RZHEV, Russia -- Alexei Serov knew it was time to evacuate the pregnant mothers from his maternity hospital in central Russia when pipes began bursting and plaster started falling off walls. Health regulators closed the clinic, which hadn't been renovated in 40 years, and Dr. Serov moved his patients to a makeshift ward across the street. Conditions there aren't much better. There is no elevator, so women must be carried upstairs to the operating room if complications arise during birth. A clinic for tuberculosis patients stands next door. And two children died last year because the hospital lacked a simple breathing machine that costs just $15,000.
"We physicians are working on the razor's edge," says Dr. Serov, who earns the equivalent of $130 a month. "All our problems boil down to a lack of financing."
The dire state of Russia's public-health system has helped create what President Vladimir Putin calls a national emergency: Every year nearly a million more Russians die than are born. Even with surging immigration, mostly from former Soviet republics, Russia's population has dropped from 147 million in 1989 to 145 million last year. Life expectancy among men -- who have been hit especially hard by alcoholism and heart disease -- has dropped by five years in that period to 58.5, the lowest level in the developed world. If current trends continue, many demographers predict Russia's population could fall to as low as 100 million by 2050.
These statistics have inescapable economic consequences. Economists say declining health will shrink the nation's labor pool and reduce its productivity, potentially complicating Mr. Putin's stated aim of doubling Russia's gross domestic product over the next 10 years. The cost of treating the nation's looming HIV crisis and the disease's drain on the work force, for example, will shave 10% off the country's GDP by 2010 if it isn't combated properly, according to a World Bank study.
In his first four years in office, Mr. Putin has introduced a number of tax and legal reforms that have helped strengthen state finances and ignite economic growth. But like many of the priorities he has set for the second term he is universally expected to win next month, improving the nation's health will be much harder. Beyond grappling with the widespread unemployment and low living standards that underpin the rise in illness, Mr. Putin must fix a broken-down health-care system largely untouched by the reforms that have swept other areas of society.
For decades before the Soviet Union collapsed in 1991, citizens received free health care, though the quality of service often depended on one's Communist Party connections. Though the system is still state-run, government financing has fallen by more than a third since Soviet times and covers only a fraction of patients' real medical costs -- forcing them to pay the rest out of pocket. Equipment is outdated; doctors and nurses earn barely enough to justify showing up to work. And a Soviet-era focus on in-patient treatment leaves far too many hospital beds and not enough general-practice doctors.
Russian officials are drafting a plan to overhaul the system, but many physicians criticize the Health Ministry in particular for moving slowly. The ministry didn't respond to an interview request, but in a report last year, Health Minister Yuri Shevchenko called health "an indicator of national prestige ... a necessary condition for high labor performance ... [and] the clearest measure of the effectiveness of government leadership."
In what Mr. Putin called a sign of hope, the birth rate began to rise last year for the first time since the fall of the Soviet Union. But being born in Russia is still a dangerous experience. Last month, six premature infants died in a regional hospital of a bacterial infection after nurses failed to sanitize machines that were helping them breathe. A state inquiry blamed the deaths in part on a lack of qualified personnel and equipment, and the chief doctor of the hospital was fired.
Because regional budgets fund the bulk of health-care costs, standards and health statistics vary drastically across Russia's economically diverse regions. Life expectancies can differ by as many as 16 years, according to a World Bank report published in October. And mortality rates in Moscow, home to most of Russia's new wealth, are now 55% lower than rates in some poorer regions, state statistics show.
A short drive out of Moscow reveals the rifts. Rzhev, population 70,000, produces most of the cranes building luxury apartment blocks and shopping malls 300 kilometers away in Moscow. But little of the capital's financial boom has trickled out to Rzhev. Local salaries are about $150 a month, compared with $380 in Moscow. Per-capita spending on health care is about $50 a year, or half what is spent in the capital.
Over the past 13 years, Dr. Serov has watched his maternity ward literally fall apart. He says the hospital has received no government funds for repairs or new equipment for more than a decade, forcing Dr. Serov to beg for grants from local businessmen to buy the occasional incubator. Across town, the chief doctor at Rzhev's main city hospital says he calls the crane factory when he needs an emergency infusion of cash.
Worsening standards of living, meanwhile, have damaged the health of local residents. "Earlier, women who gave birth were healthy, but now every other woman has some sort of pathology," says Galina Zuikova, an obstetrician at the hospital. Stress, unemployment and poor nutrition have helped lead to an increase in hypertension, kidney disease and infections in the women who come to the clinic. Smoking has climbed, too. Because of these problems, "there are more complications at birth than there were 20 or 30 years ago," Dr. Zuikova says.
Russia's constitution guarantees free health care for everyone, but very little is in fact free. Patients often pay the hospital or the doctor extra for better service or medicines. A recent study by the Independent Institute for Social Policy, a Moscow think tank, found that state financing covers only a third of health-care costs, with the rest paid by patients. Some Russians also have private health insurance, but this is still rare.
Where there is money, care can be quite good. Moscow's Center for Endosurgery and Lithotripsy, a private hospital founded 11 years ago by surgeon Alexander Bronshtein, offers Western-standard surgical and clinical care for Moscow's wealthy and upper-middle class residents. Heart surgery runs about $5,000. Top-notch physicians at the clinic earn $3,000 to $5,000 a month. "Patients come here for the high qualifications of our doctors, for the lack of lines -- they get things fast," says Mr. Bronshtein, 65 years old. "Unfortunately, not everyone can afford this clinic," he adds.
Sergei Shishkin, a health-care expert helping the state draft a plan for reform, says the government needs to scale back free care, boost the role of private insurance and drastically increase the number of general-practice doctors. He also advocates closing inefficient hospitals and reallocating funds to the best institutions and workers. Some of these changes will be introduced in draft legislation later this year, he said.
But cutting any of the cherished benefits could be a political minefield for Mr. Putin, who has been very protective of his sky-high approval ratings. One Moscow newspaper Wednesday reported that health-care reform will include the closing of some specialized clinics for children and women. The newspaper quoted Russia's chief pediatrician resurrecting a Soviet-era propaganda cliche in denouncing the move as "machinations of imperialism."