EDITORIALS
The need for development assistance for health in the eastern European Region
Martin McKee
London School of Hygiene and Tropical Medicine, Keppel Street, London WC1 7HT, England (email: martin.mckee@lshtm.ac.uk)
The period 195080 was characterized by sustained gains in life expectancy throughout the world. This was not to continue and, in the decades that followed, the trend has been reversed in several places. Sub-Saharan Africa has faced a massive increase in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) with, in some places, the added trauma of civil conflict; in the countries of the former Soviet Union the decline in life expectancy has been driven by cardiovascular diseases, injuries and other noncommunicable diseases, which in turn have been caused by, among other things, poor nutrition, weak health-care systems and hazardous levels of alcohol consumption (1, 2).
The response to the health problems facing sub-Saharan Africa remains far from adequate, but at least the situation has attracted the attention of world leaders as well as many millions of ordinary people (as in the recent "Live 8" campaign). In contrast, the health of people living in the former Soviet Union has received remarkably little notice, in some cases even among their own leaders. In this issue of the Bulletin, Suhrcke et al. (920927) demonstrate the apparent lack of political attention to the health of populations in the countries of the former Soviet Union, associated with a lack of financial commitment. Although the international community has not held back from providing development assistance to these countries, the share that has gone to improving health has been very small and is disproportionately low in the light of the health challenges they face.
Suhrcke at al. identify a number of factors that might explain but not justify this observation. One is an international development discourse that is dominated by child and maternal health (largely because, in many parts of the world, these are two of the few subjects on which there are reasonable data) and by infectious disease. As a consequence, adult mortality from noncommunicable diseases is often pushed off the agenda, exemplified by their absence from the Millennium Development Goals (3). It is easy to overlook the rising burden of noncommunicable diseases in developing countries: the absence of effective vital statistics systems means that, outside some sentinel surveillance sites, these deaths often remain unrecorded. While it is obviously important to ensure that those who need antiretrovirals in Africa receive them, it is a tragedy that so many people die from lack of simple anti-hypertensives.
Another contributing factor is a lack of demand from the countries concerned. Some governments have taken actions that suggest scant regard for either the human rights or the health of their populations. The most extreme example is Turkmenistan, where the health-care system has essentially been dismantled, with most health-care workers being dismissed and facilities outside the capital city closed (4). Even now, 15 years after the break-up of the Soviet Union, there is still very limited capacity to formulate and implement effective health policies, and the few people who have obtained training in modern public health are often grossly overstretched. The situation is complicated further by the very limited access to the international literature, possibly somewhat worse than in many developing countries, reflecting both linguistic and technological barriers (5).
A third factor is the high level of corruption in several countries in this region, which is an obvious disincentive to provide development assistance. In an area such as health policy there is considerable scope for funds to be diverted, although, as Suhrcke et al. note, this does not account fully for the degree of neglect.
It may be, however, that the greatest problem is simply indifference among the world community. The countries of eastern Europe have emerged from a state that was recently a global superpower. Several are potentially wealthy, with significant natural resources such as oil; their health problems may be great, but they are obviously not as great as those in Africa. In contrast with countries in much of the developing world, there are very few people in development agencies who have any direct experience or even knowledge of this region, and support for research on its health problems is minimal. As a result, despite its poor situation, this region is simply not on the global health agenda. This is a tragedy, not only for those who will die prematurely because of this lack of attention but also because the experience of this region holds many lessons for other parts of the world, in particular about scaling up basic interventions (as the Soviet Union did in the 1950s and 1960s). These basic interventions are unable to cope with the challenges that are already emerging in the developing world, confronted by high levels of adult mortality from causes that demand a much more complex set of responses. 
References
1. McMichael AJ, McKee M, Shkolnikov V, Valkonen T. Mortality trends and setbacks: global convergence or divergence? Lancet 2004;363:1155-9.
2. Shkolnikov V, McKee M, Leon DA. Changes in life expectancy in Russia in the 1990s. Lancet 2001;357:917-21.
3. Rechel B, Shapo L, McKee M, Health, Nutrition, Population Group, ECA, The World Bank. Are the health Millennium Development Goals appropriate for Eastern Europe and Central Asia? Health Policy 2005;73:339-51.
4. Rechel B, McKee M. Human rights and health in Turkmenistan. London: London School of Hygiene and Tropical Medicine; 2005.
5. McKee M. A decade of experience in eastern Europe. In: Foege W, Black R, Daulaire N, editors. Leadership and management for improving global health. New York: Joosey Bass/John Wiley & Sons; 2005. pp. 167-86.