www.thelancet.com Vol 382 July 13, 2013 113
The changing face of aid in Russia Russia is now a donor, not a recipient of international aid, but with foreign non-governmental groups leaving the country, will it pick up the pieces to help those most in need? Fiona Clark reports.
Ive thought long and hard about this, says Maia Ruskova. Do I think of myself as a spy or foreign agent? And Ive decidedyes I do.
Its a bold admission in the current political climate in Russia where non-governmental organisations (NGOs) who receive money from abroad are being randomly inspected by various government authorities who go swiftly through their offi ces to determine if they are trying to subvert the political agenda. But Ruskova, the director of the St Petersburg-based NGO Stellit, is willing to stand up and be counted. I am bringing new ideas in, and this is the work of an agent. But I am not taking foreign values [from the West], I am taking human values, she says.
Stellit works on research and prevention programmes for HIV/AIDS with marginalised groups such as sex workers and intravenous drug users. Like many other NGOs who receive funding from abroad, they are now required to register themselves as foreign agents or face quite hefty fi nes, but Ruskova says the government is barking up the wrong tree. If someone gives you money that doesnt mean youre working for them. That money is helping us fulfi l our mission. The government should clarify what they are talking about and ask if it brings good stuff or not, not whose paying for it.
Bigger international groups such as USAID, UNICEF, and World Vision have already pulled out of Russia but the reasons for these departures arent just political diffi culties, theyre also economic. Russia has travelled a long and hard road since the collapse of the Soviet Union in 1991 and the following economic crisis of the mid-1990s. This saw the once proud superpower plunge into bankruptcy
and debt which meant it needed money in the form of development aid, changing its status from a donor to a recipient nation.
But these days Russia is one of the fastest growing economies in the world. Its home to about 100 billionaires thanks to its large reserves of natural resources. These supplies have bailed the country out, delivering more than 4% annual growth over the past few years, and have cemented its place in the rapidly developing economic powerhouse known as the BRICS (Brazil, Russia, India, China, and South Africa).
Russias gross national income per head has grown six-fold over the decade to 2011 to reach US$10 650, bringing it close to the verge of where international aid usually cuts out at around $12 195. And the government has decided to call an end to its recipient status and retake its place at the donor table.
According to Samuel Greene, the newly appointed director of Kings College Londons Russia Institute, fresh from 13 years at Moscows New Economic School, the decision is more about perception than readiness for the role. Part of it is confi dence. The government looks at its state of aff airs, sees its budget and sees itself doing well, he says. The situation of the 1990s was embarrassing and now because of its political agenda it wants to make a clean break from the pastBut the reasoning behind
[the move to donor status] is more political than symbolic. It wants to be seen to have taken on a diff erent status. It wants to be able to say we are a shareholder, a participant, not a recipient, he adds.
But is Russia really ready for such a role when its own health statistics are still far from optimum? It has made progress on setting goals to improve life expectancy from around 69 years to 74 years by 2020. Its passed laws on banning smoking indoors and restricting access to alcohol after a certain hour at night in an eff ort to reduce its mortality rate from non-communicable diseases, but it also has a very heavy disease burden when it comes to tuberculosis, with a prevalence rate of 136 per 100 000 people in 2010. Many of those individuals have multidrug-resistant tuberculosis and are also HIV-positive.
HIV now ranks as the third leading cause of premature death in Russia, according to the Global Burden of Disease Study 2010, which, the studys authors note, makes it about equal with Botswana. But when it comes to actual HIV rates, its a little harder to get an exact fi x
Russias large, fast-growing economy has earned it its place among the BRICS
...USAID, UNICEF, and World Vision have already pulled out of Russia but the reasons for these departures arent just political diffi culties, theyre also economic.
Published OnlineJuly 11, 2013http://dx.doi.org/10.1016/S0140-6736(13)61543-3
For the GBD 2010 profi le for Russia see http://www.healthmetricsandevaluation.org/sites/default/fi les/country-profi les/GBD%20Country%20Report%20-%20Russia.pdf
114 www.thelancet.com Vol 382 July 13, 2013
on just how many people have the virus as the supply of offi cial fi gures can be variablein fact, for some years Russia just doesnt supply them at all. However, according to a letter sent to Russian regional health services in November, 2012, by Russias chief sanitary inspector, Gennady Onishchenko, Russia has 617 018 HIV-positive residents. A total of 62 865 people were tested HIV-positive in the fi rst 10 months of 2012, which is 125% more than last year.
WHO estimates that the number of people with HIV/AIDS ranges from somewhere between 700 000 to 13 million. Then there are diff erences in opinion about how the virus is transmitted. Onishchenkos letter said the main source of infection was injections of narcotics with non-sterile syringes562% of all cases. Homosexual relationships rank second, 414%.
However, his colleague Vadim Pokrovsky, the head of the Federal AIDS Center of Russia, said the fi gures showed that more than 200 people a day were contracting the virus but he diff ered in his interpretation of transmission routes saying that almost 39% of new cases were passed on during heterosexual sex, while men having sex with men accounted for just under 1%.
Those in a generous frame of mind would say the problems in interpreting
and reporting accurate fi gures is systemic rather than deliberate, refl ecting the countrys struggle to come to grips with up-to-date monitoring and reporting systems. Less generous opinions from sources within the aid community who did not wish to be named said the problem was that Russia simply doesnt care about its marginalised groups; they probably think its cheaper to just let them die was one response.
Offi cially, there are certainly diff erences in opinion over the best way to approach prevention and intravenous drug addiction. Berhard Schwartlander, Director for Evidence, Strategy and Results at UNAIDS, says the problem [in Russia] is not a problem with money, its with
attitude. In some cases on HIV they choose not to spend the money in ways that the rest of the world does.
Russia is against methadone pro grammes and has about only 70 needle-exchange programmes which, it is estimated, reach less than 10% of the drug-using population in a country where some $17 billion was spent on heroin in 2011.
And Ruskova says shes not seeing any signs of change on the horizon. The problem isnt so much that Russia stopped being a recipient; the problem is that we havent seen a lot of changes in policy in general. We do not have work for prevention of HIV/AIDS, for sex workers, for harm reduction, for needle exchanges, or treatment for IV drug users. The policies dont changeif they did, wed have money for working with sex workers and drug users, she says.
Schwartlander is part of the UNAIDS strategy group that is working out
how to change the current way of delivering aid to countries that are growing rapidly and want more of a say in their own projects as they shift from lower-income to middle-income status but still house the bulk of the worlds poorest. He says when it comes to the BRICS, the challenge now is to fi nd their niche and help them not only help themselves but also other countries in their region.
One plan several UN aid agencies are thinking about for Russia is to help it become a knowledge hub for other central Asian and eastern European countries. Greene believes the potential exists in the medical community to do this well, but if its left to the bureaucrats it will go the way it always does...The doctors in the hospitals do care and they understand the effi cacy of harm reduction but the government needs to change. It needs to promote people with ideas, build relations across borders, and it needs to get out of the way.
Ruskova thinks the hub idea will be well received by the Russian Government. There are a lot of training opportunities and Russia can take a leadership role, and the government will be positive toward the idea if it is identifi ed as a leader.
Ruskova understands well the importance of ego massagingin this anti-foreign NGO environment the survival of her group depends on it. She knows this government will be around for a long time to come and that she must work with it, not against it, if she is to achieve her mission. We have a moral panic in the country at the moment and that makes it very easy to stop everything. A lot of foundations have left Russia, but we cant do that, we have to keep going. Foreign policy is never easy but that doesnt mean we should stopwed lose knowledge and information and thats not the best way.
Russias needle-exchange programmes reach only a small percentage of drug users
...A lot of foundations have left Russia, but we cant do that, we have to keep going. Foreign policy is never easy but that doesnt mean we should stop...