EPIDEMIOLOGY

SYPHILIS AND OTHER SEXUALLY TRANSMITTED DISEASES

SOURCE. Papers by I. V. Zhuravleva (pp. 67-83) and L. S. Shilova (pp. 111-143) in Zdorov'e i zdravookhranenie v usloviiakh rynochnoi ekonomiki [Health and Health-Care Under Conditions of Market Economy]. Moscow: Izd-vo Instituta sotsiologii RAN [Publishing House of the Institute of Sociology of the Russian Academy of Sciences], 2000.

The public attention paid to AIDS tends to overshadow the rapid spread of other more "traditional" sexually transmitted diseases (STD), the most serious of which, syphilis, is no less fatal than AIDS unless treated properly and in time. Sterility caused by STD is also the hidden factor behind the collapse of Russia's birth rate.

Soviet medicine established quite effective control over STD. It is estimated that up to 90 per cent of cases received treatment. A 1949 decree set the goal of eliminating STD, which had spread under wartime conditions, within two years. Coercive means were used. Individuals refusing treatment could be imprisoned and treated against their will, while patients who refused to identify their sexual contacts were fined. Physicians were likewise subject to (non-criminal) penalties for failing to track down at least 60 per cent of their patients' sexual contacts. These penalties were dropped in the new criminal code of 1996, leading to a decline in the proportion of contacts traced.

In 1995 over 1.7 million people in Russia were registered as having STD, although the real figure is thought to exceed 5 million. The number of NEW cases of syphilis registered annually -- the best indicator of the rate at which an epidemic is spreading -- rose from 8,000 in 1990 to 388,000 in 1996 and 450,000 in 1997, a 57-fold increase over 7 years.

In the last few years the official figures have leveled off and started to decline. However, experts do not believe that this reflects reality. The trouble is that the official figures are based on records generated by the system of state registration of diseases inherited from Soviet times. The recent rapid expansion of commercial medical services offering anonymous treatment without registration removes an increasing proportion of cases from the statistics. Moreover, even where registration does still occur it tends to be at a later stage of the disease, as people delay seeking treatment for economic reasons -- in particular, out of fear of losing their job if their employer finds out that they are syphilitic. This shift also biases the figures downward.

The younger the age group, the faster the spread of syphilis within it. Thus between 1992 and 1998 the prevalence of syphilis increased by 5.5 times among adults, but by 17 times among children under 15. Between 1990 and 1996 newly registered cases of children with syphilis increased by 78 times, from 0.11 to 8.61 per 100,000. That is, child syphilis remains rare, but is no longer extremely so. Unlike the figures for adult syphilis, those for child syphilis have continued their upward trend in the last few years, presumably because the economic motives for concealment do not apply to children. A child is often infected with syphilis as a result of rape or from living with syphilitic parents.

It appears that in the late Soviet period congenital syphilis did not exist at all. Even in 1991 no case of a child born with syphilis was registered in Moscow. Any pregnant woman who had syphilis was detected early, and the embryo was aborted. In 1997, 34 cases of congenital syphilis were registered in Moscow. A similar trend has been found in other regions. Many women now slip through the net and do not get examined during pregnancy -- or else are examined but get infected afterward.

Besides age, exposure to syphilis and other STD depends on sex and place of residence. For example, among 15-17 year olds in the period 1993-98 girls were 3-4 times more likely to get syphilis than boys. Over twice as many new cases per 100,000 population are registered in urban as in rural areas (although this may overstate the difference, as the proportion of cases that are registered may be lower in rural areas). The situation is especially bad in Siberia and the Far East, the North Caucasus, and big cities. Syphilis is less widespread in the small towns of provincial European Russia.

The spread of STD is closely linked to prostitution and drug addiction, which are also closely linked to one another, as the cost of drugs is often covered by prostitution. (The combination of prostitution and drug addiction also plays a major role in the spread of AIDS, which passes from one person to another through shared needles as well as sex.)

Promiscuity combined with ignorance is no doubt the main culprit. A comparative survey of young people in Moscow, Estonia, and Finland conducted in 1995-96 found that only 31 per cent of the Muscovite respondents were able to identify gonorrhea, and a mere 11 per cent chlamydia, as sexually transmitted diseases, as against over 80 per cent of the Finnish respondents who correctly identified both diseases. (1)

A survey of Russian schoolgirls infected with STD gave the following results. 51 per cent had learned what they knew about STD from friends and only 3.5 per cent from school, while 40 per cent learned of STD only when they themselves were infected. 38 per cent had already had STD more than once. Asked whether any of their sexual partners had used condoms, 54 per cent answered no and just 5 per cent yes. 40 per cent had had only one sexual partner, while 10 per cent had had at least 10 partners and 15 per cent could not remember how many partners they had had. About a third of respondents regarded frequent change of partner as "normal," and 7 per cent considered it good for the health. (2)

(1) About 1,000 respondents were interviewed in each country. The survey was organized by Dr. Mussalo- Rauhamaa of the University of Helsinki.

(2) Results published in 1998. The source (Shilova) gives no information on how or when the survey was conducted.