Today seems to be the sort of day when the recurrent debate here on GNXP about the importance of HIV/AIDS . Arcane did his post, I posted a reply on my own blog.

The subtopic of HIV/AIDS in the former Soviet Union--particularly the prospects for a pandemic--has also received a lot of attention. In this vein, I thought I'd link to Michael Specter's article "The Devastation", online at The New Yorker.

We had returned to [Dr. Olga Leonova's] office, and while we talked she stood at the window, staring at the birch trees. “I worry that aids will send us over the edge—that we will become a country too sick to cope. Most people don’t get it. Many of those who do understand have left. My five closest friends now live in the United States and Israel. My generation has no children. Husbands are dead. And now the young . . . ” Her voice trailed off. Dr. Leonova is an optimist, but she knows that the illness she encounters each day is a sign of an even larger problem—one that threatens Russia at least as seriously today as the Cold War did a generation ago. “We are on the front line of a war,” she said. “This city was under siege by Hitler for years. We lived through Stalin. We have to prevail, and I think, somehow, we will. We don’t have a choice.’’

From Tambov, the old Soviet breadbasket, to the Pacific port city of Vladivostok, and even in Moscow, which has become a world showcase for conspicuous displays of wealth, Russians are dying in numbers and at ages that seem impossible to believe. Heart disease, alcohol consumption, and tuberculosis are epidemic. So is addiction to nicotine. You won’t see many pregnant women on the streets; Russia has one of the lowest peacetime birth rates in modern history. Long life is one of the central characteristics of an advanced society; in Russia, men often die too young to collect a pension. In the United States, even during the Great Depression mortality rates continued to drop, and the same has been true for all other developed countries. Except Russia. In the past decade, life expectancy has fallen so drastically that a boy born in Russia today can expect to live just to the age of fifty-eight, younger than if he were born in Bangladesh. No other educated, industrialized nation ever has suffered such a prolonged, catastrophic growth in death rates.

Even without considering HIV/AIDS, Russia has a particularly bad demographic situation. This brief 1997 paper at RAND, and these two more detailed studies, break down the current Russian demographic situation succintly. Briefly put, until the 1980s fertility rates in the territory of the modern Russian Federation were at replacement levels. However, from the mid-1960s on, life expectancies stagnated, with male life expectancies actually declining. With the dissolution of the Soviet system, fertility rates crashed far below replacement levels while mortality rose. Overall population shrinkage, manifested by an enormous surplus of deaths over births and growing emigration (particularly of ethnic Jews, Germans, Greeks, and others to their nominal homelands), was stemmed only by a migration surplus with the other Soviet successor states and, in the Far East, with China and North Korea.

Russia's demographic structure isn't as unbalanced as it could be, in terms of the crude distribution of its population across the age pyramid. In part, this is because of the enormous surplus mortality among Russian men. Over time, the immense shrinkage of Russia's young population will have serious consequences, as Specter notes.

working-age people are starting to disappear. (In the United States, fifteen per cent of men die before they retire; in Russia, nearly fifty per cent die.) By 2015, the number of children under the age of fifteen will have fallen by a quarter. There will be at least five million fewer people in the workforce. The Russian Ministry of Education projects a thirty-per-cent drop in school enrollment. Russian women already bear scarcely more than half the number of children needed to maintain the current population, and the situation will soon get worse. Between 2010 and 2025, the number of women between twenty and twenty-nine—the primary childbearing years—will plummet from eleven and a half million to six million. Unless there is sudden new immigration on a gigantic scale, fertility will fall even from today’s anemic level.

What will the outcome of the Russian HIV/AIDS epidemic be? We don't know. Even without HIV/AIDS, Russia is pioneering a new demographic model characterized by fluctuating levels of international and internal migration and by death rates substantially higher than birth rates, with overall population aging stemmed only by low male life expectancies and accelerated population shrinkage.

In gross terms, comparing Russia's population and level of economic development with other countries, Russia is most similar to Brazil. The similarities are only superficial. For our purposes here, the most significant difference is that while Brazil has dealt with the HIV/AIDS epidemic since the 1980s and has an HIV seropositivity rate of 0.6%, Russia has only had HIV/AIDS since the early 1990s but already has an HIV seropositivity rate of 0.9% of the Russian population.

When will the spread of the HIV virus in the general Russian population stop? We don't know. Russia is pioneering a new sort of demographic system characterized by mortality rates much higher than anemic birth rates. Most ominously, as Specter notes now and as I noted back in August, the Russian state appears to be both unwilling to and incapable of dealing with the epidemic, owing to a popular attitude that HIV/AIDS affects only disposable people and to a state that does not place HIV/AIDS on its list of priorities.

Why does Brazil, with a comparable population and a slightly lower per-capita income, spend nearly a billion dollars on aids each year when Russia doesn’t spend even a tenth that? It can’t be poverty; Russia is not rich, but it has eighty-five billion dollars in its financial reserves. The Kremlin is certainly capable of spending money when it wants to: last year, for example, the lavish three-hundredth-birthday party for the city of St. Petersburg—Vladimir Putin’s home town—cost $1.3 billion.

[. . .]

The Kremlin demands to be taken seriously as a world power and as an active member of the Group of Eight industrial nations. The country’s leaders often mention aids in public at international gatherings, acting as if Russia still had an empire to control. At home, though, the story is different. “Russia went ahead and made a decision to contribute money to the Global Fund,’’ Christof Rühl, who was until recently the World Bank’s chief economist in Russia, told me. The Global Fund to Fight aids was set up by the U.N. to provide money for those countries which cannot on their own defeat aids, tuberculosis, or malaria.

[. . .]

Russia invested just over four million dollars in 2003 in its federal aids program, but it committed twenty million to the Global Fund to Fight aids. Two years ago, the Kremlin’s protracted negotiations effectively delayed a hundred-and-fifty-million-dollar loan offer by the World Bank on the ground that it did not wish to incur further foreign debt. “If you watch,” Rühl said, “you will see the President and all the ministers and the economic advisers going out and saying to the world, with great pride, ‘Russia is a donor country. We are one of you. We are going to help solve this health crisis for these poor nations.’ It is cheap and cynical. It has not been about H.I.V. at all. It was to say, ‘We are a country that helps; we don’t need handouts, like Africa.’ But the truth is that the government is so disorganized and so removed from the needs of its own people that it could not even help get one application filed for the first round of this Global Fund.

“The people just don’t care. On a very broad scale, it’s a country where people care about their family and their friends. Their clan. But not their society. Yet they have this attitude that we are a great power. A donor nation. What does that really mean? It means you pay a few million dollars to the world aids fund even though you are too stupid to attempt to profit from it when your own citizens are dying.’’

Could we see a South African-style pandemic in Russia? It doesn't seem altogether impossible, though as always it's important to note that projecting rates of growth inefinitely into the future is a cheap and unreliable statistical game. It seems to be beyond question, though, that Russia will shortly have rates of HIV infection much higher than those prevailing in the European Union, in North America, in Latin America, or in much of East Asia. A 5% rate isn't out of the question.

More importantly, since HIV is a virus with a long period of latency and the Russian epidemic began at a relatively late date, the number of deaths attributable to HIV/AIDS will rise significantly. Considering the Russian health system's current state, one can legitimately speculate whether it could survive the experience. How an atomized and fragmented Russian society would cope (or not) seems to be open to question, though past trends are suggestively bad.

Will HIV/AIDS alone determine Russia's future? Likely not. Will it shift things in a bad direction? Almost certainly.