The healthcare crisis that accompanies Russia's population decline is a fact of life not only in far-flung regions and rural areas, but also in major cities. And it affects the middle class as well as the poor.
The 8.8 million people who ride the Moscow subway system every day are exposed to nearly 1 1/2 times the maximum safe level of carbon monoxide and other dangerous gases, the government reported.
An outbreak of hepatitis A traced to bad beer hospitalized 600 people in the Tver region last summer, and about 500 others were sickened with the same illness in November in Russia's third-largest city, Nizhny Novgorod. Cases of hepatitis A and typhoid fever climbed 20% in the first half of 2004, the Health Ministry reported.
But neither disease is as worrisome to health officials outside Russia as the alarming growth of AIDS and tuberculosis, a common infection associated with AIDS.
Russia and its neighboring former Soviet republics are experiencing the fastest-growing epidemics of AIDS and TB in Europe. Russia is seeing at least 120,000 new tuberculosis cases a year, 10 times the number in the United States, which has double the population. Last year, about 32,000 Russians died of the disease.
Tuberculosis, unlike AIDS, can be spread through casual contact with people who have compromised immune systems, sparking fears that Russia could become an "epidemiological pump" for spreading the disease to the rest of Europe and to North America.
"The worse off you are, the more likely you are to have tuberculosis," said Mikhail Perelman, director of Moscow's Phthisio-Pulmonary Institute, once a hospital for Napoleon's troops. Its dark, arched hallways are haunted by shuffling tuberculosis patients, many of them quarantined for months on end.
Tuberculosis has flourished in the airless confines of Russia's severely crowded prisons, and it seeps into the general population with the tens of thousands of convicts released each year. In a growing number of cases, the disease has mutated beyond the reach of drugs commonly used to treat it.
Russia has accepted international help to begin a serious fight, developing aggressive programs to make sure patients complete their treatment. In addition, $480 million a year has been allocated for expensive "second-line" treatment for the estimated 30,000 cases of drug-resistant TB.
But as with those who have AIDS, many TB patients outside Moscow have no access to the latest drugs.
Sergei Shelkovnikov, a 34-year-old fuel engineer who works for TNK-BP, British Petroleum's joint venture in Russia, was spending three months in the Moscow institute for treatment of drug-resistant tuberculosis. He thinks he caught it on the subway.
"All I know is, I had a persistent cough. It sounded like bronchitis to me," he said. "It lasted for about a month, and when I went to the doctor, a lung X-ray revealed I had tuberculosis."
Studies have shown that stress and general ill health increase susceptibility to tuberculosis. People may be exposed repeatedly but don't catch it until their resistance breaks down.
Galina Sokolova, chief physician at the Phthisio-Pulmonary Institute, cited the case of a well-educated 43-year-old man with two small children. When his wife died of cancer, he had to work as a security guard, and eventually came down with tuberculosis.
"This happens time after time," Sokolova said. "A state-owned enterprise is closed down. People lose their jobs. And they become our patients."
The office of the head of neurosurgery at St. Petersburg's City Hospital 23 is at the end of a medieval-looking corridor with bare wires and peeling paint. Stuffing and springs are falling out of a sofa in the corner.
Doctors drink tea and chain-smoke at a tiny table etched with scratches. Their ancient electroencephalogram machine looks like something out of a horror movie.
Although tuberculosis and AIDS are becoming front-line priorities for the healthcare system, hundreds of hospitals continue to languish.
Doctors struggle with poorly equipped laboratories. Expensive equipment donated by foreign aid organizations may have broken down. There is no money to fix it, or the money budgeted for repairs has evaporated in the web of corruption that strangles public spending across the country.
"The CAT scanner we have at our hospital has not been working for a year -- for a whole year," said Alexander Naryshkin, head of neurosurgery. Hospital management said that it provided $80,000 to buy replacement parts for the scanner, which served an entire district of the city, but the money disappeared.
"So this $1-million piece of equipment is standing useless, and nobody seems to care," Naryshkin said.
The doctors work with surgical instruments that are 20 to 30 years old. Naryshkin, who makes $350 a month, said he and his colleagues pooled their money to buy a piece of equipment to close blood vessels during brain surgery after hospital management refused to make the purchase.