Kost Elisevich

Over the past century, Russian leaders, excepting one, have sought to present themselves before their own government and their people by how well they waged conflict with the West. Put more bluntly, they have remained dedicated to the notion that military and global territorial dominance over the United States (U.S.) was paramount in their perception of a misguided and grossly overestimated race to the top that too often left behind the welfare of their people. Authoritarian leadership in the guise of a Soviet Communist state with its focus on the growth of its military-industrial might, finally caused the economic demise of their regime and, with it, the collapse of the Union of Soviet Socialist Republics. It will do the same in the current century.

Vladimir Putin is of this past and, by his behavior, consumed with the idea of Russia as an imperialist state. As has been customary, he is in need of something external to hate in order to redirect attention away from his more obvious obligation as the steward of a nation badly in need of repair. Rather than looking after its domestic welfare in a global community that seeks genuine cooperation over such major issues as trade, environment, climate change, food supply and security, Putin chooses the brutish behavior of a past ignominious Stalinist regime and a vision for a dark future of continued global unrest for the sake of recovering some facsimile of the ghostly glory of tsarist Russia.   

The singular characteristic that underlies all others regarding the current governmental state-of-affairs in Russia is a deeply entrenched corruption. Prevalent during the past communist regime, it has led again to an undermining of the current government’s efficacy in conducting its affairs-of-state and weakened its institutions, including the military. Putin has admitted to the problem without clarifying that it was he who had simply reconfigured and perpetuated the longstanding Russian governmental practice of graft and, despite proclamations of now attempting to resolve this state-of-affairs, little progress has been made, particularly, at the highest levels where the worst of it is perpetrated.

Moreover, Russia has exported its corruption to help achieve strategic goals in its foreign policy by the undermining of democratic institutions elsewhere as was made evident in the U.S. in the 2016 elections and within the United Kingdom, exemplified in Scotland’s independence referendum of 2014, the Brexit referendum of 2016 and the general election of 2019. Perhaps, the greatest foreign corrupting influence that Russia has exerted has been in Ukraine where, in addition to the infiltration of Russian criminal elements, efforts to control its political and electoral process succeeded in ensuring the 2010 election of a pro-Putin puppet, Victor Yanukovych, to the presidency. Yanukovych ultimately proved to be undesirable to Ukrainians for his allegiance to Russia, for acting against the will of the populace, and perpetrating corrupt governmental practices. He was ousted in the Maidan Revolution of 2013-14 which led to Putin’s near immediate and overtly illegal intervention in Crimea and his subsequent intrusion within eastern Ukraine.

Prior to his accession to the presidency in January 2000, Putin was already engaged with established Russian criminal elements, tying them closely with operations conducted with his Federal Security Service (FSB), over which he served as director when Boris Yeltsin was president. Yeltsin’s government of the 1990s had become mired in the chaos of Russia’s economic transition from a massive state-run enterprise into one of mostly private ownership of numerous industries and services, giving rise to an economy controlled, in large part, by relatively few individuals of means and a rapacious greed.  

A need for corporate security provided the newly criminalized FSB an opportunity to infiltrate the restructured economy and provide the sort of surveillance that was necessary for Putin to reach an understanding with corporate leaders that they would ultimately answer to him when he required their cooperation. Putin did succeed in restoring much of Russia’s more lucrative industries back under state control and, in doing so, provided himself, his inner circle and government operatives a means to profit from transactions occurring between the state and private companies. Regulatory standards and judicial oversight, otherwise, were corrupted in the process to facilitate the mechanics of greed. What followed has resulted in an inability for Russia to meet and maintain a universal societal standard commensurate with the developed world and to provide for the basic needs of its people.

The health care system serves as a reasonable starting point to examine the welfare of this nation that covers a territory of 6.6 million square miles and a population of 144,444,359. The sheer size of this land mass has made the uniform delivery of territorial medical services grossly unbalanced and a chronic problem for lack of public funding, particularly under Putin’s watch. Health care expenditure as a percentage of GDP ranged from 4.75% to 5.36% between 2000 and 2018, well below the European Union (EU) average of 10% and even below Soviet era expenditure of the 1960s. A 2014 Bloomberg report unsurprisingly ranked Russian health care last out of 55 developed nations.

More than 17,500 towns and villages have been reported to be without any medical infrastructure. Thirteen Russian territories are without psychologists and social workers to manage psychiatric conditions while a third of psychiatric hospitals are deemed unsanitary. An established system of universal health care has shown itself to be likewise inadequate for most of its people in this context with only sporadic attention given to it when deemed politically expedient. It does not provide coverage for most treatments considered vital, leaving patients and their families burdened with the full cost of services provided.

Private insurance seemingly remains a necessity yet only 5% of Russians have it as they are unable to afford the cost and no governmental efforts are in place to remedy the situation. Bribery of public service workers in order to render basic care is not uncommon according to a 2016 Global Corruption Barometer report with estimates of 27% of all cases nationwide having to submit to this practice. The 2022 Corruption Perceptions Index conducted by Transparency International ranked Russia’s public sector 137^th out of 180 nations. Russia’s Prosecutor General, accordingly, has designated the organization “undesirable” for its activities, accusing it of interfering with the internal affairs of the state and somehow posing a threat to its “constitutional order and security.” As a consequence of these several factors, Russia’s health care system was ranked 58 out of 89 in a 2021 Health Care Index of countries considered to have sufficient means of providing health benefits for its people.

The recent COVID-19 pandemic in Russia was met with the same inept early executive governmental intervention as was the case in the U.S., leading to disastrous consequences and a reported 1,029,180 excess Russian deaths during 2020 and 2021. Government expenditure as a percentage of GDP rose to 7.6% in 2020 when the pandemic was reaching its stride and Russian mortality figures were one of the highest worldwide. Expenditure dropped to 6.5% in 2022, similar to Soviet-era figures, despite the recent rather considerable burden of casualties brought on by Putin’s war in Ukraine launched in late February 2022.

The top causes of death in Russia in order of rank during the initial decade of Putin’s reign included heart disease, stroke, traumatic injury, lung cancer, and poisonings. Correcting for population size of the time, comparisons with the U.S. provides insight into the relative health and delivery of health care in each society. Although heart disease was ranked first in both countries, related mortality in Russia was more than triple that in the U.S. while second-ranked stroke was almost seven times higher. Trauma causing death, while ranking third in Russia with well over six times the incidence, was listed 21^st in the U.S. Likewise, poisonings in Russia took 5^th place with almost four times the incidence of that in the U.S. where these ranked 20^th as a cause of death. These latter two causes underlie serious concerns related to public policy and regulatory issues in Russia more than simply the provision of health care. Another feature that demonstrated a continuing lack of attention was the effort put forward for the treatment of human immunodeficiency disorder (HIV) and acquired immunodeficiency syndrome (AIDS) as causes of death. In Russia, these ranked 6^th with more than 8.6 times the deaths recorded in 2009 compared with the U.S. where it was ranked 34^th. Deaths attributed to the 10 leading causes of death in Russia in 2009 accounted for more than 3.4 times that from the same causes in the U.S.

In a speech given at a medical conference in 2011, Putin promised, as a top priority, to improve health care services, increase life expectancy and reduce mortality, acknowledging the decline in population at the time. Similar promises were made in the previous decade. Although, funds were directed into the effort, much was committed to equipment purchases and construction of new facilities without sufficient attention given to personnel training, organizational improvements, salaries, widespread regional imbalances, public health measures, prevention and oversight of health system financing. These issues came to light not only with the insufficient correction of existing health care problems but with the arrival of the COVID-19 pandemic in 2019-20.

Russia had the highest COVID-19 mortality rate in Europe and, in Asia, was second only to India. Because of its lack of transparency and tendency to manipulate numbers over top of its notoriously inadequate measures of testing over its vast territory, suspicions were high that the true figures were actually much greater. In 2022, 137,222 Russian deaths were still related to the pandemic translating to 95 deaths per 100,000 people compared to 72 deaths per 100,000 people in the U.S.. The latter was now related to a more accelerated and consistent public health awareness under a new government administration with an age-adjusted death rate declining by 47% from 2021. By the first quarter of 2023, Russia was ranked 7^th while the U.S. dropped to 11^th in the world for pandemic-related mortality.

More than a decade following Putin’s 2011 grand design and apparent ongoing efforts for improvement in health care, comparatively little has emerged to improve upon outcomes. Much has remained the same or worsened. The average lifespan of both males and females in 2000 was 65 years and, by 2020, estimates showed that, although females were living to 77.8 years, males still only averaged 66.3 years. The life expectancy for a Russian male aged 15 years is now comparable to that of Haiti, falling recently by almost five years as a result of the deterioration of health care agency, lack of social services and intransigent lifestyle habits exacerbated now by the crisis brought on by the war. The comparative average lifespan for males in the EU was 77.7 years in 2022, a reflection of not only the inadequacy of health care delivery in Russia but the chronic inattention toward preventative measures in health policy that would bring about the lifestyle changes necessary to overcome such a considerable discrepancy.

The recent dramatic decline in the Russian population has been attributed to the COVID-19 pandemic, military casualties, emigration of young men and their families escaping conscription and a continuing drop in birth rate. In the past three years, an estimated two million people have been lost from the population with 560,000 during 2022 alone. In 2000, when Putin became president, Russia’s birthrate was an estimated 9.3 per 1,000 people rising to 12.9 by 2014 following which a steady decline has occurred evidenced, in particular, by successive annual falls of 2.37%, 2.42%, and 2.48% from 2020 to 2023.

Mortality rates have exceeded birth rates, rising from 14.6 deaths per 1,000 people in 2020 to 16.7 in 2021, even before the outbreak of war. In absolute terms, deaths amounted to 1,043,340 in 2021, exceeding those established during Putin’s initial five years in office during which figures ranged from 792,930 to 958,530. On Putin’s watch, therefore, Russia’s population has diminished from 146.6 million in 2000 to 144.4 million in 2023, leaving it with a steadily advancing average age that has risen over the past two decades from 37.1 years to 40.5 years. As of January 2022, Russian males aged 20 to 40 years, normally comprising the bulk of recruitment for military service, numbered 19.8 million or 13.7% of the general population comparable to the 13.6% seen in the U.S. There has been a troubling decline among Russian males aged 20 to 24 years, as a percentage of the male population from 9 million in 2010 to 5 million in 2022 much of it even prior to recent war casualties and emigration numbers.

Such figures have caused the head of the Russian Orthodox Church, Patriarch Kirill, an ardent supporter of Putin’s genocide in Ukraine, to call for an end to abortions. Putin’s regime, however, appears to have come upon another more expeditious solution, that of kidnapping Ukrainian children for adoption into Russian families. A current conservative estimate identifies 16,226 Ukrainian children taken in total with little more than 300 returned, a crime for which Putin has been indicted by the International Criminal Court in The Hague. A more recent announcement from the  upper house of Russia’s parliament indicated that 700,000 children have been brought to Russia, most in the early months of the war suggesting an intentional plan of expropriation as the designated property of Russia. Considering the level of brutality of this unprovoked and illegal Russian invasion, one must argue that it is hardly for humanitarian reasons that this process of kidnapping was initiated.

In the end, the funding put forward for health care, not unexpectedly, was poorly managed allowing familiar corrupt practices by well-placed individuals to take advantage of transactional arrangements between the state and private sector. A scandal erupted over tender processes related to imaging equipment with the doubling and tripling of prices in several regions. Moreover, the mere placement of such equipment in remote regional medical facilities without local technical and medical expertise to execute and troubleshoot the necessary procedures or create the programs needed to manage patients was destined to fail in achieving the purpose of the entire venture. This only resulted in waste and inefficiency without creating the intended uniformity of health care delivery that was purportedly sought. A proper vertically integrated medical structure to service the population was never conceived in all this.

An example of the sort of graft and profiteering regarding health care funding that has gone on emerged in an investigation that identified two of Putin’s Kremlin associates who tapped into the substantial cashflow passing from state coffers to the private sector. Nikolai Shamalov, a close Putin acquaintance happened also to be a Russian regional head of sales for AG Siemens, a major German manufacturer of medical imaging equipment. A second associate, Dmitry Gorelov, who had co-founded a company, Petromed, that distributed medical equipment, was granted the right to supply several of Putin’s new hospitals and received $120 million (USD) for these efforts. Meanwhile, during a five-year period (2005-2010), Petromed had imported, on consignment, more than $205 million (USD) worth of medical equipment, mostly imaging-related from Siemens. Rather than having the payment pass directly from Petromed to Siemens, it was sent to an intermediary British company named Greathill Ltd, which had originally bought the equipment, and was controlled by Shamalov and Gorelov. Petromed now bought the equipment, mostly computed tomography (CT) scanners, from Greathill at greatly inflated prices often more than double the original cost, using the money given to it by the state. Greathill itself appeared only to exist on paper and was actually a client of an accounting firm in northern England. It used a shareholder-appointed corporate board drawn from another accounting firm in southern England. Both Shamalov and Gorelov also each engaged a Swiss trust, Interis, to acquire stakes in Greathill as a further means to profit from the transactions taking place.

The story now reverts to Putin and the creation of a vast estate, nicknamed, “Putin’s Palace,” off the northeast coast of the Black Sea in southern Russia. Following the transfer of funds from Petromed to Greathill, the latter then passed on at least $56 million (USD) into the Swiss bank accounts of a Belize company which, in turn, sent at least $48 million (USD) to a Washington DC firm, Medea Investment. This money now funded the purchase of building materials for construction of the estate. Medea Investment was owned by Italian architect, Lanfranco Cirillo, the designer of the estate.

Political opponent and head of Russia’s Anti-Corruption Foundation (FBK), Alexey Navalny, has provided considerable further detail regarding the illicit funding for the construction of the estate that ultimately amounted to $1.35 billion (USD) in addition to the layout of the several facilities connected to it. A no-fly zone is designated for the facility which is also under continual surveillance by the FSB. Diversion of funds away from projects intended to improve the welfare of the average Russian and toward benefiting the already privileged in society does remind one of the sense of entitlement typical of an aristocracy and the perspective of an imperial Russia that seems to suit Putin.

Corrupt practices of the Russian elite and Putin himself abound within the country and continue to deter not only the effective maturation and delivery of health care but many other facets of Russian society. The level of theft that has taken place to date, coupled with the absence of adequate regulatory and judicial oversight, has resulted in a failure to raise the status of health throughout the country. For all of Putin’s rhetoric promising a better future, sufficient time has passed to show that he has achieved little in the end for his people. Over 20 years of incompetent leadership on the domestic front should not be tolerated by a country that considers itself developed.

Copyright @Kost Elisevich, MD, PhD 2023. All rights reserved. Any illegal reproduction of this content will result in immediate legal action.