Russian Medical Horrors
Causing AIDS Explosion
"Elista" Incident Fosters Distrust in the System
By Laurie Garrett
Newsday Staff Correspondent
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 Bible reading.
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 virus.
"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 sex.
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 asks.
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 high-risk patients.
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 ago.
"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 Hippocratic Oath?"
"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 positive."
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 negative biocurrents."
Viktor opens his shirt to reveal a bullet-shaped piece of tin taped to his chest.

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