Cablegate: Russia's Demographic Situation: Serious, but Not

DE RUEHMO #3660/01 3521419
R 171419Z DEC 08




E.O. 12958: N/A

REFS: A. Moscow 854
B. Moscow 536
C. 07 Moscow 4543
D. 07 Moscow 1834
E. 07 Moscow 1135

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1. (SBU) SUMMARY: For several years, demographics and public health
experts have prophesied Russia's demographic demise and warned of a
potentially catastrophic loss of population. Russia indeed faces
major public health and demographic problems (reftels). However, in
certain areas there has been a stabilizing of recent trends or even
improvement in recent years. Overall mortality has fallen, while
the birth rate has risen; deaths from tuberculosis have fallen to 25
percent below their peak. Some public health problems are not as
severe as statistics might suggest when the data are taken out of
context. The government is already taking encouraging steps to
address certain key problems, including smoking habits,
tuberculosis, and the risky behaviors that contribute to the spread
of HIV/AIDS. International donors, including the USG through USAID,
the United Nations, and the World Health Organization, have
contributed much toward promoting these positive steps. If the
government is able to continue and reinforce its efforts in this
direction, then Russia's long-term demographic prognosis may be
better than many analysts fear. However, the financial crisis and
low oil prices have raised serious doubts about the future of
Russia's health spending. END SUMMARY.

2. (SBU) A number of press articles on Russia's public health and
demographic challenges, such as the article by demographics and
public health expert Murray Feshbach in the October 5, 2008, edition
of the Washington Post
/AR2008100301976.html), describe a set of problems that could lead
to a catastrophic loss of population and associated loss of economic
and political power. Russia's health indicators reached a nadir in
2000, when deaths exceeded births by 958,000. Subsequently, there
have been modest improvements in most indicators, especially in the
past two years. In 2006 and 2007, there was a significant decrease
in mortality (6 and 4 percent respectively) from almost all cases of
deaths. In addition, in 2007 there was an unprecedented 8 percent
increase in the number of births. While many demographics experts
have raised doubts that these positive changes will be sustained
beyond 2012, the positive indicators should not be ignored.

--------------------------------------------- -
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3. (SBU) Russia has a severe problem with premature mortality, as
reflected in decreased life expectancy especially for males (60.4
years in 2006). The most prevalent causes of premature death in
Russia are linked to cardiovascular disease and external causes such
as trauma, both of which are influenced by tobacco and alcohol
abuse. Twenty percent of overall mortality is attributed to
excessive alcohol consumption and 15 percent to smoking, according
to one prominent Moscow cancer researcher. These deaths are
potentially preventable if it is possible to change social norms of
alcohol abuse and smoking habits. Some favorable trends towards
healthier living are visible, though primarily anecdotally, among
the urban middle and upper classes. The Russian government
generally encourages these trends and has participated in
international efforts to limit tobacco abuse. It joined the WHO
Framework Convention on Tobacco Control earlier this year and is
expected to take the necessary steps to implement it. However,
Russia has yet to address either smoking or alcohol abuse with the
seriousness that their impact would seemingly demand. And, while
some progress may be achieved in curbing smoking, there has
apparently been insufficient political will to fight alcohol abuse.

4. (SBU) The indicator of the elevated rate of cardiovascular deaths
in Russia is important, but should be considered in light of the
concept of "competitive mortality"; as everyone dies from something,
various factors can shift the causes of mortality between groups,
and simple rate comparisons can be misleading. (Note: An example of

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competitive mortality effects in the United States is the recent
upward trend in deaths from Parkinson's disease, which may be
attributed to major declines in mortality from ischemic heart
disease and stroke. Thus, more people are living long enough to die
from Parkinson's. End note.) In Russia, the much higher number of
cardiovascular deaths than in the United States suggests there are
lower rates of deaths from some other causes. A more critical
indicator is the elevated mortality among younger age groups,
especially among middle-aged males. Smoking and alcoholism are the
primary causes of Russia's markedly higher cardiovascular mortality
relative to U.S. rates, and public health measures could
considerably help to address this excess mortality among the young.


5. (SBU) Feshbach's statement that the health of Russia's newborns
is quite poor, with about 70 percent of them experiencing
complications at birth, can be misleading; birth complications as
diagnosed in the United States do not affect 70 percent of Russian
infants. However, a high percentage of infants receive some
"diagnosis" due to a very different way of evaluating children's
health; these diagnoses can be assigned due to a maternal health
issue in pregnancy or where the infant had some minor and frequently
temporary variation in development. However, we have seen
improvements in related indicators even in areas where diagnoses are
consistent with U.S. definitions. To cite only one example, during
the course of USAID's maternal and child health program in the
Krasnoyarsk region, between 2003 and 2007 the prevalence of
hypertension among pregnant women -- one of the major contributors
to maternal death -- fell from 28 percent to 7 percent.


6. (SBU) So far, HIV/AIDS has not been a major contributor to
overall mortality, but has been focused more on a concentrated
population. Feshbach noted that "about 1 million people in Russia
have been diagnosed with HIV or AIDS, according to WHO estimates."
However, while many Russian experts now concur that there are more
cases than the 440,000 officially registered, the UNAIDS estimate of
940,000 persons living with HIV/AIDS (PLWHA) may be an overestimate.
There are lines of evidence that suggest a lower figure perhaps by
10-20 percent, and some leading Russian experts have told us
privately that they agree with the lower estimate. UNAIDS will be
reviewing its estimate this year in cooperation with the GOR. If
the revised estimate is significantly higher than the current
officially registered figure, it will still present HIV/AIDS as a
serious public health challenge that could seriously strain the
health sector if not contained.

7. (SBU) The GOR must address this epidemic, particularly in the
area of prevention, in order to avoid an expansion beyond the most
at-risk populations. The GOR has demonstrated some political will
to cope with the issue through such proactive steps as the recent
announcement of the next federal tender for AIDS prevention
programs. The government is soliciting input from the NGO community
and international partners who have supported prevention activities
in the past few years.

8. (SBU) Feshbach also wrote that "using mid-year figures, it is
estimated that 25 percent more new HIV/AIDS cases will be recorded
in 2008 than in 2007." Because of the peak of transmission that
occurred around 2000, increasing numbers of PLWHA are now getting
sicker and presenting for care. This factor could account for much
or all of the increase in the number of newly detected cases.
However, this alone underscores the seriousness of this epidemic.
Even under conservative estimates of the size of the epidemic, the
GOR will need to consider options, such as greater flexibility in
access to care and treatment outside the limited number of existing
AIDS centers. In one example of such an approach, the USG's PEPFAR
program introduced a pilot expansion of HIV care to primary care
clinics in St. Petersburg, which has widened the range of care
options for those infected with the virus.

9. (SBU) Feshbach continued: "This should be all the more worrisome
because young people are most at risk in Russia. In the United

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States and Western Europe, 70 percent of those with HIV/AIDS are men
over age 30; in Russia, 80 percent of this group are aged 15 to 29."
The statement about the age groups at risk seems to disregard
"cohort effects" in HIV epidemics. HIV transmission usually is
highest among young people, as that is the age of maximum
risk-taking. In the earlier stages of an HIV epidemic, there are
not many long-time PLWHA, and the bulk of those infected are young.
However, later in most epidemics, transmission decreases, and the
large initial cohort of PLWHA ages (if treatment is available),
while subsequent cohorts of young, recently infected persons are
smaller. The "70 percent over 30 years" figure for the United
States and Europe reflects the passage of time since the peak of
transmission during the 1980s and 1990s; the surviving individuals
are now older and reflect the bulk of PLWHA. However, new
transmission in the United States still disproportionately affects
younger individuals. In Russia, the HIV epidemic (which began in
1995) is at least 15 years younger than in the United States and
Europe (beginning in the late 1970s); therefore, one would expect a
major difference in the average age, even if transmission patterns
were identical. In addition, the comparison is misleading because
the Russian figure reflects the age at which people were diagnosed,
not their current age. While 80 percent of those diagnosed up to
about 2006 were diagnosed at ages 15-29, the average age at
diagnosis gradually rose during that period; now more than 20
percent are being diagnosed beyond age 30, and no figure is
available for the current average age of PLWHA. The truer Russian
picture reflects maximum HIV transmission earlier in the epidemic
with a serious but lower current rate.


10. (SBU) Feshbach warned that "tuberculosis deaths in Russia are
about triple the World Health Organization's definition of an
epidemic, which is based on a new-case rate of 50 cases per 100,000
people..." This statement most likely refers to tuberculosis (TB)
cases, not deaths; the rate of tuberculosis deaths in Russia is only
approximately 17 per 100,000 population. Feshbach cited Russia's
rate of tuberculosis deaths -- 24,000 TB deaths in 2007 out of a
population of 142 million -- and compares it to the much lower U.S.
rate of 650 deaths of a population of 303 million. While the TB
epidemic in Russia was a major public health failure in the 1990s,
and the current TB case and death levels remain far too high, the
situation has stabilized and improved in recent years. After
doubling in the 1990s, TB cases peaked in 2000. Subsequently, new
TB cases dropped about 10 percent until 2004 and have been stable
since then. This change has been most marked in prison systems,
which have seen a drop of two-thirds in what was a catastrophic case
rate in 2000, and an even bigger decline in deaths. The 24,000
overall TB deaths in 2007 are almost 25 percent below their peak.
Further substantial public health improvements and reforms are
needed to approach low Western levels of TB morbidity and death.
International donors like the World Bank; the Global Fund Against
HIV/AIDS, TB and Malaria; and USAID have contributed much toward
stabilizing the situation. In all seven USAID-supported regions, TB
treatment success rates have exceeded the national average of 59
percent, demonstrating local commitment to improving the situation
and the impact of international best practices. However, while some
public health improvements are occurring, rising rates of TB/HIV
co-infection may offset their beneficial effect over the next
several years.

11. (SBU) COMMENT: A truly "healthy" Russia will require serious
improvements in the health sector and some major changes in current
cultural norms, and the financial crisis and low oil prices have
raised serious doubts about the future of Russia's health spending.
Nevertheless, we do not share the deterministic view of Feshbach and
others that this "national calamity" is happening "inexorably."
During the past two years, the GOR has finally started paying
attention to demographic issues. Unfortunately, so far the policy
and the financial incentives have been focused more on increasing
births than decreasing premature deaths. However, the Russian
government's recent steps to join the WHO Framework Convention on
Tobacco Control and its decision to put a significant amount of
money into prevention of smoking and alcohol abuse in 2009-2011
inspire hope for some progress in reducing mortality and improving
the overall health of the population.

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