Epidemics in Transitional Societies:: Epidemics in Transitional Societies: The Former Soviet Union Michele Rivkin-Fish Associate Professor of Anthropology University of North Carolina, Chapel Hill


2 Goals of Presentation: 2 Goals of Presentation Post-Soviet Transitions: What can they teach us about epidemics, and What can epidemics teach us about them? Medical Anthropology & the Study of Epidemics What does an anthropological lens add to our understanding of disease, treatment, & public health?


From Soviet to “Post-Soviet” Societies: From Soviet to “Post-Soviet” Societies How to Conceptualize this process? we usually think of a “Transition” from…. Authoritarianism  Democracy Single Party-State  Multi-Party System Central Planning  Free Market Economy Coercion  Freedom


From Soviet to Post-Soviet Societies: Another View: From Soviet to Post-Soviet Societies: Another View Soviet welfare state (1917-1991): Free & universal health care, full employment, housing, free education; Quality of Services unsatisfactory, underfunded Extensive Preventive Care Neighborhood & Workplace health clinics Mass, Routine, Compulsory Screenings Infectious Diseases at low levels Travel & contact with foreigners tightly controlled; State paternalism both controlled & protected


From Soviet to Post-Soviet Societies: Multiple, Contradictory Transitions: From Soviet to Post-Soviet Societies: Multiple, Contradictory Transitions Market Reforms (c.1988- present): End of safety net & universal, free health care Massive Economic Crisis, Upheaval Previous Rights & Protections Lost New System in formation, uncertain, unstable Individual initiative required & rewarded Intensive Stratification of options & opportunities


Slide6: Cases of Syphilis per 100,000


Russia’s Rapid Rise in HIV: Russia’s Rapid Rise in HIV Mid 1990s saw beginning of epidemic New Cases of HIV 1994: 163; 2001: 87,177 UNAIDS estim. 1% of population HIV+ (Russia, Ukraine, Estonia, end of 2001)


Comparative Rates HIV Worldwide: Comparative Rates HIV Worldwide (Estimated Prevalence, as % of population infected) Russia 1.10 (2001) Estonia 1.10 India .90 USA .60 (2003) Belarus .30 (2001) Denmark .20 (2003) (Wikipedia.org, The World Fact Book, Sept. 2005)


Tuberculosis, Comparative Prevalence Rates (2004): Tuberculosis, Comparative Prevalence Rates (2004) Per 100,000 population Russia 160 Georgia 89 Belarus 68 Estonia 49 India 312 Denmark 6 USA 4 (Globalhealthfacts.org)


Medical Anthropology’s Lens :: Medical Anthropology’s Lens : Epidemics as Social Phenomena: Their Trajectory: Which social groups are at risk? Which individuals, groups get infected, why? Once infected, who gets access to effective treatment? How does social & economic marginalization make certain groups vulnerable?


Medical Anthropology’s Lens:: Medical Anthropology’s Lens: Efforts to Control Epidemics: Who undertakes prevention & treatment efforts? State, market, church, NGOs? How do they organize prevention/ treatment? Do they present competing approaches to prevention/ treatment? How do their approaches reflect specific cultural meanings (about the disease, morality, stigma, healing, etc.)?


Medical Anthropology’s Lens:: Medical Anthropology’s Lens: How Epidemics become Cultural & Political Phenomena: Acquire Broader Cultural Resonance Integrated into existing symbolic systems & debates Become a Social Force for Change Get used to make political statements, to promote certain agendas, interests


Case Study: STIs in Russia: Case Study: STIs in Russia Cultural Context of “Sexual Revolution” Since mid-1980s, end of censorship & tight social controls: Newly ubiquitous Pornography Sexually Explicit films, ads, TV (prime time) Legalization of Travel, meeting with foreigners Increases in out-of-wedlock births to 30% Mid-1990s: High rates of teen pregnancy, abortion, skyrocketing STIs Very Underdeveloped Sexuality Education


Trajectory of STIs, 1992-1998: Trajectory of STIs, 1992-1998 Prevalence of Syphilis increased 5.5 times among adults; 17 times among children under 15. Growing #s Babies born with syphilis Poorer prenatal care 1993-98 Girls 3-4 times more likely to get syphilis than boys Twice as many registered cases in urban as rural (undiagnosed in rural areas??) (JList 1-15-02; Zhuravleva 2000 and Shilova 2000)


Trajectory of HIV in Russia: Trajectory of HIV in Russia 70% newly registered HIV+ from IDU (2001-02) Rise in Babies born to HIV + Mothers Blood transfusions (11 recorded cases in 2001) How is HIV trajectory linked to socio-economic vulnerability? 80% HIV+ 30 yrs old) Concentrated in wealthier regions 10 / 89 administrative regions account for 60% of reported HIV cases But we need to know which groups are most at risk!


Soviet Control of STIs : Soviet Control of STIs Pre-Glasnost People w/ STIs-- Morally undesirable No confidentiality/ Anonymity Compulsory Contact Tracing Routine Screening of occupational groups Extensive hospitalization for syphillis Virtually no sex education resources (censored)


STI Control in Transition: STI Control in Transition 1980s ->present Decline in state funding Gradual shift towards voluntary attendance, treatment & partner notification Pressure to identity partners continues, but fewer legal requirements Increase in private (fee based) services w/ anonymity Outpatient treatment increasing, hospitalization still frequent


Efforts to Control STIs:Managing “Sexual Revolution”: Efforts to Control STIs: Managing “Sexual Revolution” Competing Approaches & Their Meanings Psychologists: Inform, Teach, Provide Resources; “Liberate” from Soviet taboos for Democratic Revival Gynecologists: Warn, Dissuade, Threaten, Instill Fear; Reintroduce Soviet era modesty and control; see sex as needing containment & as source of shame; R. Orthodox Church, Nationalists: Prohibit, Threaten, Encourage Moral Discipline; Address Demographic Crisis (low fertility) for traditional family values and nationalist political interests


Managing Sexual Revolution: International Involvement: Managing Sexual Revolution: International Involvement Global Anti-Abortion Movement supportive of Russian attempts to reduce abortion Revival of Religious Foundation after atheism Global feminist & reproductive health orgs active in promoting women’s rts, sex ed; Revival of Women’s Rights after authoritarianism Intern’l pharmaceutical companies promoting oral contraceptives Market interests/ humanitarian aid?


Russian Nationalist Politics & Demographic Anxieties: Russian Nationalist Politics & Demographic Anxieties “Democracy” denigrated as “Anything Goes” mentality antithetical to Russian spirituality and national interests; Nationalists charge Intern’l orgs w/ ‘conspiracy’ to reduce Russian fertility; Presidential Family Planning Program Loses Funding 1998 Stigma of STIs related to post-Soviet “immorality” and depraved “democratic” freedoms


HIV and Post-Soviet Control Challenges: HIV and Post-Soviet Control Challenges Stigma Continues: Sexuality, Drug Use, Marginalized Populations Severe underfunding (budget allows c.600 patients per yr to receive AIDS drugs) Injecting Drug Use Services are minimal Medical approach to detox w/little counseling Methadone is illegal 20% of people w/AIDS-- in prison


Conclusions: Post-Soviet Transitions and Epidemics:: Conclusions: Post-Soviet Transitions and Epidemics: New Vulnerabilities Created by Soviet Collapse Loss of safety net, economic desperation & new opportunities / requiremts & loosening of central controls; Most affecting the poorest, most socially marginal, least educated New opportunities Created by Soviet Collapse Accessible to those w/econ, social resources


Conclusions: Epidemics & Post-Soviet Transitions: Conclusions: Epidemics & Post-Soviet Transitions Exponential rise in STIs & HIV threatens continued economic growth & political democratization Siphon resources from general health care Losses affecting youngest generation STIs become used by interest groups to promote their own political agendas Stigma against poor, IDUs, sex workers, continues


Conclusions: Medical Anthropology’s Lens: Conclusions: Medical Anthropology’s Lens Meanings of STIs shaped by – and help constitute– broader upheaval of transitions Actual Shifts in Treatment & Prevention Methods require research (provider-patient interactions) Much remains unknown about specific social groups most at risk and how to conduct effective prevention efforts among all segments of population.