Health-care system frailties and public health control of communicable disease on the European Union's new eastern border

doi:10.1016/S0140-6736(04)16053-4

The Lancet

Volume 363, Issue 9418, 24 April 2004, Pages 1389-1392

https://doi.org/10.1016/S0140-6736(04)16053-4 Get rights and content

Summary

In May, 2004, the border of the European Union (EU) will shift eastward such that the new frontier will be made up by Ukraine, Belarus, and a considerably longer Russian border. Here, we discuss three issues: first, the factors that have contributed to the growth of communicable disease in Russia, Ukraine, and Belarus; second, how public health systems have responded to these challenges; and third, the implications for the EU as a whole. Since the break-up of the Soviet Union, Russia, Ukraine, and Belarus have witnessed substantial political, social, and economic changes. These events have been reflected in changes in the epidemiology of communicable diseases, including tuberculosis and HIV (ie, HIV-1). Moreover, public health systems, rooted in Soviet traditions, are struggling to respond effectively to the challenges of resurgent infectious diseases, such as tuberculosis, and newly emergent challenges such as HIV. The changing patterns of communicable diseases east of the EU's new border has implications for how the EU aids the strengthening of public health systems east of the new frontier. Transborder spread of communicable diseases also challenges communicable disease control systems within the EU. Concerted action is needed by member states and the EU, building on models of cooperation between institutions that have been successful in areas beyond health, if public health systems are to meet the emerging challenges to communicable disease control.

Introduction

“Do they give you no medicines?” he asked.

“There aren't any. Those who bring them, get given them. For the others, it's bed and rest.”

Andrey Kurkov, Death and the Penguin

(The Harvill Press, London, 2001)

In May, 2004, ten new member states (Slovenia, Hungary, Slovakia, Czech Republic, Poland, Lithuania, Latvia, Estonia, Cyprus, and Malta) will join the European Union (EU). Eight of these are former communist countries in central and eastern Europe. This momentous event will shift the EU's frontier eastward to border Ukraine and Belarus, and greatly lengthen its existing frontier with Russia (figure). In 2007, with the probable accession of Romania, the EU will acquire a common border with Moldova.

Events since the break-up of the Soviet Union remind us of the lesson of history: that patterns of communicable diseases often reflect complex social, political, and economic changes, be they cultural shifts, rapid industrialisation with changes in employment patterns, shifts in migration patterns and trade, or wars. Over the past two decades the countries that will lie just beyond the EU's new borders have had striking increases in communicable diseases; yet their public health systems, grounded in the Soviet tradition, have struggled to respond. The weaknesses of these public health responses have represented, in part, the magnitude of the challenge but also the limited capacity within the public health systems, and the inability to apply modern concepts of communicable disease control. In view of the ease with which pathogenic micro-organisms can cross countries' borders, it is important to ask whether the challenge of communicable disease control beyond the EU's new eastern border has implications for the EU as a whole.

We discuss three issues: first, the factors that have contributed to the growth of communicable disease in Russia, Ukraine, and Belarus; second, how public health systems have responded to these challenges; and third, the implications for the EU as a whole. We explore these issues with two “tracer” diseases: tuberculosis and HIV (HIV-1).

Section snippets

Socio-economic and cultural determinants of communicable disease epidemics

The political transition led to striking declines in gross domestic product (GDP) in the former communist countries, with increases in unemployment, widening income inequalities, and an expansion in informal and criminal economies.¹ Although the countries of central and eastern Europe that are in the process of acceding to the EU have since recovered, the economic upturn has been less favourable in the western Commonwealth of Independent States (CIS) countries; Belarus, Moldova, Russia, and

Frail public health systems east of the Union

The tradition of public health is powerfully rooted in Soviet tradition. Under Lenin and subsequently Stalin, a small, elite, prestigious medical profession working in private practice was transformed into a large, publicly employed profession spanning the entire Soviet Union whose purpose was to maintain a workforce and ensure productivity.¹³ In the post-war period this model achieved much, bringing basic care to widely dispersed populations at low cost. Labour was cheap, few skills were

Implications for a wider European Union

The epidemics of tuberculosis and HIV in the western CIS illustrate the potential of frail health systems to affect communicable disease control, and thus the need for action to strengthen them. We argue that the EU should play a major role in this process.

The case for action is not, however, based solely on altruism, although there is a strong argument that those parts of Europe that can afford to, should assist their less fortunate neighbours. Self-interest is also a factor. These frailties

Conclusion

The epidemics of tuberculosis and HIV in Russia, Ukraine, and Belarus have their roots in profound cultural and socio-economic disjunctions. These countries' public health systems are weak in several respects. Whereas international partnerships focus predominantly on disease-specific remedies to communicable disease challenges in these countries, attempts to strengthen broader system weaknesses in public health functions remain under-resourced.³²

Enlargement of the EU will have important

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Public HealthHealth-care system frailties and public health control of communicable disease on the European Union's new eastern border

Summary

Introduction

Section snippets

Socio-economic and cultural determinants of communicable disease epidemics

Frail public health systems east of the Union

Implications for a wider European Union

Conclusion

A decade of transition, Regional Monitoring Report, No 8. Florence

Poverty in transition: social expenditures and the working-age poor. Innocenti Working Paper No. 91. Florence

Changes in life expectancy in Russia in the mid-1990s

Lancet

Global tuberculosis control: surveillance, planning, financing

Health care systems in transition: Russian Federation

Health care systems in transition: Ukraine

Report on the global HIV/AIDS epidemic

Social change and HIV in the former USSR: the making of a new epidemic

Soc Sci Med

HIV infection associated with drug injecting in the Newly Independent States, eastern Europe: the social and economic context of epidemics

Addiction

Structural barriers and facilitators in HIV prevention: a review of international research

AIDS

The HIV/AIDS epidemic in Ukraine: its potential social and economic impact

Soc Sci Med

Sexuality education in Russia: defining pleasure and danger for a fledgling democratic society

Soc Sci Med

Is there epidemiology in Russia?

J Epidemiol Community Health

The dilemma of MDR-TB in the global era

Int J Tuberc Lung Dis

Public Health
Health-care system frailties and public health control of communicable disease on the European Union's new eastern border