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