Karabash, Russia — He was 40 when he had his first heart surgery, a quadruple bypass to correct damage caused by the swirling poisons of the ancient copper smelter where he worked. But that was a decade ago, when the decrepit Russian healthcare system still provided low-cost care to those who could wait.
Now, Mikhail Lychmanyuk has been told he will die unless he has a second heart operation. This time, it will cost him $5,000.
It might as well be $1 million.
"I'll wait for the end," he said, sitting in an empty playground in this desolate industrial town about 1,000 miles east of Moscow. "What can I do without money? Wait for the end."
Russia's steep population decline in the 15 years since the collapse of the Soviet Union has many causes, but the end of the Soviet healthcare system and the debut of free-market medicine have added to the slide.
In the new Russia, millions are born sick. Many succumb to poisons in the air and water around them, or are slowly killed by alcohol, cigarettes or stress. Most are too poor to buy back their health.
The overwhelmed healthcare system can't help much. Although medical care still is nominally free, in practice all but the most basic services are available only to those able to pay hefty fees.
Bribes, the cost of superior treatment even in the Soviet era, are a feature of nearly every successful medical transaction. They can ensure that a patient will be admitted to a decent hospital and increase the chances that a doctor will be diligent.
For the well-off -- mostly foreigners and those who struck it rich in Russia's transition from communism -- there are gleaming "European medical centers" with modern equipment and foreign-trained physicians who charge $100 a visit. Everyone else is relegated to foul-smelling infirmaries with stained sheets, no food and a dearth of equipment as basic as a functioning X-ray machine. The doctors work for as little as $140 a month.
The Scientific Center of Children's Health, a branch of the Russian Academy of Medical Sciences, estimates that 45% of Russian children are born with "health deviations," including problems of the central nervous system, faulty hearts, malformed urinary tracts and low birth weight.
Heart disease and strokes among those younger than 40 have increased by as much as 36% in the last five years, said Yevgeny Chazov, who heads the Russian Cardiological Center in Moscow and was personal physician to most of the Soviet leaders since the Leonid I. Brezhnev era.
Russian President Vladimir V. Putin has responded to the problem, pushing healthcare to the top of the nation's priorities. This year, his government is spending $24.6 billion to more than quadruple some doctors' salaries, build hospitals, buy ambulances and equipment, pay for more surgeries, vaccinations and AIDS treatment, and subsidize medicines for children and pregnant women.
"It finally took Putin himself to understand what was happening," said Murray Feshbach of the Woodrow Wilson International Center for Scholars in Washington, who has long studied health and demographics in Russia. "But it's very late."
Nowhere is the healthcare crisis more pronounced than in Karabash and other poisoned cities of the Soviet-era industrial belt. A legacy of chemical and heavy metal emissions and radiation leaks, including one worse that Chernobyl, earned the Karabash region a reputation in the 1990s as the most polluted spot on Earth.
The looming smokestack of Karabash's blister-copper smelter has been venting as much as 180 tons of sulfur dioxide and metal particulates into the air annually since 1910, before the Bolsheviks came to power.
Lychmanyuk knew he was slowly killing himself every time he stepped inside the smelter oven, where it was too stifling to even wear a gas mask.
"The stove is stopped for 24 hours. It gets a little cooler, and you go inside and start cleaning," he recalled. "But five minutes in there, and your clothes and felt boots start catching fire."
He started having pains in his chest and trouble breathing. His bypass surgery alleviated the problem for a while.
Outside the smelter, the particles spewed from what residents call "the torch" have settled over every yard, rooftop and doorstep for a mile or more. The hillside along the road into town, once a dense forest, is bare earth. Hardly a blade of grass grows in the yards near the smelter.
By 2000, deaths in Karabash were exceeding births 3.5 to 1. Although Karabash is subject to the same poverty and social ills as the rest of the country, residents have no doubt about why they're dying.
"No one in this town isn't sick. Not a single one. If they don't have bronchitis, they have problems with their stomach. If it's not the stomach, it's the heart," said Alevtina Nazarova, 40. "It's all because of the gas. You walk in the street, you come home and you cough like a madman."