Moscow’s tree-lined Rozhdestvensky Boulevard was almost deserted. Behind a barrier, a litter-picker was at work while another rested on a bench. These municipal employees in Day-Glo orange overalls were among the few Muscovites who could enjoy the tulip display. Russia’s capital normally returns to life in spring, but this year has stayed dormant: shops, restaurants, and cafés closed, public spaces padlocked. People go out to buy food or walk their dogs, but this mega-city of 12 million, on lockdown since March 30, is quiet. There are no children or old people in the streets, as they are forbidden to leave home except to go to the family dacha.

Russia managed to delay the coronavirus outbreak by a few weeks through early preventive action: It closed its land border with China on January 30, banned Chinese nationals from entering the country soon after, quarantined citizens returning from high-risk countries, and began disinfecting public transport and taking the temperature of Moscow school pupils daily.

But the virus began to spread throughout the country. In May new infections rose steeply, with almost 31,000 registered during the long May 1 holiday weekend. Just before it, Prime Minister Mikhail Mishustin was hospitalized with the virus, as were two other ministers and the president’s spokesperson.

By May 19 there had been 300,000 infections but only 2,837 deaths, which caused western media to speculate that the Russian statistics understated the true death rate by as much as 70 percent (The New York Times and Financial Times, both May 11). The Russian authorities acknowledged that a patient who tested positive for Covid-19 but died of another cause would not be included in their figures, but denied any manipulation. Even if revised upward, Russia’s Covid-19 deaths remain below those of Italy, Spain, and the United States. But if the infection rate grows, will Russia’s medical infrastructure be able to cope?

Russia’s experience of fighting infectious diseases may help explain the authorities’ swift initial response. It dates from 1918 when the Narkomzdrav, the People’s Commissariat of Public Health, was created. The Narkomzdrav, led by medic Nikolai Semashko, developed the world’s first unitary national health system, known as the Semashko system: free, universal, and founded on a multi-level organization of care according to the severity of the condition.

Free district clinics

District polyclinics were the first link, offering outpatient treatment for common ailments and ensuring coordination within the system. In these free clinics, patients could see general practitioners and specialists such as ENT doctors, urologists, and dentists. Semashko wrote, “The organization of the health system on the district principle gives health care providers a chance to know their patients’ working and living conditions better, so the district doctor becomes the ‘local’ doctor, a friend of the family.” The family practice was the forerunner of similar systems later adopted in other countries.

Particular attention was paid to infectious disease prevention. In 1922 Sanepid, the State Sanitary and Epidemiological Service, was created, with intervention teams that could be deployed nationwide, from factories to villages. Their vigilance, together with mass vaccination, allowed the USSR to eliminate tuberculosis and malaria. Average life expectancy in Russia, just 31 at the end of the 19th century, rose to 69 by the 1960s; the Soviets had closed the gap with Western nations.

Today’s successor to Sanepid, Rospotrebnadzor (Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing) is in daily contact with the health ministry but reports directly to President Vladimir Putin, who is in charge of Russia’s overall anti-Covid-19 strategy. According to Ivan Konovalov, a researcher in the department of childhood infectious diseases at Pirogov Russian National Research Medical University, this organization has helped alleviate the burden on hospitals, using large-scale CCTV surveillance and policies that discriminate by age. On March 23 a mayoral decree in Moscow forbade anyone over 65 who suffers from a chronic illness to leave home. As a result, 85 percent of Russia’s Covid-19 patients are under 65 so on average experience less acute symptoms. Russia boasts of one of the lowest Covid-19 death rates in the world (0.9 percent, according to April 25 data), but this might be due to its comparatively low national life expectancy, which averages 72 years overall, 67.6 for men.

Russia’s mass testing strategy is another contributory factor. Rospotrebnadzor said it had carried out 2.5 million tests by April 24, the second-highest figure in the world, which allowed early isolation and treatment, and brought down the percentage mortality rate by identifying people with asymptomatic forms.

Soviet-era hospital capacity

Russia retains significant hospital capacity from the Soviet era. This anomaly in a country that devotes just 3.5 percent of GDP to public health, compared to an OECD average of 6.5 percent, has been ascribed to organizational shortcomings from the 1960s. At that time, the health system began prioritizing hospitals over primary care. A sharp increase in cardiovascular disease and cancers, poorly treated by the Soviet system because of a lack of investment in expensive technology, explains the fall in life expectancy by three years between 1965 and 1974. Judyth Twigg, a US expert on Russia’s health system, said, “To fulfill the objectives of the plan, there was a tendency to open as many beds as possible and hospitalize people for as long as possible. There was little regard for quality and innovation. Only quantity counted.” Prevention, the strength of the Semashko system, was relegated to second place.

Despite a drastic reduction in numbers of health care institutions—the number of hospitals halved between 2000 and 2015 and the number of beds per 10,000 inhabitants was reduced by a quarter—Russia still has one of the highest beds-per-capita rates in the world, with 8.1 for every 1,000 inhabitants compared with six in France and 2.8 in the United States, according to OECD figures. This capacity will be an asset during the pandemic, especially as Russia is also well equipped with ventilators and respiratory equipment—around 40,000 according to the authorities—but behind these figures the reality of health care provision is highly variable.

The system never really recovered from the collapse of the 1990s, when the brutal decline in economic and social conditions led to the reemergence of tuberculosis and other previously eradicated infectious diseases. The introduction in 1993 of an Obligatory Medical Insurance scheme, which currently takes 5.1 percent of a worker’s net salary, as part of every employment contract has made it possible to improve the system over time, at the cost of widening inequalities in access. Consultations with a GP and hospital stays remain free, but prescriptions have to be paid for.

Regional inequalities have grown too. The restructuring that began to optimize expenditure in the 2000s led to rural hospital closures and the construction of high tech facilities in big cities. Many Russian health care workers complain on social media about a lack of equipment and medicines, outdated technology, and low pay. In 2019 there were strikes and collective resignations in several cities, often with support from the Doctors’ Alliance. Last August, at a hospital in Pyatigorsk, near the Georgian border, doctors resigned en masse.

Does Russia have the resources?

This anger is not confined to outlying regions. In Tarusa, a town of 10,000 inhabitants more than 90 miles south of the capital, health care workers say they lack such basics as disposable gowns and disinfectant. Twigg points out, “Putting someone on a ventilator requires not just a qualified doctor but also anesthesiologists, lab technicians, and, in particular, intensive care nurses. It’s not certain that Russia has such resources.”

Even if the system holds up against Covid-19, structural problems remain. Provision of primary care is being neglected. The number of district doctors nationally fell from 73,200 in 2005 to 60,900 in 2016. In 2017 just 13 percent of Russia’s doctors were GPs, compared to an average of 33 percent across the OECD. Russians are rejecting public polyclinics when seeking treatment. According to a study in August 2019, 57 percent of Russians self-medicate rather than go to the doctor.

The better-off are turning to a booming private sector. Since MD Medical Group opened its first private maternity hospital in Moscow in 2006, the big health companies have accelerated their growth, targeting the upper middle class in big cities. In 2016 private health care providers’ share of the Obligatory Medical Insurance sector was 29 percent, compared to 16 percent just three years before. Medsi, owned by the Sistema holding company, already does 8 million consultations a year in Russia and this year planned to open a 365,000 square-foot multi-speciality medical center in Moscow.

Igor Sheiman, a researcher at the Moscow School of Social and Economic Sciences, has long advocated a return to the basics of the Semashko system, based on affordable care and the central role of polyclinics. “Unfortunately, that’s not where efforts have gone,” he concedes. He believes the 550 billion rubles ($7.55 billion) earmarked for the national health program (one of 13 national priority projects for 2019–24) is not enough to modernize primary care. And these funds are at risk of cuts. The Russian government, obsessed with the stability of the ruble, is reluctant to increase its budget deficit and is only unwillingly dipping into its sovereign fund to finance emergency measures. The modernization of the health care system may have to wait.