Order Code RL30970
CRS Report for Congress
Received through the CRS Web
Health in Russia and
Other Soviet Successor States:
Context and Issues for Congress
Updated November 19, 2003
Jim Nichol
Analyst in Foreign Affairs
Foreign Affairs, Defense, and Trade Division
Congressional Research Service ˜ The Library of Congress

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Health in Russia and Other Soviet Successor States:
Context and Issues for Congress
Summary
Health issues in the Eurasian states of the former Soviet Union have received
increased U.S. attention in recent years. As part of this concern, a January 2000 U.S.
National Intelligence Estimate (NIE) highlighted global threats posed to U.S. citizens
and interests by increasing tuberculosis, hepatitis, HIV/AIDS, and other infectious
diseases outside U.S. borders. While mostly focusing on disease threats emanating
from Africa and Asia, the NIE also highlighted emerging disease threats in Eurasia.
It warned that increased political, military, social, and economic disorder in the
Eurasian states could be worsened by the spread of disease, thereby setting back their
democratic and free market reforms, and that such instability might further
complicate U.S. arms control cooperation and efforts to contain the proliferation of
weapons of mass destruction. In addition, the NIE cautioned that Eurasian militaries
and populations could face increased ill-health, harming the national security of the
Eurasian states and diminishing the effectiveness of the militaries in international
peacekeeping. Also, ill military forces and populations could become agents for the
spread of diseases among U.S. forces involved in international exercises and training
and to the U.S. homeland population.
After the terrorist attacks on the United States on September 11, 2001, the
spread of anthrax by mail later in the year, and other incidents, there were heightened
policy concerns about biological terrorism and disease threats to the U.S. homeland.
These concerns are increasingly informing the debate over health policy and aid to
Eurasia, where the major foci of U.S. policy long have been democratic and
economic reforms and arms control, and
health aid has been viewed as
complementing reforms and as justified on humanitarian grounds.
Congressional concerns about health conditions in Eurasia have been reflected
in legislative language and other actions. Although U.S. health aid for Eurasia has
long been overshadowed by other U.S. aid priorities, it increased as a percentage of
all U.S. foreign assistance to Eurasia in FY2002, partly as a response to 9/11. The
dollar amounts of health aid funded under the authority of the FREEDOM Support
Act and carried out by the U.S. Agency for International Development in FY2003
declined from FY2002 for most Eurasian countries. However, other agency and
program budgets provide health-related aid that fills this gap to some extent, but
much of this assistance tends to be focused on narrow programs such as transporting
medical cargoes, re-training scientists, or Peace Corps activities.
This report provides an overview of health conditions in the Eurasian states,
U.S. aid efforts in recent years, and issues which Congress might consider in
providing health assistance to the Eurasian states.

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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Overview of U.S. Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Post 9/11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Health in the Eurasian States:
Context and Current Developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Selected Health Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Childhood and Maternal Mortality Rates . . . . . . . . . . . . . . . . . . . . . . . 10
The Increase in Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Drug Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Alcoholism and Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Water-Borne Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Non-Medical indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Refugees and Displaced Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Orphans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
U.S. and International Health Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
International Assistance Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Issues for Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
How Significant are Health Issues in Eurasia to U.S. Interests? . . . . . . . . . 23
How Much Can the United States do to Improve Health Conditions in
Eurasia and What Types of Health Aid are Appropriate? . . . . . . . . . . 24
List of Tables
Table 1. U.S. Health Aid to Eurasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Table 2. Health Spending and Life Expectancy . . . . . . . . . . . . . . . . . . . . . . . . . 28
Table 3. Tuberculosis, HIV/AIDS, STD Rates and Drug Use . . . . . . . . . . . . . . . 29
Table 4. Refugees and Internally Displaced Persons . . . . . . . . . . . . . . . . . . . . . . 30
Table 5. Abortion Rates and Contraceptive Use . . . . . . . . . . . . . . . . . . . . . . . . . 31

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Health in Russia and
Other Soviet Successor States:
Context and Issues for Congress
Introduction
During the Soviet era, health information was closely guarded and government
health statistics highly suspect. The Soviet government proclaimed the high quality
of its socialized healthcare system. Soviet data showed numbers of hospital beds and
doctors per capita as among the highest in the world and life spans comparable to
those in other developed countries. As became more apparent after the Soviet
collapse, such data were often incomplete or falsified and covered up substantial and
growing health problems.
The Eurasian states of the former Soviet Union1 faced problems sustaining the
huge, expensive, and ineffective healthcare systems they inherited. Health conditions
seemed to deteriorate during the 1990s, as measured by life expectancy at birth,
infant and maternal mortality, drug addiction, rates of infectious disease, and other
measures. On some measures, these states now face health challenges common to
developing countries, and these challenges are hindering their economic and
democratic development, according to many observers.2
Data on health and healthcare in the Eurasian states are poor, but some general
conditions and trends may be discerned. Besides healthcare quality and access,
factors affecting health touched on but not analyzed in detail in this report include
poverty rates, conflict, living and working conditions, and the environment.
Overview of U.S. Policy
Although health issues in the Eurasian states have been a lower priority in U.S.
assistance and relations than arms control and economic and democratic reforms,
they have been a matter of U.S. concern since the early 1990s and have received
1 The Eurasian states (also termed the Newly Independent States or NIS) are generally
considered as including the Western Soviet successor states (Belarus, Moldova, Russia, and
Ukraine), the South Caucasian states (Armenia, Azerbaijan, and Georgia), and the Central
Asian states (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan).
2 According to the U.S. Agency for International Development (USAID), “the health of the
population and the capacity of the health systems to serve them have worsened in the twelve
countries of the Eurasia region,” since the countries gained independence in 1991. Budget
Justification to the Congress FY2004, Annex III, Europe and Eurasia, p. 527.

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CRS-2
increased attention in recent years. U.S. health assistance to Eurasia began even
before the collapse of the Soviet Union with a public-private medical aid program to
distribute pharmaceuticals and medical supplies to the Soviet republics. Later, the
Bush-1 and Clinton Administrations led international efforts to address needs in
Eurasia, including health needs. The 1992 FREEDOM Support Act (P.L. 102-511),
the major authorization for aid to Eurasia, included the provision of medicine and
medical supplies and equipment and other aid to create quality healthcare and family
planning services as priorities of U.S. assistance.3 In the early 1990s, however, U.S.
and Western donors lacked a clear picture of health conditions in the Eurasian states
(largely because of the mostly sanguine picture painted by Soviet health officials),
and some donors tended to assume that a short-term aid infusion would put Eurasian
health systems “back on their feet” in a short time. It later became clear that the
Eurasian states faced massive health problems that would be hard to ameliorate.
Increased attention in the United States to global disease threats included a
January 2000 unclassified National Intelligence Estimate (NIE) on the implications
for U.S. national security of rising infectious disease outside U.S. borders.
According to the NIE, infectious diseases could add to political, military, social, and
economic disorder in the Eurasian states and could set back democratic and free
market reforms.
Such instability might further complicate U.S. arms control
cooperation and efforts to contain the proliferation of weapons of mass destruction.
In addition, the NIE cautioned that Eurasian militaries and populations could face
increased ill-health, harming the national security of the Eurasian states and
diminishing the effectiveness of the militaries in international peacekeeping. Also,
ill military forces and populations could become agents for the spread of diseases
among U.S. forces involved in international exercises and training and to the U.S.
homeland population.4
Post 9/11. After the terrorist attacks on the United States on September 11,
2001, the spread of anthrax by mail later in the year, and the more recent foreign
threats of new or lesser-known diseases such as the West Nile virus and severe acute
respiratory syndrome (SARS), there were heightened policy concerns about
biological terrorism and international disease threats to the U.S. homeland and U.S.
foreign interests. In September 2002, the National Intelligence Council issued a
follow-on report to its Global Infectious Disease Threat which highlighted the threat
of HIV/AIDS and other infectious diseases in countries of strategic importance to the
3 Silk Road Act language in P.L. 106-113, signed into law in November 1999, also
authorized enhanced policy and aid to support humanitarian needs in the South Caucasus
and Central Asia, including the provision of medicines and medical equipment.
4 CIA. National Intelligence Council. The Global Infectious Disease Threat and Its
Implications for the United States, NIE 99-17D, January 2000. Russian troops serve in
seven U.N. and Organization for Security and Cooperation in Europe missions, are
“peacekeepers” in Georgia, are stationed in Armenia, Georgia, Moldova, and Tajikistan, and
serve as advisors in India, Cuba, Peru, and Syria. See Johnson’s List, March 13, 2001. See
also the NIC’s Global Trends 2015: A Dialogue About the Future With Nongovernment
Experts, NIC 2000-02, December 2000.

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United States, including Russia.5 This new report warned that infectious diseases
“exacerbate social and political instability in key countries,” and threaten the United
States, since it is a major hub of world travel with a large number of citizens residing
overseas. The report states that major means of combating the infectious disease
threat, as well as biological terrorism, include the establishment of effective global
surveillance and response systems, but that the lack of capacity, funds, and
commitment in many Eurasian states stymie such efforts.
In the Bush-2 Administration, Secretary of State Colin Powell testified in March
2001 that increased foreign affairs expenditures for child survival and diseases were
a high priority, including because HIV/AIDS is “spreading into the [new] countries
of the [former] Soviet Union,” and he termed HIV/AIDS a national security concern.6
U.S. policymaking on health issues in Eurasia involves the State Department’s
Bureau of European and Eurasian Affairs, the Office of the Coordinator of U.S.
Assistance to Europe and Eurasia, the Office of International Health Affairs, and
USAID, and the Department of Health and Human Services (HHS) and other
agencies. The Coordinator for Assistance plays a major role in integrating policy and
implementation goals, but interagency cooperation is challenged by new health
emphases such as HIV/AIDS and other changes in funding. USAID is the lead
agency in implementing healthcare aid programs in the Eurasian states. Its Bureau
of Global Health provides guidance to field offices and evaluates programs and
needs. Through interagency agreements, it works with HHS’s Europe and North
Eurasia regional bureau of the Office of Global Health Affairs, and with HHS’s
Centers for Disease Control and Prevention (CDC). The Office helps host the U.S.-
Russia Health Committee. CDC has assumed greater prominence post-9/11 in
helping to implement, often in cooperation with USAID, efforts to prevent and
control infectious diseases in Eurasia, including biological agents.7
The CDC has emphasized that combating infectious diseases in Eurasia protects
U.S. citizens at home and abroad, serves humanitarian and goodwill aims, and
buttresses the world economy, democratization, and stability. It views aid for
strengthening public health infrastructures and establishing strong infectious disease
surveillance systems 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 Intelligence Council. The Next Wave of HIV/AIDS: Nigeria, Ethiopia,
Russia, India, and China, ICA 2002-04D, September 2002.
6 The Republican Party’s 2000 campaign platform had been critical of the 2000 NIE, stating
that it had added “disease . . . to an undiminished set of existing American responsibilities”
in the world.” However, the platform also supported U.S. assistance for urgent humanitarian
needs and for combating HIV/AIDS internationally. Republican National Convention. The
Republican Party Platform 2000, July 31, 2000. Testimony of Secretary of State Colin
Powell. Senate Foreign Relations Committee, March 8, 2001; and to the Senate Budget
Committee, March 14, 2001.
7 The State Department. State Department Organization, [http://www.state.gov]; The
Department of Health and Human Services.
Office of Global Health Affairs,
[http://www.globalhealth.gov]; The White House. Office of the Press Secretary. Fact
Sheet: The President’s Emergency Plan for AIDS Relief, January 29, 2003

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projects support rebuilding or expanding the public health infrastructure in Eurasia,
and include CDC staffers in Russia, Kazakhstan, and Uzbekistan.8
Despite an enhanced focus on health programs as a percentage of U.S. aid to
Eurasia in FY2002, the most recent FREEDOM Support Act annual report
emphasizes that such aid serves humanitarian purposes and helps ensure the success
of other U.S. aid for democratization, economic reforms, and the security of the
Eurasian states, and does not appear to highlight the U.S. homeland security benefits
of such aid.9 In the State Department-USAID Strategic Plan for FY2004-FY2009,
Eurasian healthcare issues are mentioned as affecting U.S. security. While the main
rationale given for healthcare aid appears humanitarian rather than strategic, the plan
states that a healthy world will be more stable and secure and “prevent adverse
conditions from spilling across our borders.” The problem of Eurasian HIV/AIDS,
however, is not stressed as a security issue. The State Department’s Performance
Plans for FY2003 and for FY2004 do not highlight health problems in Eurasia, but
the FY2003 plan does aver that “the unmitigated spread of major virulent diseases
poses a direct threat to the American people .... The campaign against global diseases
directly supports U.S. national interests and major foreign policy goals, such as
promoting stable societies and economies.” The FY2004 plan does not explicitly
link Eurasian health to homeland security or other means to protect U.S. citizens, but
includes health among a second priority of enhancing global development.10
Congress has become increasingly concerned about the rising global threat of
infectious diseases, including HIV/AIDS, TB, and malaria, and has authorized and
appropriated funds reflecting that concern.11 Though primary attention in Congress
is focused currently on the threat these diseases pose in Africa, and much of the
increased funding is directed to African programs, there is some increased attention
to health problems in Eurasia and other regions. Members of the House Banking
Committee (H.Rept.106-548), in reporting the Global AIDS and Tuberculosis Relief
Act of 2000 (P.L. 106-264), cited the January 2000 NIE to the effect that increases
in HIV/AIDS are threatening Africa, Asia, and Eurasia. On the appropriations side,
Foreign Operations Appropriations for FY2001 (P.L. 106-429) for the first time
allocated a small amount ($6 million) to Eurasia from the Child Survival and Disease
Programs (CSD) account to combat infectious diseases.
In the most recently enacted legislation, Foreign Operations Appropriations for
FY2003 (P.L. 108-7), Congress provided not less than $60 million in FREEDOM
Support Act aid for Eurasia (in addition to other available funding) for child survival,
8 CDC. Office of Global Health. Global Health Activities Report, 1999-2000: The Work
of CDC in the New Independent States, 2001, pp. 261-282; and Protecting the Nation’s
Health in an Era of Globalization: CDC’s Global Infectious Disease Strategy, 2002.
9 The State Department. Bureau of European and Eurasian Affairs. Introduction, U.S.
Government Assistance to and Cooperative Activities with Eurasia FY2002, January 2003.
10 Implications of health problems to U.S. interests are slightly mentioned in USAID,
Foreign Aid in the National Interest: Promoting Freedom, Security, and Opportunity, 2002.
11 For information on health aid legislation in the 106th Congress, see CRS Report RL30793,
Health in Developing Countries: The U.S. Response.

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CRS-5
basic education, environmental and reproductive health, family planning, and to
combat HIV/AIDS, TB, and other infectious diseases. In addition, not less than $1.5
million was provided to meet the health and other needs of victims of trafficking in
persons. P.L. 108-7 excluded health aid from restrictions on assistance provided for
Russia and Ukraine. The conferees (H.Rept.108-10) indicated that they wanted to
sustain the momentum of the previous year on health reforms. They directed that of
the $60 million in health aid, $15 million be provided for reproductive health and
family planning, and that some aid should be used to expand primary and advanced
healthcare and to combat TB in Central Asia. As in previous years, they endorsed
the Eurasian healthcare work of the World Council of Hellenes and strongly
recommended that not less than $2.5 million be provided to help make the initiative
self-sustaining.
Besides the health assistance programs carried out by USAID under the
authority of the FREEDOM Support Act, some health-related programs are either
funded under the FREEDOM Support Act or under other agency budgets or
authorities, such as the Peace Corps, bio-technical re-direction programs carried out
to retrain former biological warfare scientists in medical and pharmaceutical fields,
the excess property program of the Defense Department, and transporting privately
donated medical aid. The CSD account provided $5.75 million in FY2003 to Russia,
Ukraine, and Central Asia to combat HIV/AIDS.
Congress has generally appeared to support health assistance that amounts to a
few percent of the overall aid to Eurasia (see Table 1 at the end of the report). Total
U.S. aid budgeted for FY1992-FY2003 for health programs in Eurasia was about
5.1% of about $24.5 billion of all aid for Eurasia. Health aid has been dwarfed by
that provided for democratization, economic reform, and arms control.
In early 2003, Rep. Barbara Boxer was among Members generally calling for
more emphasis on international health aid, arguing “the tragic events of September
11, 2001, has forced the United States to broaden its concept of threat .... U.S.
national security is buttressed by combating infectious diseases before they reach
U.S. borders, and ... is also served when diseases do not threaten global economic
growth.12 In keeping with this enhanced concern, the Senate in August 2002
approved S. 2487, the bipartisan Global Pathogen Surveillance Act.13 Although not
enacted into law by the 107th Congress, a similar bill, S. 871, was introduced in the
Senate in April 2003, and H.R. 2329 was introduced in the House in June 2003. In
introducing S. 871, Sen. Joseph Biden stressed that U.S. support for international
surveillance to detect terrorist-related or naturally occurring disease outbreaks
buttressed homeland security, since travel or other means could permit pathogens to
quickly enter the United States.14 In May 2003, S. 871 was incorporated substantially
12 Washington Quarterly, Spring 2003, pp. 199-207.
13 S. 2487 was described as lending 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 refers to the report Microbial Threats
to Health — which discusses the growth of HIV/AIDS and multi-drug resistant TB in Russia
— in stressing the need for enhanced international disease surveillance. The National
(continued...)

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into S. 1161, the Foreign Assistance Authorization Act for FY2004, as Title IV,
authorizing $35 million for FY2004 to be drawn from the Nonproliferation, Anti-
Terrorism, Demining, and Related Programs (NADR) account.
H.R. 2329,
introduced by Rep. Mark Kirk, is identical to the Senate language of S. 1161 but
authorizes $150 million over FY2004-FY2005.
In support of H.R. 1298 (P.L. 108-25), the United States Leadership Against
HIV/AIDS, Tuberculosis, and Malaria Act of 2003, Rep. Alcee Hastings and Sen.
John McCain were among those who warned that Eurasia represented a coming
HIV/AIDS crisis area that could harm global security and economics, and Sen. Jeff
Bingaman was among those mentioning this area in calling for adequate HIV/AIDS
funding.
Among other
Congressional activities, Sen. Richard Lugar visited
Uzbekistan in August 2003 and reportedly discussed healthcare aid and medical
training exchanges, including funding for efforts by U.S. and Uzbek virologists to
develop new infectious disease treatments.15 In February 2001, Rep. Curt Weldon
led a bipartisan congressional delegation to visit legislators and medical officials in
Russia, Ukraine, and Moldova, which included discussions of healthcare needs and
U.S. assistance.16 In January 2003, he stressed the need for continued healthcare
cooperation with Russia and Belarus.17
Health in the Eurasian States:
Context and Current Developments
As part of the legacy of the former Soviet Union, the Eurasian states inherited
a large centralized healthcare apparatus that provided good care for some medical
conditions but relied on outdated practices to treat other illnesses. The health of
Soviet citizens lagged behind that of U.S. and other Western populations in terms of
access to many new medical procedures and medicines and even in terms of prosaic
measures such as the number of hospitals with plumbing and heat. The healthcare
system emphasized a large number of specialized medical facilities with large staffs
and prolonged hospitalizations, rather than primary and preventive care, including
regular check-ups.
The healthcare system was isolated from changing world
standards of treatment of diseases such as TB, it followed secretive practices that
prevented the operation of a competent disease surveillance system, and it suffered
from a lack of medical supplies and equipment outside of the major medical centers.
After the Eurasian states gained independence, the new international borders
14 (...continued)
Academies. Institute of Medicine. Microbial Threats to Health: Emergence, Detection, and
Response, March 18, 2003.
15 CR, May 1, 2003, p. H3576; May 15, 2003, p. S6491; and July 10, 2003, p. S9183;
Interfax, August 19, 2003.
16 CR, February 28, 2001, pp. H485-H493.
17 CR, January 28, 2003, pp. H204-H210. See also Rep. Curt Weldon, U.S.-Russia
Partnership, 2001, pp. 22-23, [http://www.house.gov/curtweldon/usrussia].

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CRS-7
separated many medical industries from their customers and required the re-
negotiation of business relations that are still not satisfactory.
Despite this shared legacy, the Eurasian states emerged from the Soviet collapse
with varying health situations. Some of the Eurasian states had better healthcare
facilities and healthier populations than others. Many observers have viewed Central
Asia’s population as having suffered the most from inadequate healthcare during the
Soviet period. The Western Eurasian states had older populations than the Central
Asian states at the time of the Soviet collapse, reflecting differences in fertility and
mortality. Environmental catastrophe affected health in several regions, including
the Chernobyl area (radiation fallout in Ukraine and Belarus), Chelyabinsk area
(radiation contamination in Russia and Kazakhstan), Semipalatinsk (radiation from
nuclear weapons testing in Kazakhstan) and the Aral Sea area (desertification in
Kazakhstan and Uzbekistan).18 The Eurasian states also differed in their rates of
economic decline during the 1990s, and in such related issues as healthcare funding,
the diets of the people, and living conditions, which affected infant survival and life
expectancies. Conflicts in Eurasia also damaged health, leading to casualties,
injuries, orphans, and displaced persons who suffered physically and psychologically.
Health challenges in all the Eurasian states loom larger because of the very low
percentages of gross domestic product (GDP) they have devoted to healthcare. Table
2 shows GDP per capita in the Eurasian states and the percent going to health. Health
spending levels are low in the Eurasian states in comparison to the more than 8% on
average spent in the Organization for Economic Cooperation and Development
countries (OECD; composed mostly of European countries and the United States).
In most of the Eurasian states, central governments have devolved much fiscal and
operational responsibility for healthcare to cash-strapped and ill-prepared localities,
resulting in chronic under-funding and the heavy reliance on legal or under-the-table
user fees to obtain healthcare. In Armenia and Georgia, most healthcare is paid for
privately. The juxtaposition of low government spending for healthcare and high
poverty rates mean that large percentages of the populations throughout Eurasia, and
particularly in Central Asia, cannot afford to pay for healthcare.
In the post-Soviet era, demographers have been able to scrutinize previously
suppressed health data and conduct analyses that suggest that some aspects of the
health crisis in Russia and other Eurasian states can be traced back to the 1960s. A
major indicator of overall health, life expectancy, peaked in the 1960s and began a
downward trend in Russia and other republics of the former Soviet Union by the late
1960s, perhaps caused by an increase in alcoholism, violence, tobacco use, and poor
diet. Another peak occurred in the mid-1980s (mostly attributed to government
restrictions on alcohol consumption), followed by a decline that deepened after the
Soviet breakup, though life expectancy in most Eurasian states began to rise again
18 Christopher Murray and Jose Bobadilla, in Premature Death in the New Independent
States, Washington, D.C., National Research Council, 1997, pp. 184-219. Other notable
overviews include Murray Feshbach and Alfred Friendly, Jr., Ecocide in the USSR, New
York, Basic Books, 1992; Murray Feshbach, Russia’s Health and Demographic Crises,
Chemical and Biological Arms Control Institute, April 2003; and Laurie Garrett, Betrayal
of Trust, New York, Hyperion, 2000.

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after the mid-1990s. Nonetheless, life expectancy remains lower than in most
European states. Life expectancy for males in the Eurasian states in 2002 is 62 years
(See table 2). This compares unfavorably to 74 years for males from countries
belonging to the OECD, and 72 years for U.S. males.19
Some policymakers and analysts have warned that adverse health trends in
Russia — “unprecedented for an urban, literate society in the 21th century” — are
contributing to a dwindling population, limiting its economic potential, and
“reducing its influence on the international stage.” Some even warn that such trends
may raise the specter of political disintegration and the subsequent establishment of
authoritarian rule hostile to Western interests.20 Major causes of bad health in Russia
include cardiovascular disease, cancer, untreated chronic illnesses (high blood
pressure, diabetes, high cholesterol), alcoholism (contributing to homicide, vehicular
accidents, and suicide), drug abuse, and infectious disease. The threat of large
increases in HIV/AIDS, hepatitis, and TB could further depress life expectancy.
Although births in Russia may have increased in 2003, perhaps partly because of an
improved economy and a larger cohort of females aged 20-29, deaths continued to
outpace them.21
Russia has only begun to address systematic healthcare reforms. Hospitals and
clinics remain largely government-owned, though there are private physicians and a
private health insurance industry. Compulsory payroll contributions for healthcare
began in 1993, but basic public health issues involving sanitation, pharmaceuticals,
vaccinations, ambulances, and the distribution of medical staff countrywide remain
unresolved. While Russian policy and U.S. aid programs have emphasized the
theoretical economic benefits of decentralization of healthcare to the regions, some
health experts have argued that decentralization has harmed healthcare, at least in the
short term, in part because many public health issues are not fully addressable at the
regional level.22
Perhaps reversing what some observers have termed a policy of “malign
neglect” of health issues by the Russian government, President Vladimir Putin in his
2001 state-of-the-nation address criticized the lack of fundamental reforms of the
19 Russia’s demographic problems, however, are attributable not only to declining health,
but also to population dynamics, including the ripple effects of World War II and evolving
family planning attitudes. See U.S. Department of Commerce. Bureau of the Census. Ward
Kingkade, Population Trends: Russia, International Brief IB/96-2, February 1997; George
Demko, Grigory Ioffe, and Zhanna Zayonchkovskaya, eds., Population Under Duress,
Boulder, CO: Westview Press, 1999, pp. 9, 24-27, 48, 55-56; Murray Feshbach, Woodrow
Wilson Center talk, May 12, 2003.
20 Nicholas Eberstadt, Kennan Institute, February 5, 2001; Demko, p. 63; Murray Feshbach,
Washington Quarterly, Winter 2001, p. 16-18.
21 Interfax, July 18, 2003; The data on increased births is questioned by Murray Feshbach,
Johnson’s List, November 5, 2003.
22 Diane Duffy in Vicki L. Hesli and Margaret H. Mills, eds., Medical Issues and Health
Care Reform in Russia, Lewiston, N.Y., Edwin Mellon Press, 1999, pp. 47-48, 52-53;
United Nations.
World Health Organization.
Highlights on Health in the Russian
Federation, November 1999, p. 23.

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Soviet-era healthcare system, the lack of federal and local budgetary support for
healthcare, inadequate functioning of the insurance system, and the widespread
demand by state hospitals and doctors for illicit under-the-table payments. In his
state-of-the-nation address in 2003, Putin pointed to increasing birth rates and
progress in lowering infant mortality as positive trends, but decried increasing death
rates attributable to illness and injuries. He stated that the government was moving
to strengthen the medical insurance system to reduce the inequalities of the present
system.23 Putin’s concerns were reflected in the trebling of the budget for healthcare
in 2000-2003, and plans for $35 billion rubles ($1.17 billion) for healthcare in 2004.
In 2001, Russia launched an annual survey of children’s health, and in 2003 Putin
ordered checkups for 34 million children.
Faltering healthcare in Central Asia has been reflected in decreasing life spans,
high infant and maternal mortality rates, and increases in cardiovascular/circulatory,
parasitic, infectious, and respiratory diseases. While the spread of TB and hepatitis
in Central Asia is most worrisome, the U.N. office coordinating U.N. interagency and
international aid efforts on HIV/AIDS (the Joint United Nations Program on
HIV/AIDS, or UNAIDS) has pointed to rising HIV/AIDS rates in Kazakhstan and
elsewhere in Central Asia as a global concern.24 Poor sanitation and increasing drug
abuse, tobacco and alcohol use, malnutrition, diet deficiencies, and tainted blood
supplies contribute to declining health. Healthcare reforms have focused on making
the healthcare system more efficient by closing excess hospitals and other means.
Efforts to obtain more funding through taxes and payroll deductions have been
disappointing, resulting in a heavy reliance on user fees for service. Tajikistan
altered its constitution in a referendum in June 2003 to remove a provision
guaranteeing free healthcare, because “in reality,” the government explained, the
majority of patients were required to pay for care and medicines. Only in Kyrgyzstan
has a compulsory health insurance plan had some success.25 Kyrgyzstan has made the
most progress in healthcare reform (though its fragile economy places them at risk),
and Tajikistan and Turkmenistan the least. The health consequences of poor quality
healthcare seriously constrain economic development in the region, according to
many observers.26
23 Putin had received a government report in January 2003 that estimated that only 31% of
medical services were covered by state insurance, and that the insurance program was
shockingly mis-managed. FBIS, January 27, 2003, Doc. No. CEP-245.
24 UNAIDS. Fact Sheet 2002: Eastern Europe and Central Asia, January 12, 2002.
25 Farangis Najibullah, RFE/RL, March 29, 2003.
26 Martin McKee, Judith Healy, and Jane Falkingham, eds., Health Care in Central Asia,
Buckingham, UK: Open University Press, 2002, pp. 179-193. In a concluding chapter, these
authors suggest that international efforts to foster gradual healthcare reforms will be most
effective, although other observers advocate more rapid reforms.
See also USAID,
Infectious Disease Assessment, pp. 1-2; USAID, Health Program Review: Central Asia:
September-November 1999, p. 2; Kevin Rushing, USAID Central Asian Republics Desk
Officer, Paper, Panel on Public Health and Environmental Issues, Harvard Colloquium on
International Affairs, March 11, 2000.

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Selected Health Indicators
By looking at how a country measures up in certain categories of health over
time, it is possible to get a picture of the health situation in that country.
Unfortunately, another legacy of the Soviet healthcare system is the lack of reliable
health statistics. The Soviet Union did not follow U.N. World Health Organization
(WHO) methods for coming up with birth, death, and other data and the Eurasian
states are at various stages in implementing WHO data standards, making it difficult
to compare many health indicators across Eurasia and with other countries.
Reputable international organizations may not agree with each other’s estimates, such
as the U.N.’s Human Development Report and the World Bank’s World Development
Report. This report usually uses statistics from U.N. agencies. Although the U.N.
agencies rely on government-provided data, they sometimes prefer their own
estimates, and an estimate by one agency may not match that of another. The
statistics used in this paper should be used only as a general view of the situation in
and among the Eurasian states and should not be assumed to be directly comparable
to U.S. or European health statistics.
Most observers agree that the early 1990s saw major declines in health in
virtually all Eurasian states in terms of such measures as infant mortality, alcoholism,
and cardiovascular disease. The Central Asian states suffered the greatest declines
in Eurasia in life expectancy, increased morbidity, deterioration of conditions in
hospitals and other health facilities, and failures to control and prevent infectious
diseases. From 1995 onward, as Eurasian economies began to stabilize, there were
improvements (or slowing declines) in these health conditions. Concerning other
problems, such as infectious diseases, tobacco use, and drug addiction, the situation
has become worse in many of the states. By most measures, health in the Eurasian
states in 2003 continues to lag behind that in most developed countries.
Childhood and Maternal Mortality Rates. Table 2 shows mortality rates
for children under five years of age. According to USAID, increasing mortality rates
in the Eurasian states among children under five years old are telling signs of the
deterioration of healthcare and the plight of many families suffering from poverty and
malnutrition.27 USAID estimates that mortality rates for children under five years of
age increased in all the Eurasian states over the period 1990-1997, the worst record
in all its geographic bureaus.28 Maternal mortality rates are much higher in the
Eurasian states than in many other European countries (see Table 5). Causes include
poor nutrition, lack of maternal care, and extremely high rates of abortion, compared
to the United States and most of Europe. High rates of abortion and maternal
mortality are being reduced in several Eurasian states by education and access to
other contraceptive methods (Table 5). In Russia, concerns about morality and
27 Infant mortality is generally used to determine the overall health of a country. However,
because most of the Eurasian states still use the Soviet system of measuring infant mortality,
which undercounts deaths, this report 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, July 2000, p. 56; Broadening the Benefits of Reform,
p. 11, from U.S. Census Bureau data.

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CRS-11
population decline led the government in 2003 to propose banning many abortions,
and the legislature to cut off funding for family planning clinics.29
Childhood vaccination rates in Eurasia declined dangerously in the late 1980s
and early 1990s, contributing to a diphtheria epidemic in the early 1990s. By the
mid-1990s, this epidemic accounted for 90% of worldwide cases. Ukraine, Russia,
and Tajikistan were hardest hit. The Bush-1 Administration and USAID collaborated
with WHO in delivering vaccines and the United States later advocated international
donor assistance for childhood immunizations. By the latter 1990s, diphtheria cases
had declined greatly, as had some other childhood diseases, but still-inadequate
vaccination rates raise the threat of new outbreaks.30
A report issued by UNICEF in July 2003 indicated that infant mortality rates in
many Eurasian states were “considerably higher” than data provided by Eurasian
governments, and warned that its findings pointed to a “child survival crisis” in the
South Caucasus and Central Asia. The widest discrepancies between UNICEF’s
estimates and official data for the 1990s were found in Azerbaijan (where the
estimate was 74 infant deaths for every 1,000 live births versus an official rate of 17
per 1,000), Georgia (43 versus 16), Kazakhstan (62 versus 24), and Turkmenistan (74
versus 33). UNICEF’s Executive Director, Carol Bellamy, stated that such “flawed
[official] statistics are a danger to children,” because they keep “governments and
health workers and even parents in the dark on the true nature of the threats to child
survival.” A report on surveys issued by the U.S. Department of Health and Human
Services in April 2003 came to similar conclusions regarding Eurasian government
data on infant mortality.31 Perhaps partly in response to the international critiques,
Uzbekistan decided to implement the WHO standards for reporting infant mortality.
The Increase in Infectious Diseases. The sharp deterioration of the
health infrastructure due to economic conditions has contributed to a dramatic
increase in infectious disease cases. Increasing levels of infectious diseases such as
TB, HIV/AIDS, and malaria have raised great concerns from the international
community. Statistics for the Eurasian states provided by UNAIDS and the WHO’s
29 The proposed restrictions on abortions after the twelfth week of pregnancy have fueled
much debate. Russia’s Human Rights Ombudsman protested that the proposal overly
limited women’s freedom of choice. Financial Times Information, June 12, 2003. One
commentator argued for retaining abortion guidelines already in place, which include
whether the mother is able or can afford to care for the baby, warning that Russia’s large
orphan population otherwise could vastly increase. FBIS, September 2, 2003, Doc. No. 162.
See also FBIS, August 26, 2003, Doc. No. 110; and New York Times, September 2, 2003.
30 A recent increase in diphtheria cases in Russia led to a June 2003 announcement by public
health officials that all adults and children would be inoculated over the next two years.
ITAR-TASS, June 25, 2003.
31 UNICEF. Innocenti Report Monitor: A Region Fit for Children? July 22, 2003. The
UNICEF analysis included 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, Maternal, and Child Health in Eastern
Europe and Eurasia, April 2003, pp. 167-171; and a CDC report on Kazakhstan in
Pediatrics, May 2003, pp. 596-600.

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“Stop TB” program are generally regarded as reliable. Comparable statistics for
other infectious diseases are not available. Table 3 shows the number of new cases
of TB and the numbers living with HIV/AIDS. Although HIV/AIDS is currently
spreading throughout Eurasia largely among injecting drug users, rising rates of
sexually transmitted disease (STD) are a worrisome sign that HIV/AIDS may spread
into the general population.
Tuberculosis. TB, including drug-resistant TB, appears to be increasing in
most of the Eurasian states because of poor living conditions and inadequate
treatment. Drug-resistant TB can be extremely costly to treat, further burdening
already strained healthcare finances in the Eurasian states.32 The WHO ranks Russia
among the top ten countries worldwide in terms of new cases of TB, and at the
bottom (along with Afghanistan) among twenty-two countries with high TB rates that
falter in using an effective TB treatment termed the Directly Observed Treatment
Short-course (DOTS). WHO estimates that DOTS treatment was available to less
that one-third of the population at the end of 2002. In 2001, Russia refused a World
Bank loan to fight TB and HIV/AIDS, apparently because it did not wish to increase
the amount of its debt. However, it accepted the aid in 2003 and has worked with
USAID and WHO to disseminate DOTS and DOTS-Plus more widely and integrate
the treatment into the general healthcare system.33 The dramatic increase of drug-
resistant TB in Russia was fueled by the release, through amnesties or the completion
of sentences, of tens of thousands of prisoners with TB into the general population.
Also, convicts with the final stages of TB (or cancer or AIDS) have been released on
humane grounds, possibly spreading the disease. The Russian Health Ministry has
announced that Chechnya and surrounding areas with high numbers of displaced
persons have become a major locus of drug-resistant TB.
TB rates in all the Eurasian states except Armenia are higher than in the rest of
Europe. The highest numbers of new cases besides Russia are in Kazakhstan,
Ukraine, and Uzbekistan.34 USAID’s support for DOTS in Kazakhstan may have
contributed to a significant 37% decline in TB mortality from 1998 to 2001. USAID-
supported DOTS programs now reportedly cover 52.7% of the Central Asian
population, more than are covered in Russia.
HIV/AIDS. Although the actual numbers are still seemingly small, compared
to Africa and parts of Asia and Latin America, Eurasia has the fastest rate of growth
of HIV/AIDS infection in the world, amounting to about one million cases in 2002.
During the 1990s, the Eurasian states witnessed growth in injecting drug use,
prostitution, and population mobility that spread HIV/AIDS, but many of the
32 The burden of TB in Russia is estimated to have cost society over $4 billion in 1999.
United States Senate.
Committee on Foreign Relations. Statement by Dr. David L.
Heymann, Executive Director for Communicable Diseases, World Health Organization,
September 5, 2001.
33 WHO. WHO Report 2003: Global Tuberculosis Control, January 2003, pp. 105-107; FSA
Annual Report FY2002.
34 The rate of multidrug-resistant TB in Uzbekistan is among the highest in the world,
attributable in part to the collapse of the traditional healthcare system. Lancet, March 1,
2003, pp. 714-715.

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governments have been slow in responding to the HIV/AIDS threat. HIV/AIDS
infection rates in Ukraine are the highest among the Eurasian states and the highest
in Europe, according to the UNAIDS, and infection recently has spread widely into
the larger population through heterosexual transmission. UNAIDS also reported
“explosive growth” in infection rates in Uzbekistan in 2002.35
The number of confirmed cases of HIV/AIDS in Russia has greatly expanded
from the end of 1998 to the end of 2002, from about 11,000 to more than 700,000
cases. UNAIDS warns, however, that inadequate diagnosis and reporting may mean
that the actual incidence in Russia is underestimated by a “large margin.”36
HIV/AIDS appears to be spreading rapidly in Russia among intravenous-drug users,
prostitutes, and prisoners, threatening a breakout into the wider population. At the
same time, the Russian government appears to still follow a policy of “malign
neglect” regarding HIV/AIDS by spending only $6 million a year on the disease
(compared to larger sums spent by international NGOs), although effective
prevention and treatment would require sums larger than the present health budget.37
The U.S. State Department warns that rising numbers of AIDS cases in Russia
threaten economic growth there (since funds will need to be shifted from investment
to healthcare), and adds to deaths among the working age population, hastening the
aging of the population.38 At the September 2003 U.S.-Russia summit, Presidents
Bush and Putin pledged to step up collaboration on research, treatment, prevention,
and diagnostics to combat HIV/AIDS. The two Presidents endorsed the efforts of a
newly formed NGO, the Transatlantic Partners Against AIDS, which had urged that
the disease be discussed at the summit. At a conference in Moscow in May 2003
35 Among the security implications of the spread of HIV/AIDS, Analyst Justin Redulson has
warned that Central Asia’s military forces would be expected to be highly vulnerable to
increasing rates of HIV infection in the larger population, weakening military readiness.
RFE/RL Daily Report, July 20, 2003.
36 UNAIDS. Fact Sheet 2003: Commonwealth of Independent States, March 19, 2003. An
UNAIDS survey of injecting drug users in the Russian city of Togliatti in late 2001 found
that three-quarters of the users were unaware 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. The National
Intelligence Council has suggested that HIV/AIDS infections in Russia could rise to 5-8
million by 2010, about 6-11% of the adult population. Global Infectious Disease Threat,
September 2002.
37 Nicholas Eberstadt, The Future of AIDS, Foreign Affairs, November-December 2002, pp.
22-45.
38 State Department. Bureau of European and Eurasian Affairs. Background Note: Russia,
May 2003. Among security implications of the spread of HIV/AIDS, one in three Russian
military recruits reportedly is rejected for drug-related hepatitis or HIV/AIDS, although
screening is hit-or-miss because of the expense of testing all recruits. According to analyst
Mark Schneider, there is a danger that HIV-positive Russian soldiers who need money for
treatment and have access to nuclear materials might be tempted to steal and sell such
materials. Mark Schneider and Michael Moodie, The Destabilizing Impacts of HIV/AIDS,
May 2002, available online at [http://www.csis.org/africa/0205_DestImp.pdf]. See also
Radhika Sarin, A New Security Threat: HIV/AIDS in the Military, World Watch, March-
April 2003, pp. 16-22.

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attended by Secretary Powell, who highlighted the U.S. concern, the NGO warned
that Russia has become a world epicenter of new HIV/AIDS cases.39
Seven Eurasian states in 2003 reportedly have received aid from the U.N.’s
Global Fund to Fight AIDS, Tuberculosis and Malaria, including Kyrgyzstan ($4.9
million), Moldova ($5.2 million), Tajikistan ($1.5 million), Ukraine ($24.9 million),
Armenia ($3.1 million), Georgia ($4.0 million), and Kazakhstan ($6.5 million). The
United States is a major donor to the Global Fund. There have been some belated
efforts at cooperation among the Eurasian states, including the launch of the Program
of Urgent Response to HIV/AIDS by the Commonwealth of Independent States.
Drug Addiction. All of the Eurasian states face increased drug use, with the
greatest estimated increases in Russia, Ukraine, Turkmenistan, and Uzbekistan. In
all of the Eurasian states, demand reduction efforts are inadequate, according to the
U.S. State Department’s International Narcotics Control Strategy Report, because
of inadequate budgets, inadequate treatment services in rural areas, and a lack of
focus on drug use prevention by officials. Table 3 presents some drug abuse data
derived from government estimates. Some observers suggest that actual rates may
be much higher.
Drug treatment is poor or lacking in most of Eurasia, and where available,
mainly entails involuntary confinement after arrest.
Treatment consists of
detoxification with little or no follow-up rehabilitation efforts. Laws are mostly
aimed at interdiction and punishment of drug traffickers and users, and drug users
avoid seeking treatment out of fear of arrest. The 1998 Russian narcotics law, which
provides for the involuntary commitment of drug users who come to the attention of
the authorities, is criticized by many observers for preventing most addicts from
seeking treatment. In major cities in Tajikistan and Kyrgyzstan, heroin is cheaper
to buy than vodka, according to the nongovernmental Open Society Institute,
threatening to lead to much higher future drug addiction rates in these Eurasian
states.40 Religious and non-governmental organizations have opened several drug
rehabilitation centers throughout Ukraine.
High-level attention to the drug problem in Russia was demonstrated in March
2001, when Premier Mikhail Kasyanov convened a government commission to study
increasing drug abuse and HIV/AIDS cases among youth. He warned that Russia had
changed from a drug transit country to a consumption country, and that organized
crime was increasingly involved in the drug market.
Recognizing that a
comprehensive counternarcotics strategy must be adopted that embraces demand
reduction and rehabilitation as well as law enforcement, Russian officials have met
39 The White House. Fact Sheet: U.S.-Russian Cooperation on HIV/AIDS, September 27,
2003. Transatlantic Partners Against AIDS, On the Frontline of an Epidemic: The Need for
Urgency in Russia’s Fight Against AIDS, September 2003.
40 Matthew Curtis, Eurasianet, February 21, 2001 and March 2, 2001; Open Society
Institute, International Harm Reduction Project, Uncovering the Dangers of Drug Use in
Kazakhstan, Kyrgyzstan and Tajikistan; Peak Options Consulting, for the Open Society
Institute, Summary of Fact Finding Mission to Kyrgyzstan, March 1, 2001; U.N. Office of
Drugs and Crime, Global Illicit Drug Trends 2003, 2003.

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with the U.S. Office of National Drug Control and Prevention to discuss how to set
up an analogous agency. In March 2003, Russia established a State Committee on
Drug Trafficking, with a planned staff of 40,000, to investigate drug trafficking and
related crimes. Its chairman, Viktor Cherkesov, has asserted that there are about four
million regular drug users and addicts in Russia, reflecting a 23-fold increase in the
use of heroin and a ten-fold increase in the use of cocaine over the past five years.41
Alcoholism and Smoking. Alcohol consumption in Russia and many other
Eurasian states remains much higher than in most of the world. Russian observers
have stressed that alcoholism is linked to other causes of increased mortality in
Russia, including traffic accidents and injuries (homicides and suicides). Alcohol
consumption in Russia declined briefly in the mid-1980s as a result of a sobriety
campaign, but rose thereafter. Beginning in 1993, there was a large increase in male
alcohol poisoning in Russia, along with increases in male homicide and suicide and
in circulatory and respiratory diseases.42
According to the WHO, smoking in most of Eurasia continued to increase
during the 1990s. In Russia, the majority of adult males smoke, with many starting
at young ages, while in the countries belonging to the European Union (EU), rates of
smoking are declining. Smoking has been linked to high percentages of male deaths
among those aged 35-69 in Russia, Kazakhstan, Ukraine, Armenia, and Belarus, rates
that are substantially higher than in the United States.43 In 2003, Georgia and
Ukraine introduced restrictions on tobacco advertising.
Water-Borne Disease. Deteriorating water and sewer systems (often water
and sewer pipes are co-located), in conjunction with other causes such as injecting
drug use, are linked to large increases in the incidence of hepatitis, cholera, and
typhoid fever throughout Eurasia. Ukrainian media reported that hundreds of people
in the Luhansk region contracted viral hepatitis type-A in mid-2003 from
contaminated drinking water. In Chechnya, cholera as well as intestinal diseases are
common because sewer systems are nonfunctional in the regional capital of Grozny.
Hundreds of children in Irkutsk, Russia were reported to have contracted
enteroviruses leading to meningitis in July-September 2003, possibly traceable to
leaking sewers (then spread person-to-person), leading to the vaccination of 75,000
children against polio (a type of enterovirus).44
41 Interfax, June 26, 2003; BBC Global News Wire, June 30, 2003, July 1, 2003; RFE/RL
Daily Report, July 3, 2003; FBIS, September 10, 2003, Doc. No. CEP-64.
42 Vladimir Treml, in Herlemann, pp. 151-162. According to Russian analysts Vladimir
Shkolnikov and Alexander Nemtsov, “in the period from 1988-1992, the biggest share of
the increase in Russian mortality was attributable to alcohol consumption.” Premature
Death in the New Independent States, pp. 232-233, 240-241, 256; Feshbach, Washington
Quarterly, p. 19; FBIS, January 28, 2003, Doc. No. CEP-161; Interfax, February 18, 2003.
43 United Nations. World Health Organization. Highlights on Health in the Russian
Federation, November 1999, p. 19; Premature Death in the New Independent States, pp.
274, 275-286, 287-313.
44 BBC Global News Wire, July 4, 2003; on the Irkutsk outbreak, see FBIS, September 2,
2003, Doc. No. 82; FBIS, September 6, 2003, Doc. No. 16. A similar outbreak in Omsk,
(continued...)

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Non-Medical indicators
Increasing numbers of people in Eurasia belong to subgroups that face special
health needs, including orphans, refugees, and the internally displaced.
Refugees and Displaced Persons. Eurasian health conditions have been
impacted by the large number of persons forced from their homes by warfare and
discrimination since the breakup of the Soviet Union. The U.N. High Commissioner
for Refugees has estimated that during the 1990’s as many as nine million people left
their homes in Eurasia. These included refugees who fled their country’s warfare,
those displaced within their own country by war or returned from exile to find their
homes and communities destroyed, and those forced to leave their homes, denied
citizenship or declared aliens in their homeland under new residence or citizenship
laws. Lack of routine health care and immunization, poor food and sanitation,
exposure to disease, and violence against vulnerable groups all result in declines in
health among those living in crowded refugee camps or makeshift housing.
International humanitarian assistance to victims of either warfare or natural disasters
always includes emergency health care and some routine preventive health assistance,
aid which does not necessarily improve the overall health picture in a country but
does address life threatening health needs.
Major humanitarian emergencies caused by conflict have occurred in Armenia,
Azerbaijan, Georgia, Russia, and Tajikistan. During the 1990s, conflict resulted in
the exile or displacement of over 1.5 million Armenians, Azerbaijanis, Georgians,
and Chechens and other residents of Russia, according to the U.N. High
Commissioner for Refugees.45 Other population shifts have included ethnic Russians
leaving former republics where they are ethnic minorities and returning to Russia (3
million between 1992 and 1996), and Crimean Tatars returning to their homeland in
Ukraine (250,000 between 1988-1999). While aid agencies have responded to the
urgent health needs of the refugees and some of the displaced, their longer-term
health needs are harder to address, particularly if the refugees and displaced face
inhospitable living conditions and limited access to local healthcare facilities. Table
4 shows the current estimates of refugees and displaced in Eurasia.
Orphans. According to UNICEF, the numbers of children aged 0-3 years
placed in orphanages greatly increased in all the Western Eurasian states and in
Kazakhstan over the period 1991-1998, from an average of 165 children per 100,000
population in 1991 to an average of 304 children in 1998 for these Eurasian states.
The number of such children in 1998 in other Eurasian states was substantially lower,
about 39 per 100,000. While numbers of institutionalized children have been
growing, declining public funding has led to increasingly poorer care.
The
orphanages in Eurasia, unlike in most of Europe, often include children with birth
defects, mental disabilities, and chronic health conditions. USAID and international
44 (...continued)
Russia led to vaccinations in September 2003 for 30,000 people. FBIS, September 2, 2003,
Doc. No. 54.
45 United Nations. High Commissioner for Refugees. The State of the World’s Refugees
2000, p.185-209.

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donors have increasingly provided assistance, including urgent and other healthcare.
In Russia, USAID and other donors have encouraged the establishment of a foster
care system to replace orphanages and community-based services so that parents can
continue to care for their challenged children. The numbers of homeless and street
children in Russia and other Eurasian states reportedly also have expanded, and these
children are helped only on an ad hoc basis by existing healthcare programs and most
international aid.46
U.S. and International Health Aid
Soon after the Soviet collapse, USAID focused on healthcare reforms in Eurasia
as one of its objectives. It developed the Hospital Partnership Program, to be carried
out by a newly created American International Health Alliance (AIHA), as its major
public-private vehicle for aid efforts focusing on educational activities and
professional exchanges by U.S. medical volunteers. A related Health Reform Project
by USAID launched in 1993 focused on the reorganization of healthcare institutions
and financing in the Eurasian states, to “increase economic efficiencies, quality of
care, access, and provider choices ... through market-oriented reforms.” These
changes have faced obstacles in Russia and other Eurasian states, including resistance
from Soviet-era healthcare establishments and officials and skyrocketing poverty
rates, which have placed fee-for-service healthcare out of reach for many people.47
However, the changes are seen by USAID as essential to the ability of the healthcare
systems to modernize and function on their own without ongoing international donor
assistance.
The Clinton Administration asked Congress in 1997 to begin supporting a new
“Partnership for Freedom” initiative as part of boosted Eurasian assistance that would
emphasize grass-roots economic and social reforms, including health. Additional aid
was sought for hospital and health facility partnerships, programs to combat
infectious diseases, and efforts to bolster clean water supplies, childhood survival,
and maternal health.48 The request for a large boost in Eurasian aid was not
46 United Nations. United Nations Children’s Fund. Young People in 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; FBIS,
June 11, 2003, Doc. No. CEP-183; FBIS, July 18, 2003, Doc. No. CEP-319. Russian law
enforcement reportedly has cracked down on “wayward” homeless children, sending some
to shelters and orphanages. ITAR-TASS, January 28, 2003.
47 Edward Burger, Jr., in Russia’s Torn Safety Nets, ed. by Mark Field and Judyth Twigg,
New York, St. Martin’s Press, 2000, pp. 291-292; About AIHA, see [http://www.aiha.com].
Burger criticizes the Health Reform Project as “clearly out of phase with the political and
economic realities of the time in Russia.”
48 Spurring these emphases, conferrees on Foreign Operations Appropriations for FY1997
(H.Rept.104-863) had criticized the Administration for not including health and
environmental health as Eurasian aid priorities, and had urged that the treatment of
childhood illnesses in Ukraine related to Chernobyl supercede other aid objectives.

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supported by Congress, but many of the programmatic emphases, including health
aid, were endorsed.49
Building on the “Partnership for Freedom” initiative, USAID increasingly
emphasized social needs in Eurasia. USAID came to argue that economic reforms
in the Eurasian states had not always contributed to the growth of middle classes, and
also helped create “a new class of chronically poor,” who lost the meager state
benefits they received under communism. While democratization and economic
reforms remained U.S. objectives, USAID stressed that without adequate healthcare
and other social services, populations in the Eurasian states would lose faith in the
reform process. USAID stated that it would increasingly take social issues into
account in designing and implementing programs, so that “the broadest possible
spectrum of [Eurasian] citizens...have the opportunity to enjoy the benefits of
reform.”50
In keeping with the new emphasis, USAID’s assistance activities in recent years
have been divided into three broad strategic areas, economic, democratic, and social
transition or global health. The objectives of social transition assistance include
improving Eurasian health and other social benefits and services. USAID healthcare
goals included helping the Eurasian states to draw up healthcare and insurance
legislation and policy focusing on community-based primary health care; to improve
the cost-effectiveness of healthcare budgets; to improve the quality of healthcare; to
educate citizens about their personal healthcare rights and obligations; and to reduce
environmental and occupational health risks. Since 9/11, more health aid has been
dedicated to Eurasian states under the rationales of buttressing their ability to conduct
the war on terrorism, fostering democratization and free market reforms, and
ensuring their stability, but such aid usually has not been explicitly linked to potential
health threats to the U.S. homeland.
USAID provides the largest share of U.S. health aid to Eurasia, though notable
amounts are also provided by the Defense, Health and Human Services, and Energy
Departments and the Peace Corps (see text box). Table 1 shows the amount of health
aid to the Eurasian states provided or proposed for FY2001-FY2004. Before 9/11,
health aid held fairly steady at about 5% or less of Eurasian funding from FY1998
through FY2001. For FY2002, funding rose to 8.2%, which included emergency
supplemental funds for health amounting to $19.55 million. These funds bolstered
programs in the “front-line” Central Asian states (Kyrgyzstan, Tajikistan, and
Uzbekistan) and Armenia, and to a lesser degree in several other Eurasian states. The
percentages of Eurasian aid devoted to health appear to be slightly higher than the
historical average in FY2003 and as requested in FY2004, perhaps reflecting a
49 CRS Report RL30148, U.S. Assistance to the Soviet Union and Its Successor States
1991-2001.
50 USAID, Budget Justification FY2001, Annex III, Europe and Eurasia, p. 9. See also
USAID, Broadening the Benefits of Reform in Central and Eastern Europe and the New
Independent States: A Social transition Strategy for USAID, Bureau for Europe and Eurasia,
February 2000, pp. 8-9, 23-24.

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CRS-19
greater U.S. emphasis on health
Cumulative Funds Budgeted FY1992-FY2003 for
reforms in Eurasia despite aid
Health and Related Programs in Eurasia
constraints.
(FREEDOM Support Act and Other Funds)
(million dollars)
The
largest
amounts
of
USAID Global Health
576.98
Presidential Medical Initiative
5.0
USAID health aid have been
Coordinator’s Office transport costs
234.2*
provided
to
Russia,
Ukraine,
Defense Department Excess Defense
Kazakhstan,
Uzbekistan,
and
Articles: Hospitals and Related
294.8
Armenia, partly reflecting broad
Peace Corps Health Initiatives
38.0**
U.S. policy interests in these states.
Bio-technical Redirection
86.9
Global AIDS Fund
2.5
Within each Eurasian state, the
Subtotal U.S. Government Health Aid
1,238.4
percentages of U.S. aid devoted to
Coordinator’s Office: Value of privately-
health
as
opposed
to
other
donated cargoes transported
1,928.3*
programs have been highest in the
Total
3,166.7
Central Asian states in recent years
Sources: State Department, Office of the Coordinator
(usually
more
than
10%),
of U.S. Assistance to Europe and Eurasia (EUR/ACE:
reflecting heightened U.S. concern
Linick & Kuskevics); FREEDOM Support Act Annual
about poor healthcare situations
Reports for FY1993-FY2002; The Peace Corps,
and the need to bolster the stability
Congressional Budget Presentation, FY2004.
*Health-related; Estimate by the Coordinator’s Office
of states that are strategically
and CRS
significant to the fight against
**Estimated: a program breakdown by health activities
terrorism.
in the Eurasian states is not available, but the Peace
Corps reports that about 20% of global projects involve
U.S.
assistance
budgeted
health.
FY1992-FY2003 for health was
about 5.1% of total aid to Eurasia
of $24.5 billion (excluding the value of privately donated cargoes), indicating the
relatively low priority of such aid until after 9/11. U.S. government health aid to
Eurasia has been less than private donations of medical goods and expertise, which
were worth about $1.9 billion during FY1992-FY2003, including those provided
through the Health Partnerships program, implemented by AIHA (private donations
that do not use U.S. subsidized transport are not included in this total). The AIHA
leverages government and private funding to foster cooperation between U.S.
hospitals and healthcare providers and Eurasian medical facilities and experts.
Dozens of primary, urgent, or other healthcare partnerships launched by AIHA are
active in all twelve Eurasian states.51 Operation Provide Hope, an interagency
program launched in 1992, and USAID’s ocean freight program provide U.S. funded
transport services for private donations of medical goods. When the values of the
privately donated cargoes that are transported with government support are added,
U.S. public and private health-related assistance amounts to about 11% of $27.7
billion in total aid to Eurasia in FY1992-FY2003.
USAID recognizes that there are limits to what U.S. aid is able to accomplish
given massive health needs in Eurasia.52 USAID has addressed the reality of limits
by focusing on lean programs that leverage U.S. assistance to achieve maximum
results, it says. These efforts include small-scale demonstration projects in various
51 For details, see the AIHA website, [http://www.aiha.com].
52 USAID, Rushing; National Research Council, p. 18.

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CRS-20
regions of Eurasia that it is hoped Eurasian governments will replicate nationwide.
USAID has maintained that its performance measures show that its health programs
are having some impact in Eurasia.
While heralding these impacts, USAID
nonetheless cautions that more assistance is needed, since “systemic trends in the
region remain disturbing” because of rising rates of HIV/AIDS, tuberculosis, and
multi-drug resistance tuberculosis, and inadequate improvements in healthcare
systems. Progress has been made in lowering the high rates of abortion in the
Eurasian states, for instance, but abortion rates are still among “the highest in the
world.”53
In planning to phase out FREEDOM Support Act aid to Russia over the next
few years, USAID has proposed that most of the dwindling aid focus on
democratization and health issues.54 USAID has proposed somewhat less funding for
healthcare in Russia in FY2004 ($14.5 million) than in FY2003 ($18.1 million), but
proportionately more than for other programs. Starting in FY2003, USAID health
programs were incorporated into a new activity, Healthy Russia 2020, that aims to
bring several Russian health indicators up to West European standards. Programs in
Russia in FY2004 are planned to emphasize primary health care, combating
infectious diseases, women’s health, and child welfare.
Besides USAID health-related programs, the Department of State coordinates
efforts by the Department of Health of Human Services and other agencies to redirect
former Soviet biological warfare scientists to peaceful research, with a focus on
healthcare (such as drug and vaccine development for the control of tuberculosis,
hepatitis, HIV/AIDS and other infectious diseases). In addition, some activities of
the Moscow and Kiev Science and Technology Centers, funded by the State
Department, deal with biomedical research by Eurasian scientists. With major U.S.
backing, a Civilian Research and Development Foundation NGO was set up in 1995,
including a Biomedical and Behavioral Sciences Program that carries out
collaborative medical research, funded by the U.S. State, Defense, and Commerce
Departments, NIH, and others. Although the Administration plans to phase out
FREEDOM Support Act aid to Russia and Ukraine, programs involving retraining
for scientists from these countries and from Central Asia who previously worked on
biological and chemical warfare will increase in keeping with post-9/11 U.S. security
emphases.55
Among other Eurasian health programs, the Peace Corps has carried out
preventive health education in Armenia, Kazakhstan, and Moldova, and community
health development activities in Turkmenistan and Uzbekistan.
Peace Corps
programs in Kazakhstan, Moldova, Turkmenistan, and Uzbekistan stress education
on preventing HIV/AIDS, and in Kazakhstan, Turkmenistan, and Uzbekistan
emphasize maternal and child health. The Defense Department has donated military
hospitals under the Excess Defense Articles program and has provided follow-on
53 Broadening the Benefits of Reform, pp. 8, 38; FSA Annual Report FY2002.
54 State Department. Congressional Budget Justification, Foreign Operations, FY2004, p.
371; USAID. Budget Justification to the Congress, Annex III, Europe and Eurasia, p. 356.
55 Congressional Budget Justification, Foreign Operations, FY2004, pp. 370, 385.

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CRS-21
equipment packages and training worth $294.8 million to virtually all of the Eurasian
states during FY1992-FY2003.56
International Assistance Efforts.57 International organizations with health
programs in Eurasia include the World Health Organization(WHO), the U.N. Fund
for Population Activities, UNICEF, U.N. Development Program and the World
Bank. A consortium of seven U.N. agencies established UNAIDS in 1995 to focus
on curbing the spread of HIV/AIDS, including in Eurasia. Health programs also have
become a growing part of the activities of the U.N. International Drug Control
Program and UNESCO (U.N. Educational, Scientific, and Cultural Organization).
The European Union’s Technical Assistance for Central Europe and the Independent
States (TACIS) program includes health assistance. The World Bank plays an
important role in funding health initiatives as a participant in UNAIDS and the
Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), and in accordance
with the U.N. General Assembly’s September 2000 Millennium Development
Declaration and its June 2001 commitment to combat HIV/AIDS.
WHO’s budgetary emphasis is on functional programs and regions, with only
small amounts earmarked for specific countries. The Regional Office for Europe in
2000-2001 provided small amounts of technical assistance to Armenia, Azerbaijan,
Kyrgyzstan, Moldova and Tajikistan ($463,000), Russia ($200,000), and other
Eurasian states ($130,000). The programs focused on communicable diseases, non-
communicable diseases and health promotion, health policy, health care reform,
women’s and children’s health, and environment and health. Each country has a
WHO special representative who coordinates regional programs. In 1993, WHO
Europe launched a special project in the Eurasian states to reform their
pharmaceutical sectors so that citizens would have better and more affordable access
to medicines. WHO Europe also has supported such projects as training in Central
Asia on food safety and on waterborne sanitation, in Arkhangelsk and Murmansk,
Russia, on maternal nutrition, and in Korolev, Russia, on energy and water
conservation.58
U.N. interagency HIV/AIDS programs have been operating in all the Eurasian
states since the mid-1990s.
Most of these countries also have active private
voluntary organization partners and programs run by bilateral aid agencies such as
USAID. The projects address the populations currently most likely to spread
HIV/AIDS (injecting drug users, prostitutes, and men who have sex with men),
education for young people and schoolchildren, vulnerable groups (prisoners, street
children, refugees, ethnic minorities), care for people living with HIV/AIDS and for
their human rights, condom distribution, blood safety programs, prevention and
treatment of STDs, disease surveillance, and public service information on
56 Peace Corps, Congressional Budget Presentation, FY2004; Background Paper on State
Department-Directed Humanitarian Assistance to [Eurasia], January 11, 2001; FSA Annual
Report FY2002. H.R. 1950, the Foreign Relations Authorization Act for FY2004-FY2005,
approved in the House in July 2003, calls for Peace Corps volunteers to devote more time
to the prevention and treatment of infectious diseases.
57 Prepared by Lois McHugh and Jim Nichol, Foreign Affairs, Defense, and Trade Division.
58 See World Health Organization. Regional Office for Europe, [http://www.euro.who.int].

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CRS-22
HIV/AIDS. According to the database of the Global Fund to Fight AIDS, TB, and
Malaria, it has approved two-year funding of $50.3 million to combat HIV/AIDS in
Eurasia, with about one-half going to Ukraine, and the rest to Armenia, Georgia,
Kazakhstan, Kyrgyzstan, Moldova, and Tajikistan.59
The U.N. Children’s Fund (UNICEF) has health and nutrition programs in all
the Eurasian states. Program totals in 1999 ranged from a high of $882,000 in Russia
to a low of $152,000 in Belarus, according to UNICEF. Programs include aid to
Uzbekistan to vaccinate children against hepatitis B and to help create maternal and
children’s health centers. The U.N. Population Fund (UNFPA)also has programs in
all the Eurasian states.
Among the UNFPA programs being carried out in 2000-
2004, those for Azerbaijan ($4 million in direct funds), Kazakhstan ($4 million),
Kyrgyzstan ($3.5 million), Tajikistan ($4 million), Turkmenistan ($3.5 million), and
Uzbekistan ($6 million) devote a substantial portion of to reproductive health issues,
and that for 2000-2003 for Russia devoted a small part of $820,000 to quality
healthcare and HIV/AIDS issues.
The TACIS program is the major assistance program of the EU for Eurasia. A
recent annual report indicates that about 393 million euro were paid out in 2001 for
Eurasia (excluding Mongolia) and 381 million euros in 2002, with health assistance
consisting in 2002 of some thirteen programs amounting to 8.0 million euros paid out
(about 2.1% of assistance in 2002). TACIS has considered health aid to Russia,
Georgia, Moldova, Ukraine, and Uzbekistan a priority. Health aid to Russia has
included a primary healthcare project in the north-west and projects on preventive
medicine, medical education, prevention of mother-to-child HIV transmission, and
cardiovascular diseases. Health aid to Ukraine has included programs on HIV/AIDS
prevention, setting up pharmaceutical oversight, and care for the elderly. For the
remainder of Eurasia, health has not been high on the priority list for support in
negotiations with the partner governments. However, TACIS has undertaken some
small-scale projects, such as hospital management in Belarus, primary healthcare for
internally displaced persons in Azerbaijan, and combating TB in Kyrgyzstan. Drug
abuse and HIV/AIDS in Eurasia are emerging EU concerns.60
World Bank Group support for health in Eurasia has included building hospitals
and retraining doctors to serve as rural physicians in Armenia and improving primary
healthcare in Ukraine and Kyrgyzstan. The World Bank also supports efforts to set
up medical insurance systems. It is particularly interested in working with other
donors to provide technical and financial support for combating HIV/AIDS and TB
in Belarus, Georgia, Moldova, Russia, and Ukraine. HIV/AIDS programs include
support for harm reduction (needle exchange and decriminalization), ensuring the
safety of blood supplies, treatment, and education. The World Bank has approved
59 The Global Fund to Fight AIDS, TB, and Malaria, [http://www.theglobalfund.org].
60 European Commission. Annual Report 2003 from the Commission to the Council and the
European Parliament on the EC Development Policy and the Implementation of External
Assistance in 2002, Brussels, 3.9.2003, COM(2003)527 final. The EU also considers that
region-wide programs on environmental pollution, drug trafficking, and water management
have health components. TACIS Regional Cooperation Strategy Framework for 2002-2006;
TACIS Regional Cooperation: Strategy Paper and Indicative Programme 2004-2006.

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CRS-23
loans worth well over $1 billion for health projects in Eurasia. Lending to combat
HIV/AIDS has included a $150 million loan to Russia approved in April 2003, a $5.5
million loan to Moldova in June 2003, and a $60 million loan to Ukraine in
December 2002. Lending for health sector reforms has included $30 million to
Russia approved in 2003, $20.3 million to Georgia in 2002, and $5 million to
Azerbaijan in 2001.61
Issues for Congress
How Significant are Health Issues in
Eurasia to U.S. Interests?
Those who endorse continued or expanded U.S. health aid to the Eurasian states
argue that disease outbreaks in Eurasia, whether the result of nature or bio-terrorism,
are among those that might spread to U.S. shores. Particularly since 9/11, they
emphasize the significance to homeland security of disease prevention and
surveillance beyond U.S. shores. Other observers urge not diluting recently focused
U.S. policy and assistance aimed at combating health problems in some areas of
Africa, Asia, and Latin America by shifting attention to Eurasia. They argue that
infectious disease rates are not as great in Eurasia, so do not pose as severe a near-
term threat to U.S. interests. Some argue that U.S. ties with Russia and other
Eurasian states on arms control and eliminating terrorists are more important to U.S.
homeland security and that Eurasian health matters are best left to the countries to
solve on their own. Some broadly call for winding down or eliminating FREEDOM
Support Act assistance (including for health programs) to many or most of the
Eurasian states, in line with plans to “graduate” or phase out this aid to countries that
have made developmental progress. Others respond that few if any of the Eurasian
states have made much healthcare progress (see below).
In addition to these issues of homeland security, many observers stress that U.S.
interests in economic and political reforms in Eurasia may be undermined by health
problems in the countries. Adverse health trends in Russia may be a drag on
economic reforms, foster civil unrest, encourage a countervailing political
authoritarianism, and perhaps lead to a more internationally belligerent, nuclear-
armed Russia.62 Even small increases in health aid may pay big dividends in
discouraging such developments in Russia, some observers argue. However, as
Table 2 indicates, governments of the Eurasian states are spending a very small
percentage of their budgets on health. Without greater commitments by the states
to healthcare, U.S. assistance appears at most palliative. In addition, the states must
address the societal roots of health problems such as alcohol and drug abuse, and
homicides and suicides.
61 The World Bank. Beyond Transition: The World Bank in Europe and Central Asia, June
2003; Averting AIDS Crises in Eastern Europe and Central Asia, 2003; Country Briefs, and
Projects Database, at [http://www.worldbank.org].
62 Nicholas Eberstadt, Kennan Institute, February 5, 2001.

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CRS-24
U.S. security interests may be served by bolstering the health of Eurasia’s
military forces and civilian populations. Declining health in the military and security
forces can harm their ability to combat terrorism and drug trafficking, to ensure the
safety and security of weapons of mass destruction, and otherwise to defend the
territorial integrity of the states. If the military forces are less capable of carrying out
these missions, then U.S. border, customs, and security aid (recently boosted by the
Administration and Congress), may be less effective than anticipated, according to
this argument. Also, terrorist groups may be able to gain more adherents when
failing healthcare systems increase popular discontent. U.S. health aid has been
considered by several Eurasian military establishments as a major benefit of military-
to-military cooperation, according to U.S. defense officials. The U.S. military also
views the rise of infectious and other diseases in the Eurasian states as risks to U.S.
troops during military training, exchanges, exercises and operations involving the
Eurasian states.63 Critics counter that the U.S. military is always concerned about
protecting personnel from disease, and that Eurasian military personnel are no more
dangerous than the personnel of other countries with large health problems.
How Much Can the United States do to Improve Health
Conditions in Eurasia and What Types of Health Aid are
Appropriate?
The United States faces competing priorities for its aid dollars and limits on its
ability to fund healthcare reforms in Eurasia. Observers who urge greater emphasis
on U.S. health aid to Eurasia argue that small increases in aid may well pay big
dividends in lowering disease rates and ameliorating social discontent in the Eurasian
states. Some call for much larger commitments to meet pressing health needs in
Eurasia, perhaps by shifting aid from democratization and economic reform
programs. Many urge caution in taking on new Eurasian health aid commitments
unilaterally.
The states face interrelated and costly healthcare, public health
infrastructure, and environmental problems — such as deteriorating hospitals, failing
water and sanitary systems, radiation hazards in Kazakhstan’s Semipalatinsk nuclear
testing site, and the evaporation of the Aral Sea — that demand large-scale,
sustained, and in many cases, multinational attention.
Congress and the Administration have clashed for several years over how much
aid to provide for Eurasia. Annual U.S. health aid to the Eurasian states has averaged
about 5.1% of total aid to the region, rising somewhat after 9/11. Due to cuts in
FREEDOM Support Act funding in recent years, excepting 9/11-related assistance
in FY2002, the actual amount of health aid provided through USAID has steadily
increased only to Kyrgyzstan and Tajikistan. Other health-related funding from
agency budgets and other programs fills this gap to some degree, but much of this
assistance tends to be focused on narrow programs such as transporting medical
cargoes, re-training scientists, or Peace Corps activities. One way to address the need
for more assistance would be to increase the percent of foreign aid devoted to health
63 The rise of diphtheria cases in Russia in the early 1990s, for instance, was traced to Soviet
troops returning from Afghanistan and to infected Russian “peacekeeping” troops that were
rotated out of Tajikistan.

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CRS-25
in Eurasia or to establish Congressional guidelines for the amount of aid to be
provided for health assistance. Either of these changes would require further shifts
in U.S. policy, which for a long time focused on democratization and economic
reforms and arms control. Also, there may be a need to consider longer-term health
aid commitments, particularly if U.S. assistance is targeted more to healthcare
institution-building and reform efforts that aim to bolster the ability of the Eurasian
states to meet their own needs. Perhaps reflecting such a partial shift in priorities and
a desire to insulate healthcare from cuts, the Administration appears to be requesting
an amount for healthcare for Eurasia for FY2004 that is slightly higher than that for
FY2003, despite calling for overall cuts in FREEDOM Support Act funding.
Some observers have suggested that the Administration’s proposed Millennium
Challenge Account and the Global AIDS initiative, or other health programs, might
include health aid for some or all Eurasian states. FY2001 was the first year that
Congress included Eurasia in the Child Survival and Disease (CSD) account —
where most U.S. foreign assistance for health is provided — possibly increasing the
percent of foreign aid available for health in Eurasia. Until that year, health programs
in Eurasia were mainly funded through the FREEDOM Support Act, where health
programs competed with other programs. Eurasia received $6.8 million in CSD
funds in FY2001, none in FY2002, and $5.75 million in FY2003.
A second possible change in health aid to Eurasia would be to alter the
distribution of aid among the countries. Table 1 shows the distribution of USAID’s
bilateral health funds to the Eurasian states in recent years. The largest aid amounts
have gone to Armenia, Kazakhstan, Russia, Ukraine and Uzbekistan. Much less
health assistance has been provided to Azerbaijan, Belarus, Moldova, and
Turkmenistan. The distribution of aid is not clearly matched to the health status of
the states, neither matching rankings of under five mortality (Table 2) nor rankings
of health system performance in Eurasia, as determined by the World Health
Organization.64 Instead, a number of considerations seem to influence decision-
making on the distribution of aid besides targeting it to the most needy Eurasian
states, including the degree to which aid should be targeted to the closest or most
strategic U.S. friends or to the most democratic and market-oriented states. Such
determinations are complicated by the added desirability of targeting U.S. aid to
Eurasian states where governments are receptive, honest, and efficient at carrying out
healthcare reforms, although these conditions are scarcely met in any of the Eurasian
states.65 In Russia and other Eurasian states, many critics charge, the governments
are highly corrupt, inefficient, and not focused on health budgets, policies, and
stewardship.66 In such conditions, U.S. and international medical assistance to the
64 WHO. The World Health Report 2000: Health Systems, Improving Performance, pp. 200-
203.
65 WHO. The World Health Report 2002: Reducing Risks, Promoting Healthy Life, October
2002, pp. ix-xi, 3-4, 131-144, 165-167. WHO argues that governments should not only
provide adequate budgetary support and policies facilitating public and private healthcare,
but also proper “stewardship” to maximize healthcare performance dollar for dollar.
66 Nicholas Eberstadt, Kennan Institute, February 5, 2001, argues that the Russian leadership
has failed, compared to other societies that have gone through economic turmoil, to provide
(continued...)

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CRS-26
Eurasian states risks being undermined or redirected for political purposes. In some
cases, Eurasian governments have blocked medical as well as other humanitarian aid
to civilians for political and military purposes (such as in Chechnya), using it as a
weapon to bring populations and separatist movements into line. To help circumvent
problems with governments, some observers have argued that U.S. health aid should
focus more on high-quality indigenous health-related NGOs in Eurasia, to ensure that
aid is used properly and to strengthen long-term self-help capabilities, while others
caution that in most of Eurasia, such local NGOs are still hard to find.
Among possibly clashing U.S. aid objectives, U.S. health aid dedicated to
disaster assistance or to IDPs and refugees in an Eurasian state may shortchange
health aid support for the rest of a country’s population. USAID family planning
programs in Eurasia must comply with policy promoting maternal health and the
provision of modern contraception methods that counteract the inordinately high
rates of abortion throughout the region.
Likewise, with HIV/AIDS spreading
throughout Eurasia primarily through injecting drug users, U.S. programs to curb the
spread of the disease must comply with restrictions on U.S. drug assistance programs.
Many in Congress suggest that other industrialized countries should bear a
greater share of Eurasian health assistance. U.S. advocacy of greater Western
involvement has in the past acted to spur European donors. (For details on Eurasian
aid issues, see CRS Issue Brief IB95077, The Former Soviet Union and U.S. Foreign
Assistance, updated regularly.)
USAID has argued that most Eurasian states have made minimal progress in
health sector reform since their independence, and that it will take several more years
before any are ready to have such aid phased out. Some of the states, it warns, have
made no progress or even lost ground.67 In a 2001 report analyzing the health
situation in Eurasia, USAID judged Armenia and Georgia as making the most
progress (although still inadequate) in health reforms. Kyrgyzstan was viewed as
appearing dedicated to healthcare reform despite its lack of resources, while
Azerbaijan, Turkmenistan, Belarus, and Tajikistan were judged as making no
progress. USAID warned that “near- to medium-term prospects for the Eurasian
countries are quite poor, given the weak commitments of many of the countries to
undertake health reforms, and their frail capacity to implement them.”
Also,
corruption was a major impediment to reforms, it averred, as were conflicts in the
South Caucasus and the diversion of scarce resources to fight epidemics. USAID
suggested possibly committing a greater percentage of its country aid to building
healthcare systems and stressing to the states that reforms in healthcare, governance,
and free markets are closely interrelated.
66 (...continued)
adequate healthcare, partly because the Russian population has not demanded it. Ukrainian
demographer Valentyna Steshenko has been critical that “neither the public in Ukraine nor
their leadership” focus on “the preservation and improvement of public health as one of the
nation’s most important priorities.” FBIS, January 24, 2001.
67 USAID. Briefing on USAID Funded Health Programs In Europe and Eurasia, May 2003;
Increased Health Promotion and Access to Quality Health Care: Graduation Report,
Program Objective Team 3.2, May 2001, pp. 4, 17, 24-26.

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CRS-27
Table 1. U.S. Health Aid to Eurasia
Country
USAID
USAID
USAID
USAID
FY2001
FY2002
FY2003
FY2004
Health
Health
Planning
Request
Funding
Funding
for Health
($ millions)
($ millions)
($ millions)
($ millions)
Armenia
6.105
8.606
5.167
4.421
Azerbaijan
1.8
3
1.83
2.1
Belarus
0
0
0
0
Georgia
3.912
4.318
3.5
4.127
Kazakhstan
6.4
6
6.47
5.707
Kyrgyzstan
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
Tajikistan
1.5
7.25
3.45
5.91
Turkmenistan
0.9
1.5
1.185
1.419
Ukraine
7.114
6.396
9.07
7.565
Uzbekistan
6.2
17
6.4
8.163
Regional
5.633
5.6
7.665
6.244
Total USAID
57.882
80.698
70.828
72.881
Other Agency Health-
46.508
108.402
37.2
—
related Aid*
Grand Total
104.39
189.1
108.0
—
As Percent of
5.3
8.2
5.5
—
Eurasian Funding
Sources: U.S. Agency for International Development, Budgets for Health Care Programs in Eurasia;
FREEDOM Support Act Annual Reports, FY2000-FY2003; State Department, Office of the
Coordinator of U.S. Assistance to Europe and Eurasia, EUR/ACE (POCs: Linick & Kuskevics).
*Other agency health-related aid includes estimates of Peace Corps activities, Department of Defense
hospital packages, bio-technical re-direction aid, and medical-related transport costs. The value of
health-related privately donated cargoes is not included.

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Table 2. Health Spending and Life Expectancy
Country
GDP
Health
Life
Life
Under-5
Per Capita
Spending
Expectancy
Expectancy
Mortality
2001
as % of
2001 Male
2001 Female
Rate/1,000
(dollars)
GDP
(years)
(years)
2001
Armenia
2,650
7.5
66.2
73
35
Azerbaijan
3,090
2.1
60.7
66.6
105
Belarus
7,620
5.7
62.9
74.2
20
Georgia
2,560
7.1
65.4
72.4
29
Kazakhstan
6,500
3.7
58.8
67.2
76
Kyrgyzstan
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
Tajikistan
1,170
2.5
59.9
66.9
72
Turkmenistan
4,320
5.4
58.9
66.5
99
Ukraine
4,350
4.1
62.2
73.3
20
Uzbekistan
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 per capita data and under 5 mortality rates are from the U.N. Development Project,
Human Development Report 2003. Health spending (based on 2000 data) and life expectancy data
are from the U.N. World Health Organization, World Health Report 2002. The OECD figure for
health spending is for 2001, and for mortality is for 1999. See OECD Health Data 2003, at
[http://www.oecd.org].

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CRS-29
Table 3. Tuberculosis, HIV/AIDS, STD Rates
and Drug Use
Country
Estimated
People
Newly
Drug Abuse as a
TB, All
Living with
Registered
Percent of the
Cases,
HIV/AIDS,
Cases of
Population Aged 15
2001
End of
Syphilis &
and Above
2001
Gonorrhea
per 100,000
Opiates
Cannabis
Population
in 2000
Armenia
2,906
2,400
30.8
0.3
0.8
Azerbaijan
6,623
1,400
18.2
0.2
1.1
Belarus
8,417
15,000
204
0.08
0.1
Georgia
4,664
900
76.1
0.6
—
Kazakhstan
29,188
6,000
323.2
1.1
1.3
Kyrgyzstan
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
Tajikistan
6,991
200
49.1
1.2
3.4
Turkmenistan
4,072
<100
—
0.3
0.3
Ukraine
41,225
250,000
144.8
0.9
3.6
Uzbekistan
23,345
740
—
0.4
1.3
Eurasia
334,347
982,740
160.5
0.8
2.3
(total
(total
(avg.)
(avg.)
(avg.)
cases)
cases)
OECD
146,900
—
—
—
5.56
Sources: U.N. World Health Organization, WHO Report 2003: Global Tuberculosis Control;
UNAIDS, Report on the Global HIV/AIDS Epidemic 2002; for sexually transmitted diseases, see U.N.
Children’s Fund (UNICEF), Monitoring in Central and Eastern Europe, the Commonwealth of
Independent States and the Baltics (MONEE) on-line database, at [http://www.unicef-icdc.org]. Drug
abuse data are varying estimates made in 1998, 1999, 2000, or 2001. See U.N. Office on Drugs and
Crime, Global Illicit Drug Trends 2003. OECD data are from Society at a Glance 2002, and OECD
Health Data 2003, at [http://www.oecd.org].

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CRS-30
Table 4. Refugees and Internally Displaced Persons
Country
Refugees (as of
Internally
December 31, 2002)
Displaced
Armenia
247,550
—
Azerbaijan
458
577,179
Belarus
618
—
Georgia
4,192
261,583
Kazakhstan
20,610
—
Kyrgyzstan
7,708
—
Moldova
173
1,000
Russia
14,969
371,195
Tajikistan
3,437
—
Turkmenistan
13,693
—
Ukraine
2,966
—
Uzbekistan
44,936
—
Eurasia Total
361,310
1,210,957*
OECD Total
2,465,000
—
Source: U.N. High Commissioner for Refugees. Population Data Unit. 2002 UNHCR POPULATION
STATISTICS (PROVISIONAL), August 4, 2003, [http://www.unhcr.ch/cgi-bin/texis/vtx/statistics/].
*The IDP data covers persons who are displaced within their country and to whom UNHCR has
extended protection and assistance. Other Eurasian IDPs, according to the U.S. Committee for
Refugees, World Refugee Survey 2003, include about 50,000 persons in Armenia still displaced by
the Armenian-Azerbaijan conflict.

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CRS-31
Table 5. Abortion Rates and Contraceptive Use
Maternal
Abortion Rates
Contraceptive Use:
Mortality/
(abortions per 100 live
All Methods
100,000
births)
Country
1985-2001
1989
2000
Year
Percent
Armenia
35
34.7
34.3
2000
61
Azerbaijan
80
21.5
15.0
2001
56
Belarus
20
163.5
130.1
1995
50
Georgia
50
75.6
37.0
2000
41
Kazakhstan
65
77.5
61.7
1999
66
Kyrgyzstan
65
66.3
22.8
1997
60
Moldova
28
97.3
70.5
1997
74
Russia
44
204.9
168.8
1999
73
Tajikistan
65
20.1
13.2
1990
21
Turkmenistan
65
31.3
22.8
2000
62
Ukraine
25
153.2
112.7
1999
68
Uzbekistan
21
27.8
12.1
1996
56
OECD
9.2
—
26*
various
74
Sources: Data on maternal mortality come from U.N. Children’s Fund (UNICEF), The State of the
World’s Children 2003; abortion rates are from UNICEF, Monitoring in Central and Eastern Europe,
the Commonwealth of Independent States and the Baltics (MONEE) on-line database, at
[http://www.unicef-icdc.org/] (data for Turkmenistan and Uzbekistan are for 1999); and contraceptive
use rates are from the U.N. Population Division, at [http://unstats.un.org]. The OECD datum on
maternal mortality is for 1999 and is derived from OECD Health Data 2003, at [http://www.oecd.org].
*Datum for 1995 for developed countries (excluding Eastern Europe) is taken from Stanley K.
Henshaw, Susheela Singh, and Taylor Haas, The Incidence of Abortion Worldwide, International
Family Planning Perspectives, January 1999, Supplement, pp. 30-38.

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