VZCZCXRO8606
RR RUEHAST RUEHHM RUEHLN RUEHMA RUEHPB RUEHPOD RUEHSK RUEHTM RUEHVK
RUEHYG
DE RUEHMO #3660/01 3521419
ZNR UUUUU ZZH
R 171419Z DEC 08
FM AMEMBASSY MOSCOW
TO RUEHC/SECSTATE WASHDC 1230
INFO RUEHVK/AMCONSUL VLADIVOSTOK 3042
RUEHYG/AMCONSUL YEKATERINBURG 3399
RUEHLN/AMCONSUL ST PETERSBURG 5157
RUCNCIS/CIS COLLECTIVE
RUEHXD/MOSCOW POLITICAL COLLECTIVE
RUEHZN/EST COLLECTIVE
RUEAUSA/DEPT OF HHS WASHINGTON DC
RUEHC/DEPT OF LABOR WASHDC
RUEHPH/CDC ATLANTA GA

UNCLAS SECTION 01 OF 04 MOSCOW 003660 
 
SENSITIVE 
SIPDIS 
 
USAID FOR GH, E&E 
HHS FOR OGHA 
 
E.O. 12958: N/A 
TAGS: TBIO KHIV SCUL SOCI EAID PGOV ECON PREL RS
SUBJECT: RUSSIA'S DEMOGRAPHIC SITUATION: SERIOUS, BUT NOT 
CATASTROPHIC 
 
REFS: A. Moscow 854 
      ¶B. Moscow 536 
      ¶C. 07 Moscow 4543 
      ¶D. 07 Moscow 1834 
      ¶E. 07 Moscow 1135 
 
MOSCOW 00003660  001.2 OF 004 
 
 
THIS CABLE IS SENSITIVE BUT UNCLASSIFIED.  PLEASE PROTECT 
ACCORDINGLY. 
 
¶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 
(http://www.washingtonpost.com 
/wp-dyn/content/article 
/2008/10/03 
/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. 
 
--------------------------------------------- - 
PREMATURE DEATHS DUE TO POOR LIFESTYLE CHOICES 
--------------------------------------------- - 
 
¶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 
 
MOSCOW 00003660  002.2 OF 004 
 
 
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. 
 
---------------------------------------- 
INFANT "COMPLICATIONS" MAY BE OVERSTATED 
---------------------------------------- 
 
¶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. 
 
--------------------------------- 
HIV/AIDS: PLACING DATA IN CONTEXT 
--------------------------------- 
 
¶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 
 
MOSCOW 00003660  003.2 OF 004 
 
 
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. 
 
------------------------------------------ 
TUBERCULOSIS: STILL SERIOUS, BUT IMPROVING 
------------------------------------------ 
 
¶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. 
 
 
MOSCOW 00003660  004.2 OF 004 
 
 
BEYRLE