Health in Russia and Other Soviet Successor States: Context and Issues for Congress

CRS Report for Congress
Health in Russia and
Other Soviet Successor States:
Context and Issues for Congress
Upda ted Novembe r 19, 2003
Analys t in Foreign Affairs
Fo reign Affairs, De fense, and Trade Division

Congressional Research Service ˜ The Library of Congress

Health in Russia and Other Soviet Successor S tates:
Context and Issues for Congress
Heal t h i ssues i n t h e E urasi an s t at es o f t he form er S ovi et U n i o n h ave recei ved
increased U.S . attention i n recent years. As part of this concern, a J anuary 2000 U.S .
National Intelligence Estimate (NIE) highlighted global t hreat s posed to U.S. citizens
and i nteres ts by increas ing t uberculosis, hepatitis, HIV/AIDS, and other infectious
diseases outside U.S. borders. W hile mostly focusing on disease t hreats emanating
from Afri ca and Asi a, t h e NIE al so hi gh l i ght ed em ergi ng di sease t hreat s i n E urasi a.
It warned that increased politi cal, military, social, and economic disorder in the
Eurasian stat es could be worsened by t he spread of diseas e, thereby s etting back thei r
democratic and free m arket reforms , a n d t hat such instability might further
complicate U.S. arms control cooperation and efforts t o contain t he proliferation o f
weapons of mass destruction. In addition, the NIE cautioned t hat Eurasian militaries
and populations could face increased ill-hea lth, h arming t he national s ecurity of the
Eurasian stat es and diminishing the effectivenes s o f t h e militaries in international
peacekeeping. Also, ill military forces and populations could b ecome agents for t he
spread of diseases among U.S. forces involved i n i nternational ex ercises and t raining
and t o t he U.S. homeland population.
A f t e r t he terrorist attacks o n t he United S tates o n S eptember 11, 2001, t h e
spread of ant h rax b y m ai l l at er i n t h e year, and ot her i nci d ent s , t here were hei ght ened
policy concerns about biological terrorism and d isease t hreats t o t he U.S. homeland.
These concerns are i ncreasi n gl y i nform i ng t he debate over h ealth policy and aid t o
Eurasia, where t he major foci o f U.S. policy l ong have b e e n d e m o c ratic and
econom i c reform s and arm s cont rol , and h eal t h ai d h a s b e e n vi ewed as
complementing reforms and as j ustified o n humanitarian grounds.
Congressional concerns about health conditions in Eurasia h ave b een reflected
in legi slative l angu age and other actions. Although U.S. h ealth aid for Eurasia h as
long been overshadowed by other U.S. aid priorities, it increas ed as a percentage of
all U.S. foreign assistance to Eurasia i n FY2002, partly as a response t o 9 /11. The
dollar amounts o f h ealth aid funded under the authority of the FREEDOM Support
Act and carried out by the U.S. Agency for In ternati o nal Development i n FY2003
declined from FY2002 for m ost E urasian countries. However, o ther agency a n d
p rogram budgets p rovide health-related aid that fills this gap t o s ome ex t ent, but
much of this assistance tends to be focused o n n arrow p rograms s uch as t ransporting
medical cargo es, re-training scientists, o r P eace Corps activities.
This report provides an ov e rv i ew of health conditions in the Euras ian s tates,
U.S . ai d effort s i n recent years, and i ssues whi ch C ongress m i ght consi d er i n
providing health assistance to the Eurasian states.

In troduction ......................................................1
OverviewofU.S.Policy ............................................1
Post 9/11 ................................................2
Health in the Eurasian S tates:
ContextandCurrent Developments ................................6
SelectedHealthIndicators ......................................10
Childhood and M aternal M ortality Rates .......................10
TheIncreaseinInfectious Diseases ...........................11
DrugAddiction ..........................................14
AlcoholismandSmoking ...................................15
Water-BorneDisease ......................................15
Non-Medical indicators ........................................16
R efugees and D i s pl aced P ersons .............................16
Orphans ................................................16
U.S.andInternationalHealthAid ....................................17
InternationalAssistanceEfforts ..............................21
Issues forCongress ...............................................23
HowSignificantareHealth Issues in EurasiatoU.S.Interests? .........23
How M uch C an the United S tates do t o Improve Health Conditions in
Eurasiaand What TypesofHealth AidareAppropriate? ..........24
Table1.U.S.Health AidtoEurasia ...................................27
Table2. Health SpendingandLifeExpectancy .........................28
Table3.Tuberculosis,HIV/AIDS, STDRates andDrugUse ...............29
Tabl e 4 . R efugees and Int ernal l y Di spl aced P ersons ......................30
Tabl e 5 . Abort i o n R at es and C ont racept i v e Use .........................31

Health in Russia and
Other Soviet Successor States:
Context and Issues for C ongress
Duri ng t h e S ovi et era, heal t h i n form at i o n w as cl osel y guarded and governm ent
health statistics highly s uspect . The Soviet government proclaimed t he high quality
of its soci alized healthcare system. Sovi et data showed numbers of hospital b eds and
d o ctors per capita as am ong the highest in the world and life spans comparab l e t o
those i n o ther developed countries. A s b ecame m ore apparent after t he S oviet
collapse, such data were often i ncomplete o r falsified and covered u p s ubstantial and
growing h ealth problems.
The Euras ian s tates of t he former Soviet Union1 faced probl em s s ust ai n i n g t he
huge, ex pensi v e, and i neffect i v e healthcare systems they inherited. Health conditions
seemed to deteriorat e d uring t he 1990s, as m easured by life ex p ectancy at birth,
infant and m at ernal m ortality, drug addiction, rates of i nfectious diseas e, and other
m easures. On s om e m easures, t hese s t a t e s now face heal t h chal l enges com m o n t o
developing co u n tries, an d t hese chal l enges are h i nderi ng t h ei r econom i c and
dem o crat i c devel opm ent , accordi n g t o m any observers. 2
Data on health and h ealthcare i n t he Eurasian states are poor, but some general
conditions and t rends may b e d iscerned. Besides h ealthcare quality a n d access,
factors affecting h ealth touched o n but not anal yz ed in detail in this report i nclude
poverty rates, conflict, living and working conditions, and the environment.
Overvi ew of U.S. Policy
Although h ealth issues in the Eurasian states h ave b een a l ower priority in U.S.
assi st ance and rel at i ons t h an arm s cont rol and econom i c and d em ocrat i c reform s,
they have been a m atter o f U.S . concern s ince the early 1990s and h ave received

1 T h e Eurasian s tates ( also termed the Newly Independent States or NIS) are general l y
considered as including the Western Sovi et successor s tates ( Belarus, Moldova, Russia, and
Ukraine), t he South Caucasian s tates ( Ar menia, Azerbaij an, and Georgi a), and the Central
Asian states ( Kazakhstan, K yr gyzstan, T aj ikistan, Turkmenistan, and Uzbeki stan).
2 According t o t he U.S. Agency for International Development ( USAID) , “ the health of the
population and the capacity of the health systems t o s erve them have worsened in the t welve
countries of the Eurasia regi on,” since t he countries ga ined independence i n 1991. Budget
Justification t o t he Congress FY 2004 , A n n e x III, E u r o p e a n d E u r a s i a , p . 527.

i n creased at t ent i o n i n recent years. U.S . heal t h assi st ance t o Eurasi a b egan even
before the collapse of t he Soviet Union with a public-private medical ai d program to
distribute pharmaceuticals and medical supplies t o t he S oviet republics. Later , t h e
Bush-1 and C linton Administrations led i nternational efforts t o add ress needs i n
Eurasia, including health needs. The 1992 FR EEDOM Support Act (P.L. 102-511),
the m aj or authorization f o r ai d t o Euras ia, i ncluded t he provision of medicine and
medical supplies and equipment and other aid to creat e quality healthcare and family
planning services as priorities of U.S. assistance.3 In the early 1990s, however, U.S.
and W estern donors l acked a clear picture o f h ealth conditions in the E urasian s tates
(l argel y because of t h e m ost l y sangui ne pi ct ure p ai nt ed by S ovi et heal t h offi ci al s),
and s ome donors t ended t o assume that a s hort-term aid i nfusion would put Eurasian
health system s “back on thei r feet ” i n a short time. It l at er b ecam e clear that the
Eurasi an st at es faced m assi ve heal t h probl em s t hat woul d b e h ard t o am el i o rat e.
Increased at t ention i n t he United S tates t o global disease t hreat s i ncluded a
J anuary 2000 unclassified Nati onal Intelligence Estimate (NIE) o n t he implications
fo r U . S . n ational s ecurity of rising infectious disease outside U.S. borders.
According t o t he NIE, infectious diseas es could add to political , military, s ocial, and
economic disorder in the Euras ian s tates and could s et back democratic and free
mark et reforms. Such instability might further complicat e U.S. arms control
cooperation and efforts t o contain t he proliferation o f weapons of mass destruction.
In addition, the NIE cau t i o n e d t hat Eurasian militaries and populations could face
increased ill-heal th, harming the national security of the Eurasian states and
diminishing the effectiveness o f t he militaries in international p eacekeeping. Also,
ill military forces and populat i o n s could b ecome agents for t he spread of diseases
among U.S. forces involved i n i nternational ex ercises and t ra i n i n g a n d to the U.S.
homeland population.4
Post 9/11. After t he terrorist attacks on t h e U n i t e d S tates on S eptember 11,
2001, the s pread of a n t h r a x b y m a i l l ater in the year, and the m ore recent foreign
threats o f n ew or lesser-known d iseases such as the W est Nile virus and severe acute
respiratory s yndrome (SARS), there w e r e h eigh tened policy concerns about
biological terrorism and i nternational d i s ease t hreat s t o t he U.S . hom el and and U.S .
foreign i nterests. In S eptember 2002, the N ational Intelligence Council issued a
follow-on report t o its Global Infectious Disease T hreat which highlighted the t hreat
of HIV/AIDS and o ther infectious diseases in countries of strategi c importance t o t he

3 S i l k R o a d Act l anguage i n P.L. 106-113, signed into law i n November 1999, also
authorized enhanced policy a nd aid t o s upport humanitarian needs i n t he South C a u c a s us
and Central Asia, i ncluding the provi si on of me dicines a nd me dical equipment.
4 CIA. National Intelligence Council. The Global Infectiou s D i sease Threat and Its
Implicatio n s f o r t he United States , NIE 99-17D, J anuary 2000. Russian troops serve i n
seven U.N . a n d Organization f or Security and Cooperation i n Europe mi ssions, are
“peacekeepers” in Georgi a, are s tationed i n Armenia, Georgia, M oldova, and T aj ikistan, and
serve a s a dvisors i n India, Cuba, Peru, and Syr ia. See Johnson’s List , M arch 13, 2001. See
also the NIC’s Global Trends 2015: A Dialogue About the Future With No ngovernment
Experts , NIC 2000-02, December 2000.

United S tates, incl uding Russia.5 This new report warned t hat i nfectious diseases
“ex acerbate social and political instability in key countries,” and t hreaten the United
Stat es , s ince it is a m aj or hub of world t ravel with a l arge number of citizens res iding
overseas. T he report s tates t hat m ajor mean s o f combating t he infec t i o u s d i s e ase
threat , as wel l as biologi cal terrorism, i nclude the establishment of effective global
surveillance and respon s e s ys t ems, but that the l ack of capacity, funds, and
commitment in many Eurasian stat es stymie such efforts.
In the Bush-2 Administration, Secret ary of S tate Colin Powell testified i n March
2001 that increased foreign affairs ex p enditures for child survival and d iseases were
a h igh p riority, i ncluding because HIV/AIDS is “spreading i nto t he [ n ew] countries
of the [ former] S oviet Union,” and h e t ermed HIV/AIDS a national s ecurity concern.6
U.S. policym ak i n g o n h ealth issues in Eurasia i nvolves t he State Department’s
Bu reau of E u r opean and E urasian Affairs, the Office of the C oordinator o f U.S.
Assi st ance t o Europe and E urasi a, t he Offi ce of In t ernat i onal Heal t h Affai rs, and
US AID, and t he Department of Health and Human Services (HHS) and other
agenci es. T he C oordi nat o r for Assi st ance plays a major role i n i ntegrating policy and
implementation goals, but interagency c ooperation i s challenged by new h ealth
emphases s uch as HIV/AIDS and other changes in funding. USA ID is the l ead
agency in implementing healthcare aid programs in the Euras ian s tates. It s Bureau
of Gl obal H eal t h pr o v i d es gu i d ance t o fi el d o ffi ces and eval u at es program s and
n e e d s . T h rough i nt eragency agreem ent s , i t works wi t h HHS ’s Europe and Nort h
Eurasia re g i onal bureau of the Office of Global Health Affairs, and with HHS’s
Centers for Disease C ontrol and Prevention (CDC). The Office helps host t he U.S.-
Russia Health Committee. CDC has assumed great er pro minence post-9/11 in
helping t o implement, o ften in cooperation with USAID, efforts t o p revent and
control i nfectious diseases in Eurasia, including biological agents. 7
The C DC has emphasiz ed t hat combating i nfect i ous di seases i n Eurasi a p rot ect s
U.S. citizens at home and abroad, s erves humanitarian and goodw i l l ai m s , and
buttresses t he world economy, democratization, and s t a b i lity. It views aid for
strengthening public health infrastruct ures and establishing strong infectious disease
surveillan ce s ys tems in the region as key to prevention, early warning, and early
response to health threats there that could impact U.S. security. Several CDC

5 CIA. National Intelligen ce Counci l . The Next Wave of HI V/AIDS: Nigeria, Ethiopia,
Russia, India, and China, ICA 2002-04D, September 2002.
6 T he Republican Party’ s 2000 campaign platform had been critical of the 2000 NIE, stating
that it had added “disease . . . to an undimi nished set of existing American responsibilities”
in the world.” However, the platform also s upported U.S. assistance for urgent humanitarian
needs a nd for c ombating HIV /AIDS i nternationally. Republican National Convention. The
Republ i c a n P arty Platform 2000, J uly 31, 2000. T estimony of Secretary of State Colin
Powell. Senate Foreign R e l a t i o n s Committee, March 8, 2001; and t o t he Senate Budget
Committee, March 14, 2001.
7 T he State Department. State Department Organization, [ ht t p : / / www.s t a t e . go v] ; T he
Department of Health and Human Services. Office of Global Health Affairs ,
[ h t t p : / / oba l h e a l t] ; T h e W hi t e Hous e . Of f i c e of t h e Pr e s s Se c r e t a r y. Fact
Sheet: The President’s Emergency Plan for AIDS Relief , J anuary 29, 2003

projects s upport rebuilding o r ex p anding the public health infrastructure i n Eurasia,
and i nclude CDC s taffers in Russia, Kaz akhstan, and Uz b ekistan. 8
Despi t e an enhanced focus o n h eal t h program s as a p e r c e n t age of U.S . ai d t o
Eurasia i n FY2002, the m ost recent FREEDOM S upport Act annu a l r e p o r t
em phasi z es t hat s uch ai d serves hum ani t ari an purposes and h el ps ensure t h e s uccess
of other U.S. aid for d emocratiz ation, economic reforms, and t he security of the
Eurasian states, and does not appear to high light the U.S. homeland s ecurity benefits
of such ai d. 9 In the S tate Department-USAID Strategic Plan f or FY 2004-FY 2009,
Eurasi an heal t h care i ssues are m ent i oned as affect i n g U .S . s ecuri t y. W hi l e t h e m ai n
rationale gi ven for healthcare aid appears humanitarian rather than strategi c, the plan
st at es t h at a h eal t h y worl d wi l l be m o re st abl e and s ecure and “ p revent adverse
conditions from s pilling across our borders.” The p roblem of Eurasian HIV/AIDS,
however, i s not st ressed as a securi t y i ssue. The S t at e De part m ent ’s P erform ance
Plans for FY2003 and for FY2004 do not high light health problems i n Eurasia, but
the FY2003 plan does aver t hat “the unmit i g a t e d spread of major v irulent d iseases
poses a d irect threat to the American people .... The campaign against gl obal d iseases
directly supports U.S. n a t i o n al i nterests and m ajor foreign policy goals, s uch as
promoting s table s ocieties and economies.” The FY2004 plan do es n o t ex plicitly
link Eurasian health to homel and security or other m eans t o protect U.S. citizens, but
includes h ealth among a s econd priority of enhancing global d evelopment.10
Congress has b ecome increasingl y con c e rned about the rising global t hreat of
infectious diseases, i ncluding HIV/AIDS , T B, and m al ari a, and has aut hori z ed and
appropriated funds refl ecting t hat concern. 11 Though p rimary attention i n C ongress
is focused currently on the t hreat these d iseases pose i n Af r i c a , a n d m uch o f t he
increased funding is directed to African programs, t here is some increased attention
to health problems i n Eura s i a a n d o t h er regi ons. M embers of the House Banking
Committee (H.Rept.106-548), i n reporting t he Global AIDS and Tuberculosis Relief
Act o f 2000 (P.L. 106-264), cited t he J anuary 2000 NIE t o t he effect that increases
i n HIV/ AIDS are t hreat eni n g A fri ca, Asi a, a nd Eurasia. On the appropriations side,
Fo reign O p e rations Appropriations for FY2001 (P.L. 106-429) for t he first time
allocated a s mall amount ($6 million) to Eurasia from t he Child Survival and Disease
Programs (CSD) account to combat infectious diseases.
In t h e m ost recent l y enact ed l egi sl at i on, Forei gn Operat i ons Appropri at i ons for
FY2003 (P .L. 108-7), C ongress provided not less than $60 million i n FREEDOM
Support Act aid for Eurasia (in addition t o o ther available funding) for child survival,

8 CDC. Office of Global Health. Gl obal He alth Activities Report, 1999-2000: The Work
of CDC i n t he New I ndependent States , 2001, pp. 261-282; and Protecting t he Nation’s
Health in an Era of Globalization: CDC’ s Global Infectious Disease Strategy , 2002.
9 T he State Department. Bureau of European and Eurasian Affairs . In t r o d uction, U.S.
Government Assistance t o and Cooperative Activities with Eurasia FY 2002, J anuary 2003.
10 Implications of health problems t o U.S. i nterests are s lightly me n tioned i n USAID,
Foreign Aid in the National Interest: Promo ting Freedom, Security, and Opportunity, 2002.
11 For i nformation on health aid l egislation i n t he 106th Congress, see CRS Report RL30793,
He alth in Developing Countries: The U.S. Response.

basic educat ion, environmental and re productive health, family planning, and to
combat HIV/AIDS, T B, and o ther infecti ous diseases. In addition, not less than $1.5
million was provided t o m eet the health and other needs of victims of trafficking i n
persons. P .L. 108-7 ex cluded h ealth aid fro m restrictions on assistance provided for
Russia and Ukraine. The conferees (H.Rep t.108-10) indicated that th e y w a nted to
sustain t he momentum of the p revious year on heal t h reform s. They di rect ed t h at of
the $60 million i n health aid, $15 million be provided f o r r e p r oductive health and
family planning, and that some aid s hould b e u sed t o ex p and p rimary and advanced
healthcare and to combat TB in Central Asia. As in previous yea r s , t h e y endorsed
the E uras i a n h e a l thcare work o f t he W o rld C ouncil of Hellenes and strongly
recommended t hat not less than $2.5 million b e p rovided t o h elp m ake t he initiative
Besides t h e h ealth assistance programs carried out by USAID under t he
authorit y o f t he FR EEDOM Support Act, s om e h ealth-related p rograms are either
funded under t he FR EEDOM Support Act or under o ther agency budgets o r
authorities, such as the P eace Corps, bio-t echnical re-direction p rograms carried out
t o ret rai n form er b i o l o gi cal warfare sci ent i s t s i n m edi cal and pharm aceut i cal fi el ds,
t h e ex cess p ropert y p rogram of t h e Defense Department, and transporting privately
donated m edical aid. The C SD account provided $5.75 million i n FY2003 to Russia,
Ukrai n e, and C ent ral Asi a t o com b at HIV/ AIDS .
Congress has generally appeared to support h ealth assistance that amounts t o a
few p ercent o f t he overal l ai d t o E urasi a (s ee Table 1 at the end of the report). T otal
U.S. aid budgeted for FY1992-FY20 03 for h ealth programs in Eurasia was about
5.1% of a bout $24.5 billion of all ai d for Eurasia. Health ai d has been dwarfed by
that provided for democratiz ation, economic reform, and arms control.
In early 2003, Rep. Barbara Box er was among Members generally calling for
more emphasis o n i nternational h ealth aid, arguing “the t ragi c events of S eptember

11, 2001, has forced the Uni t e d S tates t o b roaden its concept o f t hreat .... U.S.

nat i onal s ecuri t y i s b u t t r e ssed b y com bat i n g i nfect i ous di seases before t h ey reach
U.S. borders, and ... is also s e r v e d w h en diseases do not threaten gl obal economic
growth. 12 In keeping with this enhanced concern, t h e S enate i n August 2002
approved S . 2487, the b ipartisan Gl obal P athogen Surveillance Act. 13 Although not
enact ed i n t o l aw b y t he 107 th Congress, a s imilar bill, S. 871, was i ntroduced in the
Senate in April 2003, and H.R. 2329 was i ntroduced in the House i n J une 2003. In
introducing S . 8 7 1 , Sen. J o seph Bi den s tressed t hat U.S. s upport for international
surveillance t o det ect terrorist-relat e d o r nat urally occurring diseas e outbreaks
but t ressed hom el and s ecuri t y, s i n ce t ravel or ot her m eans coul d p erm i t pat hogens t o
quickly enter t he United S tates.14 In May 2003, S. 871 was i ncorporated substantially

12 Washington Quarterly , Spring 2003, pp. 199-207.
13 S. 248 7 was described as l ending an international dimension to the Bioterrorism
Preparedness Act ( H.R. 3448; P.L. 107-188).
14 CR , April 10, 2003, pp. S5194-S5196; Sen. Biden r efers t o t he report Microbial Threats
to Health — which discusses t he gr owth of HIV/AIDS and multi-drug resistant T B i n Russia
— i n s tressing the need for enhanced international disease s urveillance . T h e National

into S. 1161 , t he Fo reign Assistance Authorization Act for FY2004, as Title IV,
authorizing $35 million for FY2004 to be draw n f r o m t h e Nonproliferation, Anti-
Terrorism, De mining, and R elated P rograms (NADR) account. H.R. 2329,
introduced b y Rep. Mark Kirk, i s i dentical to the S enate l angu age o f S . 1161 but
authorizes $150 million over FY2004-FY2005.
In support o f H . R . 1298 (P.L. 108-25), t he United S tates Leadership Against
HIV/AIDS, Tuberculosis, and Malaria A ct of 2003, Rep. Alcee Hastings and S en.
J ohn McCain were among those who warned t h at Eurasi a represent ed a com i n g
HIV/ AIDS cri s i s area t h at coul d h arm gl obal s ecuri t y and econom i cs, and S en. J eff
Bi ngam an was among those m entioning this area in calling for adequate HIV/AIDS
funding. Among other C ongressional activities, S en. Richard Lugar visited
Uz beki st an i n A u gu s t 2 003 and report edl y d i s cussed h eal t h care ai d and m edi cal
training ex changes, inc l u d i n g f u nding for efforts b y U.S. and Uz bek v irologists to
develop n ew infectious disease t reatments. 15 In February 2001, Rep. Curt W eldon
led a bipartisan congressional d elegation t o v i s i t l egi sl at ors and m edi cal offi ci al s i n
Russia, Ukraine, and M oldova, which incl uded d iscussions of healthcare n eeds and
U.S . assi st ance.16 In J anuary 2003, he stressed t he need for c ontinued h ealthcare
cooperation with Russia and Belarus.17
Health in the E urasian States:
Context and C urrent Deve lopments
As part of the l egacy of the former S oviet Union, the Euras ian s tates i nherited
a l arge cent ral i z ed heal t h car e a p p a r a t u s t hat p rovi ded good care for som e m edi cal
conditions but relied on outdated practices to treat other illnes s e s . The health of
Soviet citizens l agged b ehind t hat o f U.S . and other W estern populations in terms o f
access t o m any n ew m edi cal procedures and m edi ci n es and even i n t erm s of prosai c
measures such as the number o f hospitals with plumbing and h eat. The healthcare
system em phasized a large number of s peci alized medical facilities with large s taffs
and p rolonged hospitaliz ations, rather t han primary and preventive care, incl u d i n g
regu lar che c k - ups. The healthcare s ys tem was isolated from changing world
st andards o f t reat m ent of di seases such as TB, i t fol l o wed s ecret i v e p ract i c e s t h at
prevented t he operation of a compet ent diseas e s urveillance s ys tem, and i t s uffered
from a lack of medical supplies and equipmen t outside of the m ajor medical centers.
After t he Eurasia n s t a t e s gained independence, the n ew international borders

14 (...continued)
Academies. Institute of Medicine. Microbial Threats t o Health: Emergence , Detection, and
Response , M arch 18, 2003.
15 CR , M ay 1, 2003, p. H3576; May 15, 2003, p. S6491; and J uly 1 0 , 2003, p. S9183;
Interfax , August 19, 2003.
16 CR , February 28, 2001, pp. H485-H493.
17 CR , J a n uary 28, 2003, pp. H204-H210. See a lso Rep. Curt Weldon, U.S.-Russia
Partnership, 2001, pp. 22-23, [ v/ curtweldon/usrussia].

separated m any m edical industries fro m t heir customers and required t he re-
negotiation of busines s rel ations that are s till not satisfact ory.
Despi t e t h i s shared l egacy, t he Eurasi an st at es em erged from t he S ovi et col l apse
with varying health situations. S ome of t he Eurasian stat es had better healthcare
facilities and healthier populations than others. M any observers have viewed Central
Asia’s population as h aving s uffered t he mo st from i nadequate healthcare during t he
Soviet period. The W estern Eurasian states had o lder populations than the C entral
Asian s tates at t he time of the S oviet collapse, reflecting differences in fertility and
mortality. Environmental cat as trop he affect ed health in several regions, i ncluding
the C hernobyl area (radiation f a l l o u t in Ukraine and Belarus), C helyabinsk area
(radiation contamination i n R ussia and Kazakhstan), S emipal atinsk (radiation from
nuclear weapons testing i n Kaz akhstan) an d t he Aral Sea area (d e s e r t i fication i n
Kaz akhstan and Uz bekist a n ) .18 The Euras ian s tates also differed i n t heir rates of
economic decline during t he 1990s, and in such related i ssues as healthcare funding,
the diets of the people, and living conditions, which affect ed infant survival and life
ex pectancies. Conflicts in Eurasia also damaged health, leading to casualties,
i n j u r i e s , o r p h a n s , a n d d i spl aced persons who s uffered p h ys i c a l l y a n d p s yc h o l o g i c a l l y.
Heal t h chal l enges i n al l t he Eurasi an st at es l oom l arger because of t h e v ery l ow
percentages o f gross domestic product (GDP) they h ave d evoted to healthcare. Table
2 s hows GDP per capita in the Euras ian s tates and the percent going to health. Health
spending levels are l ow in the Eurasian states i n comparison t o t he more than 8% on
average s pent in the Organiz at i o n for Economic Cooperation and Development
countries (OECD; composed mostly of Eur opean countries and t he United S tates).
In most of the Euras ian s tates, central governments h ave d evolved m uch fiscal and
operational responsibility for h ealthcare t o cash-strapped and ill-prepared localities,
resulting i n chronic under-funding and t he heavy reliance o n l egal or under-the-table
user fees t o obt ai n h eal t h care. In Arm eni a and Georgi a, m o st heal t h care i s p ai d for
privat el y. The j ux taposition of l ow government spendin g fo r h ealthcare and high
poverty rates mean that large p ercentages o f t he populations throughout Eurasia, and
particularly in Central Asia, cannot afford to pay for healthcare.
In the post-Soviet era, demographers have been able to scru tinize previously
suppressed h ealth data and conduct analyses t hat s uggest that some aspect s o f t he
health crisis in Russia and other Eurasian s tates can be traced back to the 1960s. A
major i ndicator of overall health, life ex p ectancy, p eaked in the 1960s and b egan a
downward t rend in Russia and other republics o f t he former Soviet Union b y t he late
1960s, p erhaps caused b y an i ncrease i n alcoholism, violence, tobacco use, and poor
diet. Another p eak occurred i n t he mid-1980s (mos t l y a t t r ibuted to government
restrictions on alcohol consumption), followed b y a decline t hat d eepened after t he
Soviet breakup, though life ex p ectancy in mo st Eurasian states began t o rise again

18 Christopher M urray and J ose Bobadilla, i n Premature Death in the New I ndependent
States , Washington, D.C., N a t ional Resear ch Council, 1997, pp. 184-219. Other notable
overvi ews i nclude Murray Feshbach and Alfred Friendly, J r ., Ecocide i n t he USSR,New
York, Basic Books, 1992; Murray Feshbach, Russia’s H ealth and Demographic Crises ,
Chemical and Biologi cal Ar ms Control Institute, April 2003; and Laurie Garrett, Betrayal
of Trust , New York, Hyperion, 2000.

after t he mid-1990s. Nonetheless, life ex p ectancy remains l ower than in most
European states. Life ex p ect ancy for m ales in the E urasian s tates i n 2002 is 62 years
(See table 2 ). This c o m p a r e s unfavorably to 74 years for males from countries
belonging t o t he OECD, and 72 years for U.S. males.19
S o m e pol i cym akers and anal ys t s have warned t h at adverse h ea l t h t rends i n
R u s s i a — “unprecedented for an urban, literate society i n t he 21th cent u ry” — are
contributing t o a dwindling popula tion, limiting its economic potential, and
“reducing its influence on t he international s tage.” Some even warn that such trends
may rai se the s pect er of political disintegration and the s ubsequent es tablishment of
authoritarian rule hostile to Western i nterests.20 Maj o r causes o f b ad heal t h i n R u ssi a
incl ude cardiovascular diseas e, cancer, untreat ed chronic illnes s e s (high blood
pressure, diabetes, high cholesterol), alcoholism (contributing t o homicide, vehicular
acci dent s, and s ui ci de), drug abuse, and i nfect i ous di sease . The t hreat of l arge
increas es i n HIV/AIDS, hepatitis, and TB could further depres s life ex pect ancy.
Although b irths i n R ussia m ay have increased in 2003, perhaps p artly because of an
improved economy and a l arger cohort o f females aged 20-29, deaths continu e d t o
out pace t h em . 21
Russia has only begun to address systematic healthcare reforms. Hospitals and
clinics remain l argely government-owned , t hough t here are p rivate physicians and a
private h ealth insurance i ndustry. Compul sory payroll contributions for h ealthcare
began i n 1993, but basic public health issues involving sanitation, pharmaceuticals,
vaccinations, ambulances, and the d istribution o f m edical staff countrywide remain
unresolved. W h i l e R u ssian policy and U.S. aid p rograms h ave emphasiz ed t he
t h eoret i cal econom i c benefi t s of decent ral i z at i o n o f h eal t h care t o t he regi ons, s om e
heal t h ex pert s h ave argued t hat d ecent ral i z at i o n h as harm ed heal t h care, at l east i n t he
short t erm, in part because many public health issues are not fully addressable at t he
regi onal l evel . 22
Perhaps reversing what some observers have termed a policy o f “ m align
negl ect ” of health issues by the R ussian government, P resident Vladimir Putin in his

2001 state-of-the-nation addr es s c r iticized the l ack of fundamental reforms o f t he

19 Russia’s demographic problems, h o w ever, are attributable not only t o declining health,
but also to population dynamics, including the r ipple effects of World War II and evolving
family planning attitudes. See U.S. Department of Commerce. Bureau of the Census. Ward
K i ngka de, Population Trends: Russia, International Brief IB/96-2, February 1997; George
Demko, Grigory Ioffe, a nd Zhanna Za yonchkovskaya, eds., Population Under Duress ,
Boulder, CO: Westview Press, 1999, pp. 9, 24-27, 48, 55-56; Murray Feshbach, W oodrow
Wilson Center talk, M ay 12, 2003.
20 Ni cholas Eberstadt, Kennan Institute, February 5, 2001; De mko, p. 63; Murray Feshbach,
Washington Quarterly , W inter 2001, p. 16-18.
21 Interfax , J uly 18, 2003; T he data on i ncreased births is questioned by M urray Feshbach,
Johnson’s List , November 5, 2003.
22 Di ane Duffy in Vicki L. Hesli and Margaret H. Mills, eds., M e d i cal I ssues and Health
Care Reform in Russia, Lewiston, N.Y., Edwin Mel l o n P r e ss, 1999, pp. 47-48, 52-53;
United Nations. World Health Or ganization. Hi ghlights on Health in the Rus s i a n
Federation, November 1999, p. 23.

Soviet-era healthcare s ys tem, the l ack of federal and local budgetary s upport for
healthcare, inadequate functioning of the i nsurance syst em , and t h e w i d espread
d e m a n d by state hospitals and doctors fo r illicit under-the-table paym ents. In h i s
state-of-t he-nation address i n 2003, Putin pointed to increasing b irth rates and
progress in lowering infant mortality as positive t rends, but decried i ncreas ing deat h
rates attributable to illnes s and injuries . He s tated t hat t he government was m oving
to strengthen the m edical insurance s ys tem t o reduce t he inequalities of t he pres ent
system.23 Putin’s concerns were reflected in the t rebling o f t he budget for h ealthcare
in 2000-2003, and p lans for $35 billion rubles ($1.17 billion) for h ealthcare i n 2004.
In 2001, Russi a l a u n c hed an annual s urvey of children’s health, and in 2003 Putin
ordered checkups for 3 4 million children.
Fal t eri ng heal t h care i n C ent ral Asi a has b een refl ect ed i n decreasi n g l i fe s pans,
high infant and m at ernal m ortality rates, and i ncreas es in cardiovascular/circulatory,
parasitic, i nfectious, and respirat ory diseas es . W hile the s pread of TB and hepatitis
in Central Asia i s m ost worrisome, t he U.N. offi ce coordi nat i n g U .N. i nt eragency and
international aid efforts on HIV/AIDS (the J oint United N ations Program on
HIV/AIDS , o r UNAIDS ) h as pointed to risi ng HIV/AID S r a tes i n Kaz akhstan and
el sewhere i n C ent ral Asi a as a gl obal concern. 24 Poor sanitation and increas ing drug
abuse, tobacco and alcohol use, malnutriti o n , d i et deficiencies, and tainted b lood
supplies contribute t o declining health. Healthcare reforms have focused on m aking
t h e h eal t h care s ys t em m ore effi ci ent b y cl o si ng ex cess hospi t al s and o t h e r m eans.
Efforts t o obtain m ore funding through t ax es and p ayroll dedu c tions have been
d i s a ppointing, resulting i n a heavy reliance o n u ser fees for s ervice. Tajikistan
altered its constitution in a referendum in J une 2003 to remove a provision
guaranteei ng free healthcare, because “i n reality,” the government ex plai ned, the
majority of patients were required t o pay for care and medici nes. Only in Kyrgyz stan
has a compulsory health insurance p lan h ad some success. 25 Kyrgyz st an has m ade t he
most progress in healthcare reform (though its fragile economy p laces them at risk),
and Tajikistan and Turkmenistan the l east. The h ealth consequences of poor quality
heal t h care s eri ousl y const rai n econom i c development i n t he regi on, ac c o r d i n g t o
many observers. 26

23 Putin had r eceived a government report i n J anuary 2003 that estimated that only 31% of
medical services were covered by s tate insurance, and t hat t h e insurance progr am was
shocki ngly mi s-ma nage d. FBI S , J anuary 27, 2003, Doc. No. CEP-245.
24 UNAIDS. Fact Sheet 2002: Eastern Europe and Central Asia, J anuary 12, 2002.
25 Farangis Naj i bullah, RFE/RL, M arch 29, 2003.
26 Martin McKee, J udith Healy, and J ane Falki ngham, eds., Health Care in Central Asia,
Buckingham, UK : Open University Press, 2002, pp. 179-193. In a c oncluding chapter, these
authors s uggest that international efforts t o f oster gradual healthcare r eforms will be most
effecti ve , a l t hough other observers advocate more r apid reforms. See also USAID,
Infectious Di sease Assessment , pp. 1-2; USAID, Health Program Review: Central Asia:
September-November 1999, p. 2; K evin Rushing, USAID Ce n t r a l Asian Republics Desk
Officer, Paper, Panel on Public Health and Environmental Issues, Harva rd Colloquium on
International Affairs, March 11, 2000.

Selected Heal th I ndi cator s
By looking at how a country measures up in certain categories o f h ealth over
time, it is possible to get a picture of the health situation in that countr y.
Unfortunately, another l egacy of the S oviet healthcare s ys tem i s t he lack of reliable
health statistics. The S oviet Union did not follow U.N. W orld Health Organization
(W HO) methods for coming u p with birth, death, and o ther data and t he Eurasian
stat es are at various stages in implementing W HO data standards, making it difficult
to compare many health indicators across Eurasia and with other countries.
Reputable international o rganiz ations may not agree with each other’s estimates, such
as the U.N.’s Human Devel opment R eport and the W o rld Bank’s Wo rl d Devel opment
Report . This report u sually uses statistics from U.N. agencies. Although t he U.N.
agenci es rely on government-provided dat a, they sometimes prefer t heir o w n
es timates, and an estimate by one agency may not match t hat of another. The
statistics u sed i n t his p aper should b e u sed only as a general v iew o f t he situation i n
and among the Eurasian s tates and should not be assumed t o b e d irectly comparable
to U.S. or European health statistics.
Most observers agree t hat t he early 1990s saw m ajor de c l i n e s in health in
virtually all Eurasian s tates i n t erms of such measures as infant mortality, alcoholism,
and cardi ovascul ar di sease. The C ent ral As ian s tates s uffered t he great es t declines
in Eurasia i n life ex pect ancy, i ncreas ed morbidity, det erioration of conditions in
hospitals and other health facilities, and failures t o control and prevent i nfectious
diseases. From 1995 onward, as Eurasian economies b egan to stabilize, there were
improvements (or slowing d eclines) i n t hese health conditions. C oncernin g o t h e r
probl em s, such as i n fect i ous di seases, t obacco use, and d rug addi ct i on, t h e s i t u at i o n
has b ecom e worse i n m any o f t he st at es. By m ost m easures, h eal t h i n t h e E urasi an
states in 2003 continues t o l ag behind that in most developed countries.
Childhood and Maternal Mortality Rates. Table 2 shows m ortality rates
for children under five years o f age. Accord ing t o USAID, i ncreasing m ortality rates
in the Eurasian s tates among children unde r f i v e years o ld are t elling s igns of the
deterioration o f h ealthcare and the p light of many families suffering from poverty and27
malnutrition. USAID estimates t hat m ortality rates for children under five years o f
age i ncreased in all t he Eurasian stat es over t he period 1990-1997, the worst record28
in all its geographic bureaus. Maternal mo rtality rates are much higher in the
Eurasian states than in many other Europ ean countries (see Table 5 ). Causes include
poor nutrition, lack of maternal care, and ex t remely high rates o f abortion, compared
to the United S tates and most of Eu ro p e . H i gh rat es of abortion and maternal
mortality a re b eing reduced in several Eurasian s tates b y education and access t o
other contraceptive m ethods ( T a b le 5). In R ussia, concerns about morality and

27 Infant mortality is generally used to determine t he overall health of a country. However,
because most of the Eurasian s tates s till use t he Sovi et system of measuring i nfant mortality,
which undercounts deaths, t his r eport uses under 5 years of age mortality statistics.
28 USAID Economic Strategy in Central Asia, November 10, 1999, p. 9; USAID’ s Assistance
Strategy for Central Asia 2001-2005, J uly 2000, p. 56; Broadening the Benefits of Reform,
p. 11, from U.S. Census Bureau data.

population d ecline l ed the government in 2003 to propose b anning many abortions,
and t he legi slature t o cut off fundi ng for family planning clinics.29
Childhood vaccination rates in Eurasia d eclined dangerously in the l ate 1980s
and early 1990s, contributing t o a diphtheria epidemic in the early 1990s. By t he
mid-1990s, t his epidemic accounted for 90% of worldwide cases. Ukraine, R ussia,
and Tajikistan were hardest hit. The Bush-1 Administration and USAID collaborat ed
with W HO i n d elivering v accines and the United S tates l ater advocated international
donor assistance for childhood immunizations . By t he latter 1990s, d iphtheria cases
had d eclined greatly, as h ad some other child hood diseases, but still-inadequate
vacci nat i o n rat es rai s e t he t h reat of new out breaks. 30
A report i ssued by UNICEF i n J uly 2003 indicated that infant mortality rates i n
many Eurasi an st at es were “considerably high er” t han d ata p rovided b y E urasian
governments, and warned t hat its findings pointed to a “child survival crisis” i n t he
South Caucasus and Central Asia. The wi dest discrepancies b etween UNICEF’s
estimates and official data for the 1990s were found in Az erbaijan (where t he
estimate was 7 4 i nfant d eaths for every 1,000 live b irths v ersus an o fficial rate of 17
per 1,000), Georgia (43 v ersus 16), Kaz akhs tan (62 versus 24), and Turkmenistan (74
versus 33). UNICEF’s Ex ecutive Director, C arol Bellamy, stated t hat such “flawed
[ o ffi ci al ] s t at i s t i cs are a d a n ge r t o chi l d ren,” because t h ey keep “governm ent s and
health workers and even parents i n t he dark on the t rue n ature o f t he threats t o child
survival.” A report o n s urveys issued by t h e U.S . Depart m ent of Heal t h and Hum an
Services in April 2003 came t o s imilar conclu sions regarding Eurasian government
data on infant mortality. 31 Perhaps p artly in response t o the international critiques,
Uzbekistan deci ded t o implement the W HO standards for reporting i nfant m ortality.
The Increase in Infectious Diseases. The s harp deterioration o f t he
health infrastruct ure due to economic conditions has contribute d to a dramatic
i n crease i n i nfect i ous di sease cases. Increasi n g l evel s o f i nfect i ous di seases such as
TB, HIV/AIDS, an d m al aria have raised great concerns from t he international
community. S tatistics for the Eurasian states p rovided b y UNAIDS and t he W HO’s

29 T he proposed restrictions on abortions afte r t he twelfth week of pregna ncy have f ueled
mu ch debate. Russia’s Human Rights Ombudsma n protested that the proposal ove r l y
limited women’s freedom of choice. Financial Times Information, J une 12, 2003. One
commentato r a r gued for r etaining abortion guidelines already i n place, which i nclude
whether t he mother is able or can afford to care f or the baby, wa r n i n g t h a t R ussia’s l arge
orphan population otherwise could vastly increase. FBI S , September 2, 2003, Doc. No. 162.
See a l s o FBI S , August 26, 2003, Doc. No. 110; and Ne w Y or k T i me s , September 2, 2003.
30 A r ecent i ncrease i n diphtheria cases in Russia l ed to a J une 2003 announcement by public
health officials t hat all adults and children would be i noculated over the nex t t w o ye a r s.
IT AR-T ASS, J une 25, 2003.
31 UNICEF. Innocenti Report M onitor: A Region Fit for Children? J uly 22, 2003 . T he
UNICEF analysis i nc l u d e d data gathered from surveys with mothers. Ukraine’s official
infant mortality rate closely matched the survey-based estimate. See also U.S. Department
of Health and Human Services. Reproductive, Mat e r n a l , a nd Child Health in Eastern
Europe and Eur a s i a , April 2003, pp. 167-171; and a CDC r eport on K azakhstan i n
Pediatrics, May 2003, pp. 596-600.

“S t op TB” program are generally regarded as reliable. Comparable statist i c s f o r
other i nfectious diseases are not available. Table 3 shows t he number o f n ew cases
of TB and t he numbers living with HIV/AIDS. Although HIV/AIDS i s currently
spreading t h roughout Eurasia l argely among injecting d rug u sers, rising rates of
sex ually transmitted diseas e (STD) are a worrisome sign that HIV/AIDS may s pread
into the general population.
Tuberculosis. TB, i ncluding drug-resistant T B, appears t o b e i ncreasing i n
most of the Eurasian s tates b ecause of poor living conditi o n s and i nadequate
t reat m ent . Dru g- r e s i st ant T B can be ex t rem el y cost l y t o t reat , furt h er burdeni ng32
al ready s t rai ned h eal t h care fi n ances i n t h e E urasi an s t at es. The W HO ranks Russia
among the t op ten countries worldwide i n t erms of new ca s e s o f TB, and at the
bottom (along with Afgh anistan) among twenty-two countries with high TB rates that
falter i n using an effective TB t reatment termed the Directly Observed Treatment
Short-cou r s e (D O T S ). W HO es timates t hat DOTS t reatment was available t o l es s
that one-third of the population at t he end o f 2002. In 2001, Russia refused a W orld
Bank l o an t o fi gh t T B and HIV/ AIDS , apparent l y because i t di d not wi sh t o i n crease
the amount of its debt. However, i t accepted t he aid i n 2003 and h as worked with
US AID and W HO t o d isseminate DOTS and DOTS -P l us more widely and i ntegrate
t h e t reat ment into the general healthcare system.33 The dramatic increas e of drug-
resi st ant T B i n R ussi a was fuel ed by t h e rel ease, t h rough am n est i es o r t he com p l et i o n
of sentences, o f t ens o f t housands of prisoners with TB into the general population.
Also, convicts with the final stages of TB (or cancer or AIDS) h ave b een released on
humane grounds, possibly s preading t he disease. The R ussian Health Ministry has
announced that Chechnya and surrounding areas with high numbers of displ aced
persons have become a m ajor locus o f d rug-resistant TB.
TB rates i n all the Euras ian s tates ex cept Armenia are higher t han i n t he rest of
Eu r o p e . The high est numbers of new cases besides R ussia are in Kaz akhstan,
Ukrai n e, and U z b eki s t an. 34 USAID’s s upport for DOT S i n Kaz akhstan m ay have
contributed to a s ignificant 37% decline i n TB m ortality from 1998 to 2001. USAID-
supported DOTS p rograms now rep o r t e d l y cover 52.7% of the C entral Asian
population, more than are covered i n R ussia.
HIV/AIDS. Although t he actual numbers are s till seemingl y s mall, compared
t o Afri ca and p art s of Asi a and Lat i n Am eri ca, Eurasi a h as t h e fast est rat e of growt h
of HIV/AIDS infection i n t he world, amounting t o about one million cases in 2002.
During the 1990s, t he Eurasian states w itnessed growth i n i njecting d rug u se,
prostitution, an d population m obility that spread HIV/AIDS, but many of the

32 T he burden of T B i n Russia i s estimated to have cost soci e t y o ve r $4 billion i n 1999.
Un i t ed St ates Senate. Committee on Foreign Relations. Statement by Dr . David L.
Heymann, Executive D i r e c t or for Communicable Diseases, W orld Health Orga niza tion,
September 5, 2001.
33 W HO. WHO Report 2003: Global Tuberculosis Control , J anuary 2003, pp. 105-107; FSA
Annual Report FY 2002.
34 The r ate of multidrug-resistant T B i n Uzbekistan i s among t h e h ighest in the world,
attributable in part to the collapse of t he traditional h e a l t h c a r e system. Lancet , M arch 1,

2003, pp. 714-715.

governments have been slow in responding to the HIV/AIDS threat. HIV/AIDS
infection rat es in Ukraine are the highest am ong the Euras ian s tates and the highest
in Europe, according t o t he UNAIDS , and infection recently has s pread widely into
the l arger population t hrough het erosex ual t ransmi ssion. UNAIDS also reported
“ex plosive growth” in infection rates in Uz bekistan in 2002. 35
The number o f confirmed cases of HIV/AIDS in Russia h as greatly ex panded
from t he e n d o f 1998 to the end of 2002, from about 11,000 to more than 700,000
cases. UNAIDS warns, however, t hat i nadequate diagnosis and reporting m ay mean
that the actual i n c i d en ce in Russia is underestimated b y a “large margin.”36
HIV/AIDS appears t o b e s preading rapidly in Russia among intravenous-drug u sers,
prostitutes, and p risoners, t hreatening a breakout into the wider population. At the
same time, t he R u s s i an government appears t o still follow a policy of “malign
negl ect” regarding HIV/AIDS by spendi ng only $ 6 m i l lion a year on the d isease
(compared t o l arger s u m s s pent by international NGOs), although effective
prevention and treatment would require su ms larger than the p resent health budget. 37
The U.S. S tate Department warns t hat rising numbers of AIDS cases in Russia
threaten economic growth there (since funds will need to be shifted from i nvestment
to healthcare), and adds to deaths among the working age population, hastening t he
aging o f t he population. 38 At the S eptember 2003 U.S.-Russia s ummit, Presidents
Bush and P utin pledged t o s tep up collaboration on res earch, t reatment, prevention,
and diagnostics t o combat HIV/AIDS. The two Presidents endorsed t he efforts o f a
newly formed NGO, the Transatlantic P art ners Against AIDS , which h ad urged t hat
the disease be discussed at t he summit. At a c o n f er en ce in Moscow in May 2003

35 Among the security implications of the spread of HIV/AIDS, Analyst J ustin Redulson has
warned that Central Asia’s milit a r y f orces would be expected to be highly vulnerable to
increasing r ates of HIV i nfec t i o n i n t he larger population, weakening military readiness.
RFE/ RL Dai l y Report , J uly 20, 2003.
36 UNAIDS. Fact Sheet 2003: Commonwealth of Independent States, March 19, 2003. An
UNAIDS sur vey of i n j ect i n g d r u g u ser s i n t h e Russi an ci t y of T o gl i a t t i i n l a t e 2001 f ound
that three-quarters of t he users were unawa re that they were HIV positive, leading UNAIDS
to suggest that the “epidemic in Russian cities could be considerably more severe than the
already-high official statistics.” AIDS Epidemic Update , December 2002. T he Nati onal
Intelligence Council has suggested t h a t HIV / AIDS infections in Russia could r ise t o 5-8
million by 2010, about 6-11% of the a dult population. Global Infectious Disease Threat,
37 Ni cholas Eberstadt, T he Future of AIDS, Foreign Affairs , November-December 2002, pp.


38 State Department. Bureau of European and Eurasian Affairs. Background Note: Russia ,
May 2003. Among security implications of the s pread of HIV / AIDS, one in three Russian
military recruits repo r t edly is rej ected for drug-related hepatitis or HIV/AIDS, although
screening i s hit-or-miss because of the expense of t esting all recruits. According t o analyst
Mark Schneider, t here is a danger t hat HIV -positive Russian soldiers who need money f or
treatment and have access t o n u c l e a r materials might be tempted t o s teal and s ell s uch
materials. Mark Schneider and M ichael Moodie, The Destabilizing I mpacts of HI V/ AI DS,
May 2002, available online at [ http://www. africa/0205_DestImp.pdf]. See also
Radhika Sarin, A New Security Threat: HIV /AIDS i n t he Military, Wo r l d W a t c h , M arch-
April 2003, pp. 16-22.

at t ended b y S ecret ary P owel l , w h o h i ghl i ght ed t h e U .S . concern, t h e NGO warned
t h at R u ssi a h as becom e a w orl d epi cent er o f n ew HIV/ AIDS cases. 39
S e v e n E urasian s tates i n 2003 reportedly h ave received aid from t he U.N.’s
Global Fund to Fi gh t AIDS, Tuberculosis and M alaria, i ncluding Kyrgyz stan ($4.9
million), M oldova ($5.2 million), Tajikistan ($1.5 million), Ukraine ($24.9 million),
Armenia ($3.1 million), Georgia ($4.0 milli on), and Kazakhstan ($6.5 million). The
United S tates i s a major donor to the Global Fund. There h a v e b e e n s o m e belated
efforts at cooperation among the Eurasian s tates, including the l aunch o f t he Program
of Urgent Response to HIV/AIDS by the C ommonwealth of Independent States.
Drug Addiction. Al l o f t he Eurasi an st at es face i n creased drug use, wi t h t h e
great es t estimated i ncreas es in Russia, Ukraine, Turkmenistan, and Uzbekistan. In
al l o f t he Eurasi an st at es, d em and reduct i o n effort s are i n adequat e, accordi n g t o t he
U.S . S t at e D epart m ent ’s International Narcotics C ontrol Strategy Report, because
of i n a d equate budgets, inadequate treatment services in rural areas, and a l ack of
f o c u s o n d rug u se prevention b y o fficials. Table 3 presents some drug abus e d a t a
derived from government es timates. Some observers suggest that act ual rat es may
Drug treatment is poor or lacking i n m ost o f Eurasia, and where a v a i l a b l e ,
mainly entails involuntary confinement after arrest. Treatment consists of
detox i fi cat i o n with little or no follow-up rehabilitation efforts. Laws are m ostly
ai m e d a t i nterdiction and punishment of drug traffickers and users, and d rug u sers
avoid s eeking t reatment out of fear of arrest. The 1998 Russian narcotics l aw, which
provides for the i nvoluntary commitment of drug users who come to the attention of
the authorities, is criticized by many observers for preventing m o s t a d dicts from
seeking t reatment. In m aj or cities i n Tajikistan and Kyrgyz stan, heroin i s cheaper
to buy than vodka, according t o t he nongovernmental Open Society Institute,
t h reat eni n g t o l ead t o m u ch hi gh er fut u re drug addi ct i o n r a t e s i n t h ese E urasi an40
st at es. R e l i gi ous and non-governmental organiz ations have opened s everal drug
rehabilitation centers throughout Ukraine.
High -level attention t o t he drug probl em i n R u ssi a w as dem onst rat ed i n March
2001, when Premier M ikhail Kasyanov convened a government commission to study
i n creasi n g d rug abuse and HIV/ AIDS cases am ong yout h. He warned t h at R u ssi a h ad
changed from a drug transit country to a cons u m p t i o n country, and that organiz ed
c r i m e was i ncreasingl y i nvolved i n t he drug market. R ecogn iz ing t ha t a
comprehensive c ount ernarco tics strat egy m ust be adopted that em braces dem and
reduction and rehabilitation as wel l as l aw enforcem ent, Russian offici al s have m et

39 T he W hite House. Fact Sheet: U.S.-Russian Cooperation on HIV/AIDS, September 27,
2003. T r ansatlantic Partners Against AIDS, On the Frontline of an Epidemi c: The Need for
Urgency i n Russia’s Fight Against AIDS, September 2003.
40 Matthew Curtis, Eurasianet , February 21, 2001 and M arch 2, 2001; Open Society
Institute, International Harm Reduction Pro j e c t , U n c overing t he Dangers of Drug Use i n
Kazakhstan, Ky rgyzstan and Tajikistan ; Peak Option s Co nsulting, for t he Open Society
Institute, Summary of Fact Finding Mission to Kyrgyzstan, M arch 1, 2001; U.N. Office of
Drugs a nd Crime, Gl obal Illicit Dr ug Trends 2003, 2003.

with the U.S. Office of National Drug C ontrol and Prevention t o d iscuss how to set
up an analogous agency. In M arch 2003, Russia established a State C ommittee o n
Drug Trafficking, with a p lanned s taff of 40,000, to investigate d rug t rafficking and
related crimes. It s chairman, Viktor Cherkesov, has asserted that there are about four
million regular drug users and addict s i n R ussia, reflecting a 23-fold increas e i n t he
use o f h eroin and a t en-fold increase i n t he use o f cocaine over t he past five years.41
Al coholism a nd Smoking. Alcohol consumption i n R ussia and many other
Eurasi an st at es rem ai n s m uch h i gher t han i n m ost o f t he world. Russian observers
have stressed t h a t alcoholism i s linked t o other causes of i ncreas ed mortality in
Russia, including traffic accidents and in juries (homicides and s ui c i des). Alcohol
c o n s u m p t i o n i n R ussia d eclined briefly i n t he mid-1980s as a result o f a sobrie t y
campaign, but rose thereafter. Begi nning in 1993, there was a l arge increase i n m ale
alcohol poisoning in Russia, along with increases in male homicide and suicide and42
i n ci rcul at ory and respi rat ory d i s eases.
According t o t he W HO, smo k ing i n m ost o f Eurasia continued t o i ncrease
during t he 1990s. In R ussia, the m ajority of adult m ales smoke, with many starting
at young ages, while in the countries belonging t o t he European Union (EU), rates o f
sm oki ng are d ecl i n i n g. S m oki ng has b een l i nked t o h i gh p ercent ages o f m al e d eat hs
amon g t hose aged 35-69 in Russia, Kaz akhstan, Ukraine, Armenia, and Belarus, rates
that are substantially higher than in the United S tates.43 In 2003, Georgi a and
Ukrai n e i nt roduced rest ri ct i ons on t obacco advert i s i n g.
Wate r-Borne Disease. Det eri orat i n g w at er and s ewer syst em s (oft en w at er
and s ewer pi pes are co-l ocat ed), i n conj unction with other causes s uch as i njecting
drug use, are linked t o l arge increas es in t he i ncidence of hepatitis, cholera, and
typhoid fever throughout Eurasia. Ukrainian m edia reported t hat hundreds o f p eople
in the Luhansk region contracted viral h epatitis type-A in m i d-2003 from
cont am i n at ed dri nki ng wat er. In C h echnya, chol era as w el l as i nt est i n al di seases are
common b ecause sewer s ys tems are nonfunctional i n t he regi onal capital o f Groz n y.
Hundreds o f children i n Irkutsk, R us s i a were reported t o h ave contracted
enteroviruses l eading t o m eningitis in J u ly-September 2003, possibly t raceable to
leaking s ewers (then spread person-to-p erson), l eading t o t he vaccination o f 75,000
children against polio (a type of enterovirus). 44

41 Interfax , J une 26, 2003; BBC Global News Wi re , J un e 30, 2003, J uly 1, 2003; RFE/ RL
Daily Report, J uly 3, 2003; FBI S , September 10, 2003, Doc. No. CEP-64.
42 V l adimir T r eml, in Herlemann, pp. 151-162. According to Russian analysts Vladimir
Shkolnikov and Alexander Nemtsov, “ in the period from 1988-1992, the bigge s t s h a r e of
the i ncrease i n Russian mortality was attributable to alcohol consumption.” Premature
Death i n t he N e w I n dependent States , pp. 232-233, 240-241, 256; Feshbach, Washington
Quarterly,p.19; FBI S , J anuary 28, 2003, Doc. No. CEP-161; Interfax , February 18, 2003.
43 United Nat i o n s . World Health Or ganization. Hi ghlights on Health in the Russian
Federation, November 1999, p. 19; Prem a t u r e Death in the New Independent States, pp.

274, 275-286, 287-313.

44 BBC Global News Wi re , J uly 4, 2003; on the Irkutsk o u t b r e a k, see FBI S , September 2,

2003, Doc. No. 82; FBI S , September 6, 2003, Doc. No. 16. A s imila r outbreak in Omsk,


Non-M e di cal i ndi cator s
In creasing numbers of people i n Eurasia belong to subgroups that face special
heal t h needs, i n cl udi ng orphans, refugees, and t h e i nt ernal l y di spl aced.
Re fugees and Displaced Persons. Eurasian health conditions have been
impacted by the l arge numb e r o f p e r s ons forced from t heir homes by warfare and
discrimination s ince the breakup of the S oviet Union. The U.N. High C ommissioner
for R efugees has estimated t hat during t he 1990’s as m any as n ine million p eople l eft
their homes in Eurasia. These i ncluded r efugees who fled t heir country’s warfare,
those d isplaced within their o wn country by war o r returned from ex ile to find their
homes and communities destroyed, and those f o r ced t o l eave t heir homes, denied
citizenship or declared aliens in their homeland under n ew residence o r citizenship
laws. Lack of routine h ealth car e and immuniz ation, poor food and s anitation,
ex posure t o d isease, and v iolence against vulnerable groups all result i n d eclines in
health among those living i n crowded refugee camps or makeshift housing.
International humanitarian assistance to victims of either warfare or natural disas ters
al ways includes emergency health care and som e rout i n e p revent i v e h eal t h assi st ance,
aid which does not necessarily imp rove the overall health picture i n a country but
does address l i fe t hreat eni n g h eal t h needs.
Maj o r hum ani t ari an em ergenci es caused b y confl i ct h ave o ccurred i n A rm eni a,
Az erbaijan, Georgi a, Russia, and Tajikis tan. During the 1990s, conflict resulted i n
the ex ile or displacement o f over 1.5 million Armenians, Az erbaijanis, G eorgi ans,
and C hechens and ot her resi d ent s of R u ssi a, accordi n g t o t he U.N. Hi gh45
Commissioner for Refugees. Other popul a t i o n s h i f t s h a v e i n c l u d e d e t h n i c R u s s i a n s
leaving former republics where they are ethnic minorities and returning t o R ussia (3
million b etween 1992 and 1996), and Crimean Tatars returning t o t heir homeland i n
Ukrai n e ( 250,000 between 1988-1999). W hile aid agencies h ave responded t o t he
u r ge n t h eal t h needs o f t he refugees and s om e o f t he di spl aced, t hei r l onger-t e r m
heal t h needs a r e h arder t o address, part i cul arl y i f t h e refugees and d i s pl aced face
inhospitable living conditions and limited access t o l ocal healthcare facilities. Table

4 s hows t he current estimates o f refugees and d isplaced in Eurasia.

Orphans. According t o UNIC E F, the numbers of chi l d ren aged 0 -3 years
pl aced i n orphanages great l y i n cre a s ed i n al l t he W est ern E urasi an s t at es and i n
Kaz akhstan over t he period 1991-1998, fro m an average of 165 children p er 100,000
population i n 1991 to an average o f 304 children i n 1998 for t hese Eurasian states.
The number o f s uch children i n 1998 in other Eurasian s tates was s ubstantially lower,
ab o ut 39 per 100,000. While numbers of institutionalized children have b een
growing, declining public funding has l e d t o increasingl y poorer care. The
orphanages i n Eurasia, unlike i n m ost o f Europe, o ften include children with birth
defects, mental disabilities, and chronic h ealth conditions. USAID and i nternational

44 (...continued)
Russia l ed to vaccinations in September 2003 for 30,000 people. FBI S , September 2, 2003,
45 United Nations. High Commi ssioner f or Refugees. The State of the World’ s Re fugees


donors h ave i ncreasingl y p rovided assistan ce, including urgent and o ther healthcare.
In Russia, USAID and other donors h ave enc our a g e d t h e establishment o f a foster
care s ys t em t o repl ace orphanages and com m uni t y-based servi ces so t h at parent s can
continue to care for thei r challenged children. The numbers of homeless and street
children i n R ussia and other Eurasian s tates reportedly also h ave ex p anded, and t hese
children are helped only o n an ad hoc basis by ex i sting healthcare program s and most
international aid.46
U.S. and I nternational H ealth Ai d
Soon after t he Soviet collapse, USAID foc used on heal t h care reform s i n Eurasi a
as one of i t s obj ect i v es. It d evel oped t he Hospi t al P art n ershi p P rogram , t o be carri ed
out by a newly creat ed American International Health Alliance (AIHA), as its major
public-private vehicl e for ai d efforts focusing o n e ducational activities and
professional ex changes by U.S. medical vol unt eers. A rel at ed Heal t h R eform P roj ect
by USAID l aunched i n 1993 focused o n t he reorganization o f h ealthcare i nstitutions
and financi ng in the E u r as i a n states, to “i ncrease economic effici enci es, quality of
care, access, and p rov i der choi ces ... t h rough m arket -ori ent ed reform s.” T hese
changes h ave faced obst acl es i n R u ssi a and ot her E urasi an s t at es, i n cl udi ng resistance
from S oviet-era healthcare establishments a n d o fficials and skyrocketing poverty47
rat es, whi ch h a v e p l aced fee-for-servi ce heal t h care out of reach for m any p eopl e.
However, the changes are s een by USAID as essential t o t he ability of the healthcare
systems t o m oderniz e and function o n t heir own without ongoing international donor
The C linton Administration asked C ongress in 1997 to begi n s upporting a new
“Partnership for Freedom” i nitiative as part of boosted Eurasian assistance that would
emph asiz e grass-roots economic and s ocial reforms, i ncluding health. Additional aid
was s ought for hospital an d h eal th facility partnerships, program s t o combat
i n f e c t ious diseases, and efforts t o bolst er clean water s upplies, childhood surviv a l ,48
and m at ernal h eal t h . The reques t f o r a l a r ge boost i n Eurasian aid was not

46 United Nations. United Nations Children’s Fund. Y oung People i n Changing Societies ,
2000, p. 153. On conditions in Russia and recommendations to international aid donors, see
Human Rights Watch, Cruelty and Neglect in Russian Orphanages, December 1998; FBI S ,
J une 11, 2003, Doc. No. CEP-183; FBI S , J uly 18, 2003, Doc. No. CEP-319. Russian law
enforcement r eportedly has cracked down on “ wa yward” homeless c hildren, sending some
to shelters and orphanage s. IT AR-T ASS, J a nuary 28, 2003.
47 Edward Burger, J r., i n Russia’s Torn Safety Nets , ed. by Mark Field and J udyth T wigg,
New York, St. M artin’s Press, 2000, pp. 291-292; About AIHA, see [].
Burger criticizes the Health Reform Pr oj ect as “clearly out of phase with the political and
economic realities of t he time i n Russia.”
48 Spurring these e mphases, conferrees on Fo reign Operations Appropriations for FY1997
(H.Rept.104-863) had criticized the Administration f or not i n c l u d i n g health and
envi ronmental health as Eurasian aid priorities, and had urged t hat t h e treatment of
childhood illnesses i n Ukr aine related t o Chernobyl s upercede other aid obj ectives.

supported b y C ongress, but many of the p ro grammatic emphases, including health
aid, were endorsed. 49
Building on t he “P artnership for Freedom” i nitiati v e , USAID increas ingl y
em phasi z ed s oci al n eeds i n E urasi a. U S A ID cam e t o argue t h at econom i c reform s
in the Euras ian s tates had not al ways contributed to the growth of middle classes, and
also helped create “a n ew class o f chroni cally poor,” w h o l o s t t h e meager state
benefits they received under communism . W hile dem o c r atiz ation and economic
reforms remained U.S. objectives, USAID stressed t hat without ad equate healthcare
and o ther social services, populations in th e Eurasian s tate s would l ose faith in the
r eform process. USAID s tated t hat i t woul d i ncreasi n gl y t ake s oci al i ssues i n t o
account in design ing a n d implementing p rograms, so that “the broadest possible
spectrum o f [ Eurasi an] citizens...have the opportunity to enjoy t he benefits of
In keeping with the n ew emphasis, USAID’s assistance activities i n recent years
have been divided i nto t hree broad s trategi c areas, econom i c, d em ocrat i c, and soci al
transition or global h eal th. The objectives of soci al transition assistance incl ude
i m p rovi ng Eurasi an heal t h and o t h er soci al benefi t s and s ervi ces. U S A ID heal t h care
go al s i ncl uded h el pi ng t h e E urasi an s t at es t o d raw u p h eal t h ca r e and i nsurance
legi slation and policy focusing on community-bas ed primary health care; to improve
the cost-effectiveness o f h ealthcare budgets; to improve the quality of healthcare; to
educate citizens about their p ersonal h ealthcare rights and obligations; and to reduce
environmental and occupational h eal t h ri sks. S i nce 9 / 11, m o re heal t h ai d h as been
dedicated to Eurasian states under t he rationales of buttressing their ability to conduct
the war on terrorism, fostering democr atiz ation and free m arket refor m s , a nd
ensuring thei r stability, but such ai d usually has not been ex plicitly linked t o potential
health threats t o t he U.S. homeland.
USAID p rovides t he largest s hare of U. S. health aid t o Eurasia, t hough notable
amounts are also provided b y t he Defense, Health and Human Services, and Energy
Departments and the P eace Corps (see t ex t box ). Table 1 shows t he amount of health
aid t o t he Eurasian states provided o r p roposed for FY2001-FY2004. Before 9/11,
health aid h eld fairly s teady at about 5% o r l e s s of Eurasian funding from FY1998
through FY200 1 . Fo r F Y2002, funding rose to 8.2%, which included emergency
supplemental funds for h ealth amounting t o $19.55 million. These funds bolstered
programs in the “front-li n e” C entral Asian stat es (Kyrgyzstan, Tajikistan, and
Uz beki st an) and Arm eni a, and t o a l esser d egree i n s everal ot her E urasi an s t at es. The
percent ages o f E urasi an ai d devot ed t o heal t h appear t o be sl i g h t l y hi gh er t h an t h e
historical average i n FY2003 and as re quested in FY2004, perhaps reflecting a

49 CRS Report RL30148, U . S . A ssistance t o t he Soviet Union and Its Successor States


50 USAID, Budget Justification FY 200 1 , A n n e x III, Europe and Eurasia,p.9. See also
USAID, Broadening the Benefits of Reform in Ce nt r a l a n d Eastern Europe and the New
Independent States: A Social t ransition Strategy f or USAI D, Bureau for Europe and Eurasia,
February 2000, pp. 8-9, 23-24.

great er U.S . em phasi s o n h eal t h
Cumulative Funds B udgeted FY1992-FY2003 forreform s i n Euras ia despite ai d
Health and Related Programs in Eurasiaconstraints.
( F REEDO M Suppo rt Act a nd O t her F unds)
(m illio n d o lla rs)
USAID Global Health 576.98The l argest amounts o f
P r esid ential M ed ical I nitiative 5 .0US AID h eal t h ai d h ave b een
Coordinato r’s Office transport costs 234.2*prov ided to Russia, Ukraine,
Defense Department E xcess DefenseKaz ak h s t an, Uz bekistan, and
Ar ticles: Ho sp itals and Related 294.8
P eace Co rp s H ealth Initiatives 3 8 . 0 **Armenia, part ly reflecting b road
B io-technical Redirection 86.9U.S. policy i nterests in these states.
Global AIDS Fund 2.5W i t h i n each Eurasi an st at e, t h e
Subtotal U.S. Go vernment Health Aid 1,238.4percentages o f U.S. aid devoted to
Co o r d ina to rs O ffice: Value o f p r iva tely-health as opposed to other
donated cargo es tr ansported 1 ,928.3*
To ta l 3,166.7programs have been high est i n t he
C ent ral A si an st at es i n recent years
Sources: State Department, Office of the Coordinator(usually m o r e t h a n 1 0 %),
of U.S. Assistance to Europe and E ur asia (EUR/ACE :refl ect i n g h ei gh t ened U .S . concern
Li ni c k & K uske vi c s ) ; FREEDOM Support Act Annual
Reports fo r FY1993-FY2002; T he P ea c e Co rps,about poor healthcare s ituations
Congressional Budget Presentation, FY2004.and t he need to bolster the stability
*Health-r elated; E stimate b y the Coordinator’s Officeof st at es t h at are s t rat egi cal l y
a nd CRSs i gn i f i c a n t t o t h e f i gh t a ga i n s t
**E stimated : a p r o gr a m b r eakd o wn b y health activitiesterrorism.
in the E ur as i a n states is not available, but the P eace
Co rps reports that about 20% of global p roj ects invo lve
health.U.S. assistance budgeted
FY1992-FY2003 for h ealth was
about 5 . 1 % o f t otal aid t o Eurasia
of $24.5 billion (ex cluding the value o f priv ately donated cargo es), indicating t he
relativel y l ow p r iority of such ai d until after 9/11. U.S. government health ai d t o
Eurasia h as been less than private donations of medical goods and ex p ertise, which
were worth about $1.9 billion during FY1992-FY2003, including t h o s e p rovided
through t he Health Partnerships program, implemented by AIHA (private donations
that do not use U.S. s ubsidiz ed transport a re not included i n t his t otal). The AIHA
leverages government and p rivate funding to foster cooperation b etween U.S.
hospitals an d h ealthcare providers and Eurasian m edical facilities and ex perts.
Doz ens of primary, u rgent, or other h ealthcare p art n ershi p s l aunched b y A IH A are
a c t i v e i n al l t wel ve Eurasi an st at es. 51 Operation P rovide Hope, an i nteragenc y
program l aunched i n 1992, and US AID’s ocean freight program p rovide U.S . funded
transport s ervice s f o r p rivate donations of medical goods. W hen t he values of the
privately donated cargo es that are t r ans ported with government support are added,
U.S. public and p rivate health-related assistance amounts t o about 11% of $27.7
billion i n t otal aid t o Eurasia in FY1992-FY2003.
USAID recogn iz es that there are limits to what U.S. aid i s able t o accomplish
gi ven m assive health needs i n Eurasia.52 USAID has addressed t he reality of limits
by focusi ng on l ean program s t h at l everage U.S . assi st ance t o achi eve m a x i m u m
resul t s , i t s ays. These effort s i ncl ude sm al l -scal e d em onst rat i o n p roj ect s i n v ari ous

51 For d e t a i l s , s e e t h e AIHA we b s i t e , [ ht t p : / / www.a i ha .c om] .
52 USAID, Rushing; National Research Council, p. 18.

regi ons of Eurasia t hat i t i s hoped Eurasian governments will replicate n ationwide.
USAID has maintained that its performance meas ures show that its health programs
are having s o m e i mpact in Eurasia. While heralding t hese impact s, USAID
nonetheless cautions that more assistance is n e e d ed, s ince “sys temic trends in the
regi on rem ai n di st urbi ng” b ecause of ri si ng r at es o f HIV/ AIDS , t ubercul osi s , and
multi-drug resistance tuberculosis, and inadequate improvements i n health care
systems. Progress has b een made in lowering the h igh rates of abortion i n t he
Eurasian stat es , for instance, but abortion rat es are s till am ong “t he highes t i n t he
In planning to phase out FR EEDOM Support Act a i d t o R u ssia over t he nex t
few years, USAID h as proposed that most of the d windling ai d f o cus o n
democratization and health issues. 54 USAID h as proposed somewhat less funding for
healthcare i n R ussia i n FY2004 ($14.5 million) than in FY2003 ($18.1 million), but
proport i o n a t e l y more than for o ther programs. S tarting i n FY2003, USAID h ealth
programs were incorporated into a n ew act i v i t y, Healthy R ussia 2020, that aims to
bri n g s everal R u ssi an heal t h i ndi cat ors u p t o W est E uropean st andards. P rogram s i n
Russia i n FY2004 are p lanned t o emphasiz e p rimary health care, combating
i n fect i ous di seases, wom en’s heal t h , and chi l d wel fare.
Besides USAID health-related program s, the Department of State coordinates
effort s b y t he Depart m ent of Heal t h of Hum an S ervi ces and o t h er agenci es t o redi rect
form er S ovi et bi ol o g i c a l w a r fare s ci ent i s t s t o peaceful research, wi t h a focus on
heal t h care (such as drug and v acci ne devel opm ent f o r t h e cont rol o f t ubercul osi s ,
hepatitis, HIV/AIDS and other i nfectious diseas es ). In addition, some activities of
the M oscow and Kiev Science and Technology C enters, funded b y t he S t ate
Department, deal with biomedical research by Eurasian scientists. W ith major U.S.
backing, a C ivilian R esearch and Development Foundation NGO was s et up in 1995,
i n cl udi ng a Bi o m edi cal and Behavi o ral S ci ences P rogram t hat carri es out
col l aborat i v e m edi cal research, fun d e d b y t he U.S . S t at e, Defense, and C om m erce
Departments, NIH, and others. Althou gh t h e Administration plans to phase out
FR EEDOM Support Act aid t o R ussia and Ukra ine, programs involving retraining
for s cientists from t hese countries and fro m C entral Asia who p reviously worked on
bi ol ogi cal and chem i cal warfare wi l l i n crease i n k eepi n g wi t h post -9/ 11 U.S . securi t y
Among other E urasian h ealth programs, t he P e ace Corps h as carried out
preventive h ealth education i n Armenia, Kaz akhstan, and M oldova, and community
health developme n t a c tivities i n Turkmenistan and Uz bekistan. P eace Corps
programs in Kaz akhstan, Moldova, Turkmenistan, and Uz b ekistan s tress education
on preventing HIV/AIDS, and i n Kaz akhstan, Turkme n i s t an, and Uz bekistan
emphasize maternal and child health. The Defense Department has donated military
hospitals under t he Ex cess Defense Articles p rogram and h as provided follow- o n

53 Broadening the Benefits of Reform, pp. 8, 38; FSA Annual Report FY 2002.
54 State Department. Congressional Budget J ustification, Foreign Operations, FY 2004 ,p.

371; USAID. Budget J ustification t o t he Congress, Annex III, Europe and Eurasia, p. 356.

55 Congressional Budget J ustification, Foreign Operations, FY 2004 , pp. 370, 385.

equipment p ackages and t raining worth $294.8 million t o v irtually all o f t he Eurasian
states during FY1992-FY2003. 56
Inte rnational Assistance Efforts.57 International organizations with health
programs in Eurasia i nclude the W orld Health Organiz ation(W HO), t he U.N. Fund
for P opulation Activities, UNICEF, U . N. Development P rogram and t he World
Bank. A consortium o f s even U.N. agencies established UNAIDS in 1995 to focus
on curbing t he spread of HIV/AIDS, i ncludi ng in Eurasia. Health programs also have
become a growing part of the activities of t h e U . N . International Drug C ontrol
Program and UNESCO (U.N. Educational, Scientific, and Cultural Organization).
The E uropean Uni on’s T echni cal Assi st ance for C entral Europe and t he Independent
S t at es (TAC IS ) p rogram i n cl udes h eal t h assi st ance. T h e W o rl d Bank pl ays an
important role in funding health initiatives as a p articipant i n UNAIDS and t he
Gl obal Fund t o Fi gh t A ID S , Tubercul osi s and M al ari a (GFATM), and i n accordance
with the U.N. General Assembly’s September 2000 Millennium Development
Declaration and its J une 2001 commitment to combat HIV/AIDS.
W HO’s budgetary emphasis i s o n functional p rograms and regi ons, with only
small amounts earmarked fo r s pecific countries. The Regi onal Office for Europe in

2000-2001 provided s mall amounts o f t echnical assistance to Armenia, Az erbaijan,

Kyrgyz stan, M oldova and Tajikistan ($463,000), R ussia ($200,000), and other
Eurasian states ($130,000). T he programs fo cused o n communicable diseases, non-
com m uni cabl e di seases and h eal t h prom ot i on, heal t h pol i cy, heal t h care reform ,
women’s and children’s h ealth, and envi ronment a n d h e a l th. E ach country has a
W HO s pecial rep resentative who coordinates regional p rograms. In 1993, W HO
Europe l a unched a special project in th e Euras ian s tates t o reform t heir
pharmaceutical sectors s o t hat citiz ens woul d h ave b etter and more affordable access
to medicines. W HO Europe also has s upported s uch p rojects as t raining i n C entral
Asia on food safety and o n waterborne sanitation, in Arkhangels k a n d M urmansk,
R u ssi a, on m at ernal nut ri t i on, and i n Kor o l e v , R ussi a, on energy and wat er58
U.N. interagency HIV/AIDS p rogram s h av e b een operating i n all the Euras ian
s t ates since t he mid-1990s. M ost o f t hese countries also have activ e p r i v a t e
vol unt ary o r g a n i z at i o n p art n ers and program s run b y b i l at eral ai d agenci es such as
USAID. The p rojects address t he popula tions currently m o s t likely t o s pread
HIV/AIDS (inject i n g d rug users, prostitutes, and m en who have s ex with men),
education for young people and schoolchildren, vulnerable groups (prisoners, s treet
children, refugees , ethnic minorities), care for people living with HIV/AIDS and for
their human rights, condom distribution, blood safet y p r o g rams, p revention and
treatment of STDs, di s ease s urveillance, and public service i nformation o n

56 Peace Corps, Congressional Budget Present ation, FY 2004; Background Paper on State
Department-Directed Humanitarian Assistance t o [ Eurasia] , J anuary 11, 2001; FSA Annual
Report FY 2002. H.R. 1950, the Foreign Relations Authorization Act for FY2004-FY2005,
approved in the House i n J uly 2003, calls for Peace Corps volunteers t o devote more time
to the prevention and treatment of infectious diseases.
57 Prepared by Lois McHugh and J im Ni chol, Foreign Affairs, Defense, and T rade Di vi sion.
58 See W or l d Heal t h Or ga ni za t i on. Regi onal Of f i ce f o r Eur ope, [ ht t p : / / www.eur o.who.i nt ] .

HIV/AIDS. According t o t he database of the Global Fund to Fi gh t AIDS, TB, and
Malaria, it has approved t wo-year fundi ng of $50.3 million t o combat HIV/AIDS i n
Eurasia, with about one-half going to Ukraine, and t he res t to Armenia, Georgi a,
Kaz akhstan, Kyrgyz stan, M oldova, and Tajikistan. 59
The U.N. C hildren’s Fund (UNICEF) has h ealth an d nutrition p rogram s i n all
the Eurasian s tates. Program t otals i n 1999 ranged from a high of $882,000 in Russia
to a l ow of $152,000 in Belarus, according t o UNICEF. P rograms include aid t o
Uz bekistan to vaccinate children against hepatitis B and to help create m aternal and
children’s h ealth centers. The U.N. Population Fund (UNFPA)also h as programs in
all t he Eurasian states. Amo n g the UNFPA programs being carried out in 2000-

2004, those for Azerbaijan ($4 million i n d irect funds), Kazakhstan ($4 milli o n ),

Kyrgyz stan ($3.5 million), Tajikistan ( $4 million), Turkmenistan ($3.5 million), and
Uzbekistan ($6 million) devote a substantial portion o f t o reproductive h ealth issues,
and that f or 2000-2003 for R ussia devoted a s mall part of $820,000 to quality
healthcare and HIV/AIDS issues.
The TACIS program i s t he major assistance program o f t he EU for Eurasia. A
recent annual report i ndicates that about 393 million euro were p aid out in 2001 for
Eurasia (ex cluding Mongolia) and 381 millio n euros in 2002, with health assistance
consisting i n 2002 of some thirteen programs amounting t o 8.0 million euros paid out
(abo u t 2.1% of assistance in 2002). TACIS has considered health aid t o R ussia,
Georgi a, Moldova, Ukraine, and Uz beki s t an a p riority. Health aid t o R ussia h as
i n cl u d e d a primary healthcare project in the north-wes t and project s on preventive
m edi ci ne, m edi cal educat i on, prevent i o n o f m other-to-child HIV t ransmission, and
cardi ovascul ar di seases. Heal t h ai d t o Ukraine has i ncluded p rograms o n HIV/AIDS
prevention, setting u p pharmaceutical oversight, and care for the eld e r l y. For the
remainder o f Eurasia, h ealth has not bee n h i gh on the priority list for support i n
nego tiations with the p artner governments. However, TACIS h as undertaken some
sm al l -scal e p roj ect s, such as hospi t al m an agem ent i n Bel arus, p ri m ary heal t h care for
i n t ernal l y di spl aced persons i n Az erbai j an, and com bat i n g T B i n Kyrgyz s t an. Drug
abuse and HIV/AIDS in Eurasia are emergi ng EU concerns. 60
W o rld Bank Group support for health in Eurasia h as included building hospitals
and ret raining doctors to serve as rural physici ans i n Armenia and improving primary
healthcare i n Ukraine and Kyrgyz s tan. The W orld Bank also supports efforts t o s et
up medical insurance s ys tems. It i s particularly interested in worki n g with other
donors t o p rovide technical and financial support for combating HIV/AIDS and TB
in Belarus, G e o r gi a, Moldova, R ussia, and Ukraine. HIV/AIDS p rograms i nclude
support for harm reduction (needle ex chan ge and d ecriminaliz at i o n), ensuring t he
safety of blo o d s upplies, treatment, and education. Th e W orld Bank has approved

59 T h e Gl obal Fund t o Fi gh t AIDS, T B, a nd Mal a r i a, [ h t t p : / / www.t h egl obal f und.or g] .
60 European Commi ssion. Annual Report 2003 from the Commission to the Council and the
European Parliame nt on the EC Development Policy and the I mpleme ntation of External
Assistance i n 2002, Brussels, 3.9.2003, COM(2003)527 final. T he EU a lso c onsiders t hat
regi on-wide programs on envi ronmental pollu tion, drug trafficking, and water management
have health components. TACIS Regional Cooperation Strategy Framework for 2002-200 6 ;
TACIS Regional Cooperation: Strategy Paper and Indicative Programme 2004-2006 .

loans worth well ov er $1 billion for health project s i n Euras ia. Lending to combat
HIV/AIDS has i ncluded a $150 million l oan t o R ussia approved i n April 2003, a $5.5
million l oan t o M oldova in J une 2003 , a n d a $60 million l oan t o Ukraine in
December 2002. Lending for h ealth sect or reforms h as included $30 million t o
Russia approved i n 2003, $20.3 million t o G eo r gi a in 2002, and $5 million t o
Az erbaijan i n 2001. 61
Issues for C ongress
How Significant are Health Issues in
Eurasia to U.S. I nterests?
Those who endorse continued o r ex p anded U.S. h ealth aid t o t he Eurasian states
argu e t hat d i s ease out breaks i n E urasi a, whet h er t h e resul t o f n at ure o r b i o -t errori sm ,
a r e a m o n g those t hat might spread to U.S. shores. P articularly since 9 /11, the y
emphasiz e the s ignificance to home l a n d s e curity of disease p revention and
surveillance b eyond U.S. shores. Other obs ervers urge not diluting recently focused
U.S . pol i cy and assi st ance ai m e d a t com bating h ealth problems i n s ome areas of
Africa, Asia, and Latin America by s hifting attention t o Euras ia. They argue that
i n fect i ous di sease rat es are not as great i n Eurasi a, so do not pose as s evere a n ear-
term t h reat to U.S. interests. Some argue t hat U.S. ties with Russia and other
Eurasian stat es on arms control and eliminating t errorists are more important to U.S.
homeland s ecurity and t hat Eurasian h ealth matters are b est l eft t o t he countries to
solve on t heir own. Some broadly cal l for winding down or eliminating FREEDOM
Support Act ass i stance (including for h ealth programs) t o m any o r m ost o f t he
Eurasian states, i n line with plans t o “gra duate” o r phase out this aid t o countries that
have made developmental p rogress. Others respond that few i f any of the E urasian
st at es have m ade m u ch heal t h care p rogress (see b el ow).
In addition t o t hese issues of homel and s ecurity, m any observers stress that U.S.
interests i n economic and political reform s i n Eurasia may b e undermined by health
problems i n t he countrie s . Adverse h ealth trends in Russia m ay be a d rag o n
economic reforms, foster ci vil unres t, encourage a cou n t ervailing political
autho ritarianism, and perhaps lead to a m ore i nternationally belligerent, nuclear-
arm ed R ussi a. 62 Even sm al l i ncreases i n heal t h ai d m ay p a y b i g di vi dends i n
discouraging s uch d e v e l o p ments i n R u ssi a, som e observers argu e. However, as
Table 2 indicates, governments o f t he Eu rasi an st at es are s pendi ng a v ery s m al l
percentage of their budgets o n h ealth. W ithout greater commitments b y t he states
to healthcare, U.S. assistance appears at m ost palliative. In addition, the states m ust
address t he socie t a l roots o f h ealth problems s uch as alcohol and d rug abuse, and
hom i ci d es and s ui ci des.

61 T he W orld Bank. Beyond Transition: The World Bank in Europe and Central Asia, J une
2003; Averting AIDS Crises i n Eastern Europe and Central Asia, 2003; Country Briefs,and
Projects Database , a t [ ht t p : / / www.wor l dba nk.or g] .
62 Ni cholas Eberstadt, Kennan Institute, February 5, 2001.

U.S . securi t y i n t e r e st s m ay be served by bol st eri n g t he heal t h of Eurasi a’s
military forces and civilian populations. Dec lining health in the military and s ecurity
forces can harm thei r ability to co mbat terrorism an d d rug t raffick ing, to en sure the
safety and s ecurity of weapons of mass destruction, and o therwise to defend the
territorial integrity of the s tates. If the military forces are l es s capable of carrying out
these missions, t hen U.S . border, customs, and s ecurity aid (recently boosted b y t he
Adm i n i s t rat i o n and C ongress), m ay be l ess effect i v e t han ant i ci p at ed, accordi n g t o
this argu ment. Also, terrorist groups m a y b e able t o gain m ore adherents when
failing h ealthcare s ys tems increase popular discontent. U.S. health aid h as been
considered by several Euras ian military es tablishments as a m aj or benefit of military-
to-military cooperation, according t o U.S. d efense officials. The U.S. military also
views t he rise of infectious and other diseas es in the Euras ian s tates as risks to U.S.
troops during military training, ex changes, ex ercises and operations involving the
Eurasi an st at es. 63 Critics counter t h at the U.S. military is always concerned about
protecting p ersonnel from d isease, and t hat Eurasian military personnel are no more
dangerous than the p ersonnel o f o ther countries with large h ealth problems.
How M uch Can the United S tates do t o I m p r o ve Health
Condi ti ons i n Eu r a s i a a nd What Types of Heal th Ai d a r e
The United S tates faces competing p ri orities for its aid dollars and limits on its
ability to fund healthcare reforms in Eurasia. Observers who urge great er em phasis
on U.S . heal t h ai d t o E urasi a argu e t h a t s m al l i n creases i n ai d m ay wel l pay b i g
dividends in lowering disease rates and ameliorating s ocial discontent i n t he Eurasian
s t at es . S ome cal l for much larger commitments t o m eet pressing health need s i n
Eurasia, perh ap s by s hifting aid from dem ocratization and economic reform
programs. M any urge cauti o n i n t a k i ng on new Euras ian health ai d commitments
unilaterally. The stat es face interrel a t e d and costly healthcare, public health
infrastruct ure, and environmental problem s — such as deteriorating hospitals, failing
water and sanitary system s, radiation haz ards in Kazakhstan’s S emipal atinsk nuclear
testi n g s i t e , and the evaporation o f t he Aral S ea — t h at dem and l arge-scal e,
sustai ned, and i n m any cas es , m ultinational attention.
C ongress and t he Adm i n i s t rat i o n h ave cl ashed for s everal years over how m u ch
aid t o p rovide for Eurasia. Annual U.S. h ealth aid t o t he Eurasian states has averaged
about 5.1% of total aid to the region, rising somewhat after 9/11. Due to cuts i n
FREEDOM S upport Act funding in recent years, ex cepting 9 /11-related assistance
in FY2002, the actual amount of h e a lth aid p rovided t hrough USAID has s teadily
increased only to Kyrgyzstan and Tajikistan. Other health-related funding from
agency budgets and other p rogr a m s f i l l s t his gap to some degree, but much of this
assi st ance t ends t o be focused o n n arrow p rogram s s uch as t ransport i n g m edi cal
cargo es, re-training scientists, o r P eace Corps activities. One way to address t he need
for m ore assi st ance woul d b e t o i ncrease t he percent o f forei gn ai d d evot ed t o heal t h

63 T he r ise of diphtheria cases in Russia i n t he early 1990s, f or instance, was t raced to Sovi et
troops returning from Afghanistan and t o i nfected Russian “peacekeeping” troops that were
rotated out of T aj i ki stan.

in Eurasia o r t o e s t ablish C ongressional guidelines for t he amount of aid t o b e
provided for health assistance. Either of th ese changes would require further s hifts
in U.S. policy, which for a l ong time focused o n d emocratization and economic
reform s and arm s cont rol . Al so, t here m ay b e a n eed t o consi d er l onger-t erm h eal t h
ai d commitments, particularly if U.S. assistance is target ed more t o h ealthcare
institution-building and reform efforts t hat aim to bolster the ability of the Euras ian
stat es to meet thei r own needs. Perhaps reflecting s uch a partial s hift in priorities and
a des ire t o i nsulat e healthcare from cuts, the Administration appears t o be requesting
an amount for h ealthcare for Eurasia for FY2004 that is slightly high er than that for
FY2003, despite calling for overall cuts in FR EEDOM Support Act funding.
Some observers have suggested that the A dministration’s p roposed Millennium
Challenge Account and t he Global AIDS i nitiative, or other h ealth programs, might
include health aid for some or all Eurasian s tates. FY2001 was t he fi rst year that
Congress incl u d ed Eurasia in the C hild Survival and Disease (CSD) account —
where m ost U.S . forei gn assi st ance for h ealth is provided — possibly i ncreasing t he
percent o f forei gn ai d avai l abl e for heal t h i n Eurasi a. Unt i l t h at year, h eal t h program s
in Eurasia were m ai nly funded t hrough t he FREEDOM S upport A ct , where health
programs competed with other p rograms. Eu r a s i a received $6.8 million i n C SD
funds in FY2001, none in FY2002, and $5.75 million i n FY2003.
A s econd possible change i n h ealth aid t o Eurasia would b e t o alter t he
distribution of aid among the countries. Table 1 s hows t he distribution of USAID’s
bilateral h ealth funds to the Eurasian s tates i n recent years. The l argest aid amounts
have gone to Armenia, Kaz akhstan, R u s s i a , Ukraine and Uz bekistan. M uch l ess
healt h a s sistance has b een provided t o Az erbaijan, Belarus, Moldova, and
Turkmenistan. The distribution o f aid is not clearly matched t o t he he a l t h status of
the s tates, neither matchi ng rankings o f under five m ortality (Table 2) nor rankings
o f health system performance in Eurasia, as determined by the W orld Health
Organiz ation. 64 In stead, a number o f considerations se e m to influence d ecision-
making on the distribution o f aid besides t argeting i t t o t he most needy Euras ian
states, i ncluding th e d e g r e e t o which ai d s hould b e t argeted t o t he closest o r m ost
strategi c U.S. friends or to t h e m o s t d emocrat i c and m arket -ori ent ed st at es. S uch
determinations are complicat ed by the add ed d esirability of targeting U.S. aid to
Eurasian states where govern ments are receptive, honest, and efficient at carrying out
healthcare reforms, although t hese conditions are s carcely m et in any o f t he Eurasian
st at es. 65 In Russia and other Euras ian s tates, many critics charge, the governments
are h i g h l y c o rrupt, i nefficient, and not focused o n h ealth budgets, policies, and
stewardship. 66 In such conditions, U.S. and interna t i onal m edi cal assi st anc e t o t h e

64 W HO. The World Health Report 2000: Health Systems, Improving Performance, pp. 200-


65 W HO. The World Health Report 2002: Reducing Risks, Promoting Healthy Life, October
2002, pp. ix-xi, 3-4, 131-144, 165-167. WHO a rgues t hat governments should not only
provide adequate budgetary s upport and policies f acilitating public and private healthcare,
but also proper “stewardship” to maximi ze healthcare performance dollar f or dollar.
66 Ni cholas Eberstadt, Kennan Institute, February 5, 2001, argues that the Russian leadership
has f ailed, compared to other s ocieties t hat have gone through economic turmoil, to provide

Eurasian states risks b eing undermined or redirected for political purposes. In s ome
cases, E urasi an governm ent s h ave b l o cked m edi cal as wel l as ot her hum ani t ari an ai d
to ci vilians for political and military p urposes (such as i n C hechnya), using it as a
weapon to bring populations and s eparatist m ovements i nto line. To help circumvent
problems with governments, some observers have argu ed that U.S. health aid s hould
focus m ore o n h igh-quality indigenous health-related NGOs in Eurasia, to ensure that
ai d i s used properly and to strengthen long-term s el f-hel p capabilities, while others
caution t hat i n m ost o f Eurasia, s uch l ocal NGOs are s till hard to find.
Am ong possi bl y cl ashi n g U.S . ai d obj ect i v es , U .S . h eal t h ai d d edi cat ed t o
d i s a s t er assi st ance or t o IDP s and refugees i n an Eurasi an st at e m ay short chan g e
health aid s upport for the res t o f a count ry’s population. USAID family planning
programs in Eu rasia m ust comply with policy promoting m at ernal health and t he
provision of modern contraception m ethods that count e ract the i nordinately high
rates o f abor t i o n t h r oughout the region. Li kewise, with HIV/AIDS spreading
throughout Eurasia p rimarily through i njecting d rug u sers, U.S. p rograms t o curb t he
spread of the disease m ust comply with restri ctions on U.S. drug assistance programs.
Many in Congress suggest that other i ndustrializ ed countries s h o u ld bear a
great er share o f E urasi an h eal t h assi st ance. U.S . advocacy of great er W est ern
involvement has i n t he past acted to spur European donors. (For details on Eurasian
aid i ssues, s ee CRS Issue Brief IB95077, The Former Soviet Union and U.S. Foreign
Assistance, updated regularly.)
USAID has argued that most Eurasian s t at es have made minimal progress i n
health sector reform since t heir independence, and t hat i t will take several m ore years
before any are ready t o h ave s uch aid phased out. S ome o f t he states, i t warns, h ave
made no progress or even l o s t ground.67 In a 2001 report analyz i ng the h ealth
situation i n Euras ia, USAID judged Armenia and Georgi a as m aking t h e most
p r o g r ess (although s till inadequate) i n h ealth reforms. Kyrgyz stan was v iewed a s
appeari n g d edi cat ed t o heal t h care ref o r m d e s pi t e i t s l ack of resources, w hi l e
Az erbai j an, Turkm eni st an, Bel arus, and Taj i k i s t an were j udged as making no
progress. USAID warned t hat “n e a r - t o m ed ium-term prospect s for the Euras ian
countries are quite poor, g i v en the weak commitments o f m any o f t he countries to
undertake h ealth reforms, and t heir frail capacity to implement them.” Also,
corruption was a m aj or impediment to refo rm s , i t averred, as were conflicts in the
South C aucasus and t he diversion o f s c a r c e resources to figh t epidemics. USAID
sugge s t ed possibly committing a greater percentage of its country aid t o building
healthcare s ys tems and s tressing to the s tates t hat reforms in healthcare, governance,
and free m arkets are closely interrelated.

66 (...continued)
adequate healthcare, partly because the Russian population has not demanded it. Ukrainian
demogr apher V alentyna Steshenko has been critical that “neither the public in Ukraine nor
their l eadership” f ocus on “the preservation and improvement of public health as one of the
nation’s most i mportant priorities.” FBI S , J anuary 24, 2001.
67 USAID. Briefing on USAID Funded Health Programs I n Europe and Eurasia, M ay 2003;
Increased Health Promotion and Access t o Quality Health Care: Graduation Rep o r t,
Program Obj ective T eam 3.2, May 2001, pp. 4, 17, 24-26.

Table 1. U .S. H ealth Aid t o Eurasia
FY2001 FY2002 FY2003 FY2004
Health Health P l a nning Request
F unding F unding for H ealth ( $ millio ns)
( $ millio ns) ( $ millio ns) ( $ millio ns)
Arme nia 6.105 8.606 5.167 4.421
Azerbaij an 1.8 3 1.83 2.1
Georgi a 3.912 4.318 3.5 4.127
K a za khstan 6.4 6 6.47 5.707
K yrgyzstan 2.8 4.5 5.458 6.217
Moldova 0.4 2.913 2.533 1.758
Russia 15.075 13.615 18.1 14.5
T a j i ki stan 1.5 7.25 3.45 5.91
T urkme nistan 0.9 1.5 1.185 1.419
Ukraine 7.114 6.396 9.07 7.565
Uzbeki stan 6.2 17 6.4 8.163
Regi onal 5.633 5.6 7.665 6.244
Tot a l USAI D 57.882 80.698 70.828 72.881
Other Age ncy Health- 46.508 108.402 37.2 —
Grand Total 104.39 189.1 108.0 —
As Percent of 5.3 8.2 5.5 —
Sources: U.S. Agency fo r I nternational Development, B udgets for Health Care P r ograms in Eurasia;
FREEDOM Support Act Annual Reports, FY2000-FY2003; State Department, Office of the
Co o r d i na t o r o f U . S . Assi st a nc e t o E ur o p e a nd E ur a s i a , E U R / ACE ( P O C s: Li ni c k & K uske vi c s ) .
*O ther agency health-r elated aid inc lud e s e stimates o f P eace Co rp s activities, Dep a rtme nt o f Defe nse
ho sp ital p ackages, b io-technical re-d irection a id, a nd me dical-r elated t r a n s p o r t c osts. T he va lue o f
health-r elated privately donated cargo es is no t inc luded.

Table 2. H ealth Spending and L ife Expectancy
Co unt ry GD P Health Lif e Lif e Under-5
Per Capita Spending Expectancy Expectancy M o rt a lit y
2001 as % of 2001 M ale 2001 Fema le Ra te/1 ,000
( do lla rs) GD P (years) (years) 2001
Arme nia 2,650 7.5 66.2 73 35
Azerbaij an 3,090 2.1 60.7 66.6 105
Belarus 7,620 5.7 62.9 74.2 20
Georgi a 2,560 7.1 65.4 72.4 29
K a za khstan 6,500 3.7 58.8 67.2 76
K yrgyzstan 2,750 6 60.1 68.2 61
Moldova 2,150 3.5 64.2 71.7 32
Russia 7,100 5.3 58.9 72.3 21
T a j i ki stan 1,170 2.5 59.9 66.9 72
T urkme nistan 4,320 5.4 58.9 66.5 99
Ukraine 4,350 4.1 62.2 73.3 20
Uzbeki stan 2,460 3.7 62.7 68.5 68
Eurasia Avg. 3,893 4.7 61.7 70.1 53.2
OECD Avg. 23,363 8.4 73.8 79.9 14
Sources: GDP p e r cap ita d a ta and und er 5 mo r tality r a tes a r e fr o m the U . N . D e v e l o p me nt P r o j ect,
Human Development Report 2003. Health sp ending (based on 2000 data) and life exp ectancy data
a r e fr o m t he U . N . W o r l d H e a l t h O r ga ni z a t i o n, Wo rld Hea l t h R e p o rt 2002. TheOECDfigurefor
health sp ending is fo r 2001, and for mo rtality is fo r 1 999. See O E CD Health Data 2003,at
[ h t t p : / / www. o e c d . o r g ] .

Table 3. Tuberculosis, H IV/AIDS, STD R ates
Count ry Estima ted People New ly Drug Abuse a s a
TB , A ll Liv i ng w i t h Regist ered Percent o f t he
Ca se s, HIV/AIDS, Ca ses o f Populatio n Aged 1 5
2001 End o f Sy philis & and Above
2001 Go norrhea
per 100,000 O pia t e s C a nna bis
P o pula t io n
in 2000
Arme nia 2,906 2,400 30.8 0.3 0.8
Azerbaij an 6,623 1,400 18.2 0.2 1.1
Belarus 8,417 15,000 204 0.08 0.1
Georgi a 4,664 900 76.1 0.6 —
K a za khstan 29,188 6,000 323.2 1.1 1.3
K yrgyzstan 7,146 500 298 2.3 8
Moldova 6,407 5,500 174.8 0.06 1.8
Russia 193,363 700,000 286.1 2 3.9
T a j i ki stan 6,991 200 49.1 1.2 3.4
T urkme nistan 4,072 <100 — 0.3 0.3
Ukraine 41,225 250,000 144.8 0.9 3.6
Uzbeki stan 23,345 740 — 0.4 1.3
Eurasia 334,347 982,740 160.5 0.8 2.3
(total (total ( a vg. ) ( a vg. ) ( a vg. )
OECD 146,900 — — — 5.56
Sources: U.N. W o rld Health Orga nizatio n, WHO Report 2003: Global Tuberculosis Contro l;
UNAIDS, Report o n the Global HIV/AIDS Epid emic 2002 ; fo r sexua lly tr ansmitted d iseases, see U.N.
Chi l d r e n’s F und ( U N I CE F) , Monito ring in Centra l and Eastern Europe, the Co mmonwealth of
I n d e p e n d e n t S t a t e s a n d t h e B a ltics ( M O N E E ) o n - l i n e d a t a b a s e , a t [ h t t p : / / www. u n i c e f - i c d c . o r g ] . D r u g
abuse d ata are varying estimates made in 1998, 1999, 2000, or 2001. See U.N. Office on Drugs and
Cr ime , Global Illicit Drug Trends 2003. OECD d ata are fro m Society at a Glance 2002,and OECD
Health Data 2003 , a t [ h t t p : / / www. o e c d . o r g ] .

Table 4. R efugees and Internally Displaced Persons
Cou n try Ref u gees (as o f In tern al l y
Decemb er 31, 2002) Di sp l a ced
Arme nia 247,550 —
Azerbaij an 458 577,179
Belarus 618 —
Georgi a 4,192 261,583
K a za khstan 20,610 —
K yrgyzstan 7,708 —
Russia 14,969 371,195
T a j i ki stan 3,437 —
T urkme nistan 13,693 —
Ukraine 2,966 —
Uzbeki stan 44,936 —
Eurasia T otal 361,310 1,210,957*
OECD T o tal 2,465,000 —
Source: U.N. High Co mmissioner fo r Refugees. P opulation Data Unit. 2002 UNHCR POPULATION
STATISTI CS (PROVISIONAL), August 4 , 2003, [http://www. unhc r . c h/ c gi -b i n/ t e xi s/ vt x/ st a t i s t i c s/ ] .
*T he IDP d ata c overs p ersons who a re displaced within their c o u ntry and to who m UNHCR has
extend ed p r o tectio n a nd a s sistance. Othe r E ur asian I DP s, acco rd ing to the U.S. Co mmittee fo r
Refugees, Wo rl d Refugee Survey 2003 , inc lud e ab o ut 5 0 , 0 0 0 p e rso ns in Armenia still d isp laced b y
the Ar menian-Azer b a ij an co nflict.

Table 5. Abortion Rates and Contraceptive Use
Maternal Abortion Rates Contraceptive Us e:
Mortality/ ( a bort i o ns per 100 l i v e Al l Met hods


Country 1985-2001 1989 2000 Y e ar P ercent
Arme nia 35 34.7 34.3 2000 61
Azerbaij an 80 21.5 15.0 2001 56
Belarus 20 163.5 130.1 1995 50
Georgi a 50 75.6 37.0 2000 41
K a za khstan 65 77.5 61.7 1999 66
K yrgyzstan 65 66.3 22.8 1997 60
Moldova 28 97.3 70.5 1997 74
Russia 44 204.9 168.8 1999 73
T a j i ki stan 65 20.1 13.2 1990 21
T urkme nistan 65 31.3 22.8 2000 62
Ukraine 25 153.2 112.7 1999 68
Uzbeki stan 21 27.8 12.1 1996 56
OECD 9.2 — 26* va rious 74
Sources: Data o n ma ter nal mo r tality co me fr o m U.N. Child r e ns Fund ( UNI CEF) , Th e S ta te o f th e
Wo rld’s Child ren 2003 ; abortion r ates are from UNICE F, Monito ring in Centra l and Eastern Europe,
th e Co mmo n wea lth o f I n d e p e n d e n t S ta tes a n d th e B a ltics (MONEE) on-li ne d atabase, at
[ h t t p : / / www. u n i c e f - i c d c . o r g / ] ( d a t a f o r T u r k m e n i s t a n a n d U z b e k i s t a n a r e f o r 1999); and contraceptive
use r ates ar e fr o m t h e U . N. P o p ulatio n D ivisio n, at [ http ://unstats.un. o r g] . T he OECD d a tum o n
maternal mo rtality is fo r 1999 and is d erived fr om OECD Health Data 2003, a t [ h t t p : / / www. o e c d . o r g ] .
*Datum fo r 1995 fo r d eveloped countries (excluding Eastern Eur ope) is taken fr o m Stanley K.
Henshaw, Susheela Si ngh, and T aylo r Haas, T he Incidence o f Abortio n W orld wide, International
Family Planning Persp ectives, January 1999, Supplement, pp. 30-38.