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Tolyatti also reveals the economic and social forces behind the rise of HIV in Russia. The trouble is drugs - to be precise, heroin. Nearly every registered case of HIV in the city stems from a shared needle, primed with $2 worth of smack. "If we didn't have heroin," proclaims Mikhailova, "we would not have HIV."
The tragedy is born of prosperity. "We're a young city, and we're a well-off city," says Mikhail Khoutorskoy, head of the local health department. Once a boon, that combination is now lethal. Jobs at the car plant pay well by Russian standards. And nearly one out of five residents is under 16 years old. "These are the kids who wanted to live free," says Alexander Ablamonov, a weary doctor who nightly crisscrosses Tolyatti's most populous region - "Car Factory District" - answering SOS calls in one of the city's 44 ambulances. "They've got freedom now, and this is what they do with it." One recent night, Ablamonov and his crew responded to seven calls. Four were drug overdoses.
The Ministry of Health - whose AIDS department comprises a staff of three - cannot cope. It cannot even keep an accurate tally of the HIV cases registered. The federal statistics lag far behind the numbers reported in the provinces. In Irkutsk, the Siberian city that thanks to a sudden flood of Central Asian heroin witnessed an HIV explosion in 1999, seven out of 10 addicts tested are infected with HIV. "The numbers grow by thousands each week," Savchenko concedes , while the federal funds budgeted for all AIDS programs in 2000 was a scant $1.75 million. "We need more than an education campaign," says Pokrovsky, the federal AIDS center director. "Putin must see this as a national security threat. He must declare war on HIV."
As grim as the epidemic is now, the prognosis is worse. Unlike the early stages of the AIDS crisis in the West, HIV in Russia is spread among the country's burgeoning population of intravenous drug users - an estimated 2 to 3 million nationally. "Today the infected are mostly addicts, but addicts are sexually active and addicts also become prostitutes," says Dr. Yevgeny Voronin, who heads a clinic in St. Petersburg that is Russia's largest facility for mothers and children with HIV. As the virus spreads through sexual contact, experts foresee a heterosexual HIV boom in three to five years. Condoms, once scarce in the U.S.S.R, are now in every pharmacy. But they are rarely used.
The virus moves swiftly but invisibly. Only 741 Russians are known to have died of AIDS to date. "It's hidden because we haven't yet had one known case of AIDS in our city," says Mikhailova in Tolyatti. "But in a few years, the plague will appear before our eyes." Pokrovsky explains: "Treatment today costs $10,000 a year, and in eight years we are likely to have a million people with AIDS. And so the state would have to spend at least $10 billion on treatment. The question 'To treat or not to treat' will arise, and given our federal budget, I think I know the answer we'll hear."
Still, those on the front lines have hope. More and more Russian cities are launching prevention programs, like those in St. Petersburg, Irkutsk and Tolyatti, where former addicts have teamed up with doctors to stem the HIV tide. Not all understand the urgency of the cause. In Irkutsk, local officials have thwarted attempts to distribute clean needles, but in Tolyatti two needle exchange points opened last fall. "It may be a small step," says Mikhailova, "but it's a big one psychologically." She notes that the city even funded the program, giving a grand total of $28,571.
"No one can save us except ourselves," says Aleksei Surikov, a 25-year-old former addict who works in a fledgling Irkutsk detox center that has helped more than 50 young addicts go clean. "If we do nothing, we'll lose every addict here. They believe in nothing. Not the state, not the church, not school, not their parents. But if we can reach them, something changes. We can help them change their lives."
These street warriors know well they face a Sisyphean struggle. Russia's health care system is antiquated, worn-out and desperately underfunded. The World Bank is expected to lend Russia $50 million for HIV and AIDS prevention and $100 million for TB treatment. "Russia still has a window," says Jean-Jacques de Saint Antoine, head of the World Bank's Russian health program. "The virus has barely entered the mainstream population." But from the country's head AIDS doctor to the prevention activists on the St. Petersburg bus, people involved in the HIV fight know that the funds, spread out over five years, will not suffice. They complain above all of the silence in the Kremlin. "It comes down to economics and a political will," says Voronin, the young doctor in St. Petersburg. "Putin must make HIV his top priority. Never mind Chechnya. This is our future and we are losing it."
Late last year the author and Nobel laureate Aleksander Solzhenitsyn described the crisis bluntly, questioning the urgency of Putin's campaign for a new state hymn and flag. "You cannot save a dying country with symbols," the writer chided. "When men are dying without any hope in the prime of their lives, it makes no difference what hymn is sung over their heads." Adds Mikhailova in Tolyatti: "Attention must be paid, and something must be done." The politicians may not like it, but as more and more young Russians succumb to HIV, it will become harder to hide the obvious: Russia stands to lose a generation.