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Unable to pay for care, many stay ill

KARABASH, Russia -- He was 40 when he had his first heart surgery, a quadruple bypass to correct damage caused by the poisons of the ancient copper smelter where he worked.

But that was a decade ago, when the decrepit Russian health care system provided low-cost care to those who could wait.

Now, Mikhail Lychmanyuk has been told he will die unless he has a second heart operation. This time, it will cost him $5,000.

It might as well be $1 million.

"I'll wait for the end," he said, sitting in an empty playground in this desolate industrial town about 1,000 miles east of Moscow.

Russia's steep population decline in the 15 years since the collapse of the Soviet Union has many causes, but the end of the Soviet health care system and the debut of free-market medicine have made matters worse.

In the new Russia, millions are born sick. Many succumb to poisons in the air and water, or are slowly killed by alcohol, cigarettes or stress. Most are too poor to buy back their health.

Medical care is nominally free; in practice, all but the most basic services are available only to those able to pay hefty fees -- or bribes.

For the well-off, mostly foreigners and those who struck it rich in Russia's transition from communism, there are gleaming "European medical centers" with modern equipment and foreign-trained doctors who charge $100 a visit. The rest are relegated to foul-smelling infirmaries with stained sheets and no food that often lack equipment as basic as a functioning X-ray machine. Doctors work for as little as $140 a month.

The Scientific Center of Children's Health, a branch of the Russian Academy of Medical Sciences, estimates that 45 percent of all Russian children are born with "health deviations," including problems in the central nervous system, faulty hearts, malformed urinary tracts and insufficient birth weight.

Heart disease and strokes have increased by as much as 36 percent in the past five years for those younger than 40, said Dr. Yevgeny Chazov, personal physician to most Soviet leaders since the Leonid I. Brezhnev era, and head of the Russian Cardiological Center in Moscow.

Russian President Vladimir V. Putin has responded, pushing health care to the top of the nation's priorities. This year, his government is spending $24.6 billion to more than quadruple some doctors' salaries; build hospitals; buy ambulances and equipment; pay for more surgeries, vaccinations and AIDS treatment; and subsidize medicines for children and pregnant women.

"It finally took Putin himself to understand what was happening," said Murray Feshbach of the Woodrow Wilson International Center for Scholars in Washington, who has long studied health and demographics in Russia. "But it's very late."

The health care crisis that accompanies Russia's demographic decline is a fact of life not only in rural areas, but in cities as well. It affects the middle class as well as the poor.

The 8.8 million people who ride the Moscow subway every day are exposed to nearly 1 1/2 times the maximum safe level of carbon monoxide and other dangerous gases, the government reported.

Russia and its neighboring former Soviet republics are experiencing the fastest-growing epidemics of AIDS and tuberculosis in Europe. Russia sees at least 120,000 new TB cases a year, 10 times the number in the United States, which has double the population. Last year, about 32,000 Russians died of the disease.

Doctors struggle with unequipped laboratories and surgical instruments 20 to 30 years old. Equipment donated by foreign aid organizations is broken down. There is no money to fix it, or the money budgeted for repairs has evaporated in the web of corruption that strangles public spending everywhere in Russia.


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