibitors
that have restored some of his weight and his ability to walk.
- As Rakhmanova and her staff move from
room to room making patient rounds they know when it is necessary to wear
gloves - and when it is not.
- But outside the rarified world of a handful
of such AIDS-specialized sophisticated hospital settings, ignorance reigns.
At the Kiev AIDS clinic, for example, 38-year-old postal worker Viktor
has had AIDS for three years. He won't take AZT - the only treatment available
in Ukraine. Instead, he sees a popular Kiev healer, "who has invented
an apparatus to measure biocurrents from my body. She charges the currents
with a piece of tin, which we call a bullet. And the bullet counters my
- Viktor opens his shirt to reveal a bullet-shaped
piece of tin taped to his chest.