§ 1.54 p.m.
§ Lord Rea rose to ask Her Majesty's Government what steps they are taking bilaterally, or multilaterally through the European Union or the World Health Organisation, to help curb the rapidly escalating epidemic of syphilis and other sexually transmitted diseases including HIV/AIDS in the countries of the former Soviet Union.
§ The noble Lord said: My Lords, first, I thank all those noble Lords who have stayed this afternoon to discuss a problem which at first glance may seem a little remote 1502 from our concerns at home. But, as all noble Lords are aware, nowhere in the world today can be regarded, as Neville Chamberlain described Czechoslovakia in 1938. as, "a faraway country of which we know little".
§ Your Lordships' House has a tradition of compassion as well as a pool of expertise which covers most countries. However, I hope to show that there is more than a little self-interest for Britain involved in this Unstarred Question. More than ever infectious diseases respect no frontiers. Many travellers and business people cross into Russia and further, into central Asia, and from those countries "go west"—if they can scrape the money together—in search of fortune and a better life. Some of those sell sexual favours and bring with them diseases which to us may be "yesterday's men of death", particularly syphilis which is still easily curable with penicillin in its early stages but which, in the presence of the HIV/AIDS virus, poses new and serious problems.
To show how relevant the Question is to those of us who live in the European Union, I should like to read from a letter published in the Lancet on 21st February this year by a group of doctors working in Verona, Italy, who surveyed 110 foreign-born prostitutes who attended their clinic. The letter states:
Immigrants from the former Soviet Union had the highest rate of active syphilis (27.8%). Compared with the rest of the group, these women had the least past experience in prostitution [were the youngest] and the highest incidence of pregnancy".
§ In other words, they did not understand the importance and had no education in the practice of safe sex.
§ My attention was brought to this growing problem by a seminar organised by the Social Market Foundation last month at which experts with knowledge of the sexually transmitted diseases (STD) situation in the former Soviet Union (FSU) discussed some very disturbing findings in a series of papers. Prominent among them were Dr. Alex Gromyko, adviser on STD and AIDS at the European Regional office of the World Health Organisation, and Dr. Adrian Renton, who is Reader in Public Health Medicine at Imperial College. He has made a special study of the problem following a fact-finding mission to Russia in December 1995.
§ They told us, for example, that the incidence of newly identified cases of syphilis in most of the countries of the FSU has risen dramatically in the past eight or nine years. In Russia, for instance, the total number of notified cases rose from just over 6,000 in 1988 to nearly 390,000 in 1996—a 62-fold increase. The notification rates per 100,000 of the population rose even more steeply in young people, especially 18–19 year-olds, with young women having twice the rate of young men.
§ Between 1990 and 1996 rates rose by multiples of 12.5 to 82 times in countries ranging from Moldova to Ukraine, Belarus, the Baltic States, through to Kazakhstan and Kirgizia. That is in contrast to the period before perestroika in which the high rates in the 1920s were brought down some 200-fold due to a vigorous public health control system and the use of penicillin. Other STDs, particularly gonorrhoea and chlamydia have probably had similar increases to syphilis, but because they are not so well notified the 1503 figures are less reliable. The law is enforced strictly on the notification of syphilis. The experts at the seminar were satisfied that the data that I summarised were based on sound laboratory methods.
§ It is worth mentioning that the rates of syphilis in most countries in northern and western Europe have been very low for some years—fewer than five per 100,000.
§ The reason that there is urgency in tackling this epidemic of "old fashioned" STDs, such as syphilis, is the now established knowledge that the spread of HIV/AIDS through sexual contact is much more rapid if the partner without HIV infection is suffering from one of the STDs that I described, particularly syphilis. That is because the protective epithelium (skin or mucous membrane) of the genital area is inflamed or ulcerated, thus offering a portal of entry for the HIV virus via inflammatory cells of the immune system where the virus flourishes.
I quote from the task force report of the WHO:
In the presence of genital ulcers, the probability of HIV transmission per sexual act is increased 50–300 fold. Non-ulcerative STDs increase the risk of HIV infection less strongly, hut the population attributable effect may he even larger in areas where these STDs are highly prevalent".
§ A famous study in Africa showed that one could practically halve the transmission of HIV if treatment was offered for the common STDs that were prevalent there.
§ There was a comparatively low incidence of HIV infection in the populations of the former Soviet Union countries until well after perestroika, largely because of their previous relative isolation. Overall, even now, the cumulative number of cases has not reached the level even of western Europe. But while the incidence of new cases here has reached a plateau, and is now beginning to fall, the number of new cases in the FSU has shot up in the past three years; in Belarus, from eight to 1,021 between 1995–96; in the Ukraine, from 44 to more than 12,000 between 1994 and 1996; and in Russia there are similar increases. Initially, infection was largely confined to intravenous drug users who shared needles and syringes, a serious and increasing problem in the FSU, but in the past two or three years, as the epidemic has grown, an increasing proportion of infection is sexually transmitted.
§ The danger of HIV spread in a population with a high level of these bacterial STDs was brought home to the seminar by Dr. Renton in a calculation which showed that in a population with a 4 per cent. prevalence of syphilis, which is the case among 18 to 19 year-olds in one city in the Urals, the rate of transmission of HIV would increase by 20-fold above that in a population without STDs, leading to a major epidemic, possibly on a African scale, with a million or more deaths.
§ So an obvious question is: how did all this come about when STDs were previously under control? Of course, a complete answer would take several hours to relate, but the underlying cause is the enormous social and economic upheaval that has occurred in Russia and its neighbours during the past decade. The removal of an authoritarian, top-down bureaucracy and the 1504 encouragement of individual initiative has led many Russians to reject the punitive basis on which the sexually transmitted disease clinics of the USSR were run. Anonymity was not observed; indeed, workplaces were notified of cases among their staff: contacts were sought with the help of the militia; and treatment was compulsory. Syphilis was treated in a somewhat punitive manner by multiple injections of penicillin as an in-patient in hospital instead of out-patient treatment with one or two injections of long-acting penicillin, which is perfectly effective. At the same time the rigid (but hypocritical) moral code of the former regime has given way to a more relaxed attitude to sexual relationships, but without—this is very important—the sex education which should accompany it.
§ There has also been much more population movement. Economics, of course, have played a major role; many STD clinics do not get regular drug supplies, their staff are underpaid, and when the money does come it is often months late, leading to a very low state of morale and the seeking of work in other occupations to boost their inadequate income. Although some 10 per cent. of Russians have grown very rich since the end of the USSR, the majority are much worse off than they were, and there is a very high rate of unemployment, particularly among the young. In effect we are seeing the effects of a raw, unadulterated capitalism of Dickensian proportions on the health and behaviour of the population. Even going to a free STD clinic requires travel and there is usually a charge for drugs, if any are available. If people have little or no money, they cannot afford to attend.
§ In this economic climate, sex is treated increasingly as a saleable commodity, as a means of livelihood, especially, but not only, by women, some of whom may hope to gain advantages by granting favours to successful men. I could say that this behaviour is not unknown nearer home, even in the Palace of Westminster, but perhaps not so blatantly or to such a wide extent.
§ In Russia those with money can now attend private sector clinics or private doctors (some unqualified) who do guarantee anonymity. But the treatment and investigations are often over-elaborate so that higher fees can be charged.
§ Finally, there comes the question of how the UK can best help the situation. Of course, it is the governments and the people of the former Soviet Union countries themselves who will have to implement the package of measures that are necessary to cut short the current epidemic (and, I should add, also deal with their intravenous drugs problem, initially by the provision of clean syringes and needles) and thus, it is to be hoped, abort the much more serious danger of an explosion of HIV/AIDS. But it is important to act quickly. The rise is potentially exponential rather than additive and could lead to the deaths of millions of people. If nothing is done, there will be spill-over effects into the rest of Europe, and even to Britain.1505
§ The World Health Organisation is fully aware of the situation as is the consortium known as UNAIDS, which includes the World Bank. Several international meetings centring on the problem have been held and a task force on the problem has been set up. Reports from these recognise that health ministries alone in the countries concerned cannot cope with the problem. Many other departments of government need to be involved at central and local level. However, at a basic level sufficient trained personnel is available, but they need to learn new methods and new attitudes to regain the confidence of young people and how to co-operate with other agencies. Even the STD and HIV programmes are run separately. And confidential treatment must be made available at low cost or free with adequate supplies of condoms. Over and above this, a major public education exercise is needed, as was mounted here in the 1980s in response to the emerging HIV epidemic then.
§ Britain is running a small bilateral programme to assist. The Know-how Fund is backing a good demonstration programme in Samara in which family planning services, another area in great need of change in the former Soviet Union, are linked to STD services, and education departments are also being involved. I am aware of good work being done in the Ukraine by a project run by London Lighthouse and supported through the Millennium Fund, to which Healthlink, formerly AHRTAG, an NGO which I chaired for five years, has been acting as a consultant.
§ According to one of the Healthlink consultants who was in Kiev recently, the situation there is "dire". I shall be grateful if my noble friend can fill in more detail of the bilateral help that the UK is backing. In fact, the United Kingdom has built up an almost unique body of experience and expertise in the field of HIV/AIDS over the past decade and a half. We have a lot to teach.
§ This is far too big and urgent a problem, though, to be left to small, bilaterally-funded demonstration projects, even though they are a vital part of the assistance that we can give. Holding the EU presidency this year gives us an ideal position from which to convince other EU countries of the urgency of the situation and to realise that a window of opportunity now exists. The UK should recommend that strong support be given to the WHO Task Force for the Urgent Response to the Epidemics of STDs in Eastern Europe and Central Asia, which was set up at a meeting earlier this year in Copenhagen. I have no time to describe its recommendations in any detail, but it has produced an excellent document which I commend to my noble friend.
§ So far little European Union money has been spent on this emerging problem, which is on its very doorstep, while substantial EU development funds are going to Aids projects in Africa and south-east Asia. On 30th April there is a meeting of EU Health Ministers. I very much hope that my noble friend will be able to confirm that we will raise this very important issue that I have outlined at that meeting and will press for substantial backing for a multi-pronged assault on this developing tragedy in order to prevent it from becoming a disaster.1506
§ 2.9 p.m.
The Earl of Carlisle
My Lords, I thank the noble Lord, Lord Rea, for introducing this timely and important subject, the spread of syphilis and HIV/AIDS and other contagious diseases in the former Soviet Union countries. If I have one quibble, it is a minor one. I hope that we shall try to get out of the habit of referring to the independent sovereign states of central and eastern Europe as former Soviet Union nations or countries. They were annexed to the Soviet Union in 1940 and subsequently in 1944, against their will.
I have to confess that I am woefully ignorant about medicine, hospitals and doctors. My knowledge is confined to what I learnt and picked up from regimental medical officers who served in my regiment; by an appendix operation; and, now, through visits to hospitals in the Baltic states. I needed to get a resident's permit. I went round a steeplechase of five hospitals having various medical checks in order to obtain it. I saw with fascination and horror how primitive the hospitals were.
I shall make two points. First, in 1945 the Allies reached Berlin. Sex from German women was available for cigarettes. The currency was a cigarette. After the Soviet forces withdrew the situation was not so bad. But sex is marketable for hard currency from the West, the Scandinavian countries or, indeed local currency.
I had the honour and privilege to lead a small team sent by the British Council to teach a United Nations peacekeeping battalion. I taught the English language for six months to 38 men between the ages of 18 and 32. To my knowledge four of them contracted syphilis during the course. Two of them were ill and their work fell off. I asked one of them why and he told me. I said, "You must tell your senior officer". He said. "I can't; I shall be thrown off the course".
Fortunately. I had met a leading psychiatrist in eastern Europe, Dr Anti Liiv, who is now a member of the Estonian Parliament. I met him at the British ambassador's table at lunch on 28th November 1994. I know the date because it is the day on which I became a Member of your Lordships' House. Dr. Anti Liiv told me this story. He was allowed to travel to the West during the Soviet occupation. He was allowed to do so because he did a great favour for the Russians. The Soviet Union had its great submarine base—the fourth largest in the world—at Paldiski on the peninsula about 15 miles from Tallinn. The Russians lost control, with alcoholism, contagious diseases, syphilis and the lot on the increase. They called in an Estonian to sort the place out.
Dr. Anti Liiv set up a clinic in Tallinn. He has informed me that syphilis, HIV and AIDS are on the increase. He says that he can provide medical support, but that it is limited and primitive. That is because the doctors need training. The Soviet Union, realising that it needed to keep control of its subject states, had to know every single detail of people's lives. So the people of eastern and central Europe were not encouraged or allowed to practise medicine. That is why the doctors need training.
1507 I am sure that we can assist, not only because of our generous nature, but also through various organisations such as the World Health Organisation and the European Union. However, time is pressing. Eastern Europe has outstanding universities. In Estonia, there is Tartu, founded in 1632. Theology, medicine, law and philosophy were its four core subjects, and have remained so. The Estonians, like, I am certain, the other 10 central and eastern European nations, look to us to assist. We have already done so to a considerable extent.
The noble Lord, Lord Rea, mentioned London Lighthouse. I have received a copy of a letter stating that,the London Lighthouse is suffering terribly from a sudden decision by the Health Authorities across London to withdraw their funding from Lighthouse's key residential unit. At a stroke, this has cut the charity's income by one-third, and they are now contemplating closure of the unit".I regard that as a disaster, knowing how much valuable work London Lighthouse has carried out in St. Petersburg, the Ukraine and elsewhere. I hope that the health authorities will be persuaded to reconsider their decision. I know that there is pressure on their resources, but I hope that London Lighthouse will be able to continue to function.
Secondly, although I have taught young people in Tallinn, I have also gone out into the rural areas. I said to the head English teacher in the Pölva Maakons, "I know how busy you are, but do you ever go to Tallinn?" She replied, "Yes, and my first port of call is the British Council. I pick up all of its pamphlets and take them back to my students. I teach lessons from them." She showed me what she regarded as the most important leaflet. It was an excellent brochure on contagious diseases, syphilis and HIV. The British Council is doing very good work in educating people in eastern and central Europe not only in the study of our language, hut also in health promotion and sex education.
Britain has provided magnificent support through our military training teams. I refer to NCOs from the Royal Marines of the calibre of Colour Sergeant Alan Sheperd who was decorated for his work by the president of Estonia. He includes in his courses advice to young NCOs and soldiers about personal hygiene. It is a small but significant process because those young men who are being trained by the British Royal Marines will rapidly grow into positions of considerable authority. Again, I use Estonia as an example because these are the facts of which I am aware, but I am certain that the same is true of other nations in central and eastern Europe. I pay tribute also to the work of the Chevening Trust in granting scholarships in every field, particularly medicine.
Our British embassies in central and eastern Europe are doing excellent work. I refer to our ambassador, Tim Craddock, and to his predecessor, Ambassador Charles de Chassiron, who, from their limited funds, gave donations and equipment to hospitals to Tallinn. That was widely appreciated. I hope that the Foreign Office will be able to continue support through the embassy funds.
1508 I do not pretend to know the answer to this problem. The five plus one nations who are rapidly transforming their economies and will shortly be allowed to start negotiations with the European Union are fully aware that unless they meet the social criteria they will not make as rapid progress as they should. Therefore, on those grounds, they could be denied full membership of the European Union. I believe that the British nation can, through its contacts with the United Nations, the World Health Organisation and its presidency of the European Union, play a considerable part in eradicating and, hopefully, eliminating this ghastly social evil that could affect us all.
§ 2.21 p.m.
§ Lord Kilmarnock
My Lords, we all owe a debt of gratitude to the noble Lord, Lord Rea, for drawing to our attention this important matter. He has already set out the facts very lucidly and I shall not repeat them. I merely reinforce them by invoking the observations of Dr.Karl Dehne, who represented UNAIDS, a United Nations consortium, at a seminar that I chaired in Amsterdam last year. It was he who first brought the whole of this field to my attention. At that seminar he said that, at a recent conference, Russia's Minister for Health had talked about 800,000 new HIV infections by the year 2000 in Russia alone. He said that in Russia there were about half a million intravenous drug users. He referred to the opening up of the gay scene and the increased contact between males from eastern and western Europe, as well as the increase in male sex workers travelling to western Europe.
He concluded his remarks at that meeting as follows:Eastwards from Central Europe there is no information, no access to counselling, STD services, condoms and so on. Some NGOs have started working with drug users in Eastern Europe but involvement is still very low. A major international initiative is now required, supported by adequate financial resources, to adapt the experience of Western Europe to the East and prevent this HIV and STD crisis from spilling over the borders of the East into the West".I also draw upon an article by Dr. Adrian Renton, reader in social medicine at Imperial College. London, to whom the noble Lord, Lord Rea, has already referred, in the last issue of the EPPNA Review, which is the journal of the European Public Policy Network on HIV and AIDS. In that article he speaks of a 48-fold (4,800 per cent.) increase in syphilis notification in the Russian Federation between 1989 and 1996. That represents 263 per 100,000 of population. The rates for Belarus, Moldova and Khazakstan are not much lower, and the Ukraine scores a hefty 144 per 100,000.
These are the raw figures for syphilis but it is not the end of the story. Dr. Renton also stresses the linkage between STDs and HIV:There is good evidence that if one or both members of a sexual partnership has an STD, and one partner has HIV. then the probability of transmission of HIV during coitus may he several times increased. At the population level this enhancement of transmission is further amplified by the fact that both HIV and STDs 1509 tend to be concentrated within the same subgroups of the population. This combination of pockets of very high HIV prevalence among IVDUs"—intravenous drug users—in major cities with high background levels of STD prevalence. … threatens to generate much larger epidemics of sexually transmitted HIV infection than have been seen in Western European countries".Like the noble Lord, Lord Rea, I take the opportunity to pay tribute to Dr. Renton, who is the medical academic who has done most to bring this situation and this threat to the attention of the political world and who has produced much valuable information for more than one speaker in this debate.
Naturally one seeks an explanation of such an explosion. Dr. Renton, the noble Lord said, attributes it to the extremely rapid cultural changes brought about by market reforms, which have stimulated travel, internal migration, casualisation of sex, decline in the age of sex initiation, increase in prostitution, and penetration of sexually orientated products, images and advertising. This cultural revolution has been accompanied by the collapse of the traditional system of STD surveillance and control which pertained under the old regime. Central funds are no longer available to support this and decent clinics are only available to those who can pay. I have no doubt this is a true picture. However, market reforms will undoubtedly continue and so will the cultural revolution. Obviously, we do not want to support a return to the old draconian powers of compulsory hospitalisation and contact tracing. That is not an option. So the question is, what can be done in the present context?
But before attempting an answer I feel I should pose a prior question. Is any of this our business? In response to this, I would like to make it plain that I am not an unqualified supporter of all public health initiatives, especially those which seem to intrude unduly into people's lifestyles where no serious risk to others is concerned. However, infectious disease does seem to me a legitimate public health concern, and there are clearly no geographical boundaries where they are concerned. That is why we have international agencies such as WHO and UNAIDS to co-ordinate the response to transnational public health threats. But such agencies are only as effective as their constituent parts, which means the member states by which they are funded. There is precious little they can do other than exhort and cajole, unless the political authorities of their member states are prepared to finance and implement their recommendations. To that extent, I would argue that the epidemics which are the subject of this question are our business, as members of and subscribers to the international agencies concerned.
It is also our business in terms of self-interest. What is now a relatively benign HIV and AIDS situation in Northern Europe, owing to the successful strategies we have adopted, could seriously worsen if a large number of HIV cases develops, riding on the back of syphilis, across the broad swathe of countries to the east of the current European Union. Of course, the EU has no common border with the newly independent states of the former Soviet Union, but that is not much protection 1510 in a period of migration of labour and internationally organised prostitution, which know no boundaries. Fortress Europe might be able to keep some tariff barriers up but it can be no protection against disease.
There is also the important dimension of enlargement of the Community to which the noble Earl, Lord Carlisle, referred, which will bring in a number of states that do have common borders with the FSUI apologise to him for the use of that phrase, but it seems to have crept into usage—in some of which those epidemics are already showing signs of taking off, as he said.
It was therefore a matter of some surprise and concern that there was no representative from either the European Commission or the European Parliament at the founding meeting of the "task force for urgent response to epidemics of sexually transmitted disease in Eastern Europe and Central Asia", organised by WHO in Copenhagen on the 23rd/24th February past. The World Bank was there. UNAIDS and other UN agencies were there. The United States Agency for International Development was there. Norway, Sweden, Denmark and Germany were there. Our own Know-how Fund was there. Medécins sans Frontieres was there. But no one was there from the EU, on whose doorstep these events are happening. That does seem rather extraordinary, especially as the Commission acquired a new public health role under the Maastricht Treaty, to which I shall return shortly.
Leaving that on one side for the moment, what can we ourselves do? What can the UK do? I am pleased to say, as the Minister will know, that I had a very positive letter from his right honourable friend Clare Short. the Secretary of State for International Development, in support of a seminar I organised on this issue on 25th February. It was well attended by representatives of her department. In her letter, the Secretary of State wrote:I share your concern about the dramatic resurgence of syphilis and other sexually transmitted diseases in Eastern Europe and the former Soviet Union"—I am afraid that the Secretary of State also uses that phrase—particularly when the link between untreated STDs and susceptibility to HIV infection is so devastatingly clear".She continues with the welcome news that,DfID expects to do more in this area".I have heard of the work by the Know-how Fund in certain Russian locations, which I applaud, but it would be interesting to hear from the Minister what form the crucial word "more" is going to take.
I have also had a letter from the public health Minister, Tessa Jowell, replying in encouraging terms to a letter of mine suggesting that this matter be placed on the agenda for discussion at the next Health Council on 30th April. She wrote to me stating:I share your concern … We will be holding a general discussion of the future priorities for the EU in the field of public health at the Health Council on 30th April, and I am sure that in that context the worrying rise in the incidence of STDs in Eastern Europe will be raised as an issue".1511 She then refers to a conference which the UK presidency is sponsoring on 19th May in London and she mentions that the Government are considering the possibility of co-hosting with the European Commission a meeting on 28th May to which health ministry officials of applicant countries will be invited.
It is certainly welcome news, after their disappointing absence from the task force foundation meeting, that the Commission seems to be involved and if the Government have played a part in this they are to be congratulated.
I wish to ask the noble Lord, Lord Whitty, whether he can clarify the Government's intentions in the following respects. First, what further action will the Government take to stimulate action by the European Union? I understand that the Community is close to agreeing a decision which will establish a network for communicable disease surveillance. Can he say how that will operate and whether it will extend to associate and applicant states? If not, there will be little advance on the surveillance arrangements which already operate among the 15.
Secondly, will the Government participate actively in the work of the task force? If so, how do they think they can make the most impact? We have a wealth of experience in this country in the operation of genito-urinary clinics based on confidentiality and free access to treatment, which sounds exactly what is required in the former Soviet Union and other affected states. We are also good at outreach programmes through voluntary agencies working with people such as prostitutes and drug users who want to have nothing to do with the official system. These are extremely cost effective and they reach the parts other lagers do not reach. Is it within the remit on DfID to contribute to such voluntary bodies? In areas where we have undoubted experience and expertise, I would suggest that bilateral aid is probably the best route.
Thirdly, as the noble Lord, Lord Rea, mentioned, the health Minister has agreed that STDs in central and eastern Europe merit discussion at the next Health Council, hut the topic could easily be crowded out by other business. Will the Government undertake that it will be raised by the UK from the chair?
Fourthly, what liaison is taking place between the lead government departments on this bundle of issues? It is already clear that both the DfID and the DoH have an involvement in the field. This might extend to the Home Office if immigration matters arise. It would be a great pity if the undoubted efforts that the Government are making were not co-ordinated to maximum effect. Can the Minister say what machinery exists to ensure that the departments involved pursue a common strategy, especially in the international arena?
Finally, I do not believe that the major international initiative, called for by Dr. Dehne, from whom I quoted earlier, need be massively expensive. The Commission already runs the Europe Against Aids programme based on the principle of subsidiarity; that is to say, it contributes to useful schemes and initiatives in member states for which about 10 million ecu (£6 to £7 million) are allocated annually across the Community. The 1512 trouble is that that is confined exclusively to the current 15 member states. The European Union is also the largest donor for AIDS control in the developing world. Unfortunately, the area we are discussing, with which we share a land mass, appears to fall between the two stools of Europe and the third world. I suggest that a sister programme could be devised, using voluntary and other bodies already in existence, at a relatively low cost which could be good value for money.
There is a good basis for that at paragraph 3 of Article 129 of the Treaty of Maastricht, which states:The Community and the Member States shall foster co-operation with third countries and the competent international organisations in the sphere of public health".I ask the Minister whether, during the United Kingdom's presidency, the Government will pursue that idea with the Commission with a view to establishing a programme which is fully targeted on the area that we are discussing this afternoon.
§ 2.25 p.m.
§ Lord Alderdice
My Lords, we are all grateful to the noble Lord, Lord Rea, for his initiative in bringing forward this important matter. He has, as have other noble Lords, outlined the nature of the problem in some detail. However, there are a number of further matters I should like to raise. I hope that the Minister will be able to give us some guidance in respect of one or two questions, particularly those outlined by the noble Lord, Lord Kilmarnock.
A few years ago there was enormous concern in this part of the world about the developing pandemic of HIV and AIDS. A considerable programme of education and disease control was embarked upon. It is encouraging to see that in the countries of northern and western Europe there has been an element of control over the epidemic. I fear that the very success of that may have blinded us at times to the fact that that has not been the case in the countries of south-western Europe and in much of the rest of the world, not least in central and eastern Europe, as the noble Lord's Question points out. For example, while the incidence of syphilis and gonorrhoea has declined in western Europe, the incidence in the former Soviet Union countries has increased from something like five per 100,000 in 1990 to 170 per 100,000 in 1995. Those are the most recent figures I have; clearly, they have continued to increase. In particular, if one looks at the Ukraine, the vulnerability of that country is demonstrated by the fact that between 1991 and 1995. the number of syphilis cases increased ten-fold. Therefore, we are looking at a very serious increase in the number of sexually transmitted diseases. We are not just talking about syphilis. We are talking about gonorrhoea, chlamydia, trichomonas and of course. HIV and AIDS.
There has been some discussion about the reasons. I shall not enumerate all of them. But, of course, there have been dramatic changes in society in central and eastern Europe: the relative freedom to travel, the changes in social mores, and the development of organised crime, to which I shall return later, which involves the sex industry and the drugs trade, a very important component in respect of HIV and AIDS.
1513 But there is another difficulty. The education programme embarked upon in that part of the world, which was markedly successful, led to a change not only in the pattern of people's behaviour but, of course, in the use of condoms as a protective device. Very little is known about the availability of condoms in central and eastern Europe but we know that in certain areas they are very restricted, simply for commercial reasons. For example, in Kazakhstan in 1995, they were available only in some pharmacies in the capital city. Moreover, in Moscow that same year, although condoms were available at most pharmacies and could be found at some commercial kiosks, supermarkets and hotels, the price of a 12-unit pack represented nearly one-third of the minimum monthly salary—a pretty expensive business in terms of protecting oneself.
I believe this to be a very important issue. Whatever the educational programme embarked upon, we should bear in mind that the very simple, straightforward and readily available precautions which may be taken in this part of the world may not be available in other places if provision is not made in that respect. I remember visiting South Africa three or four years ago. I visited a market in Johannesburg and was approached by a very pleasant young lady who supplied me with leaflets and a number of packs of condoms, as, indeed, she was supplying to everyone in the marketplace as part of an educational programme. The point is that it is okay to have the education but, if the condoms are not freely and cheaply available, then at least some of that educational component will not be successful.
When speaking about syphilis and the development of that epidemic and HIV, we must bear in mind the relationship between them because both are sexually transmitted diseases. The acquiral of syphilis, as the noble Lord, Lord Rea, pointed out, leaves one even more vulnerable to HIV because of the ulceration, but it is also true in cases of gonorrhoea, chlamydia and trichomonas that the inflammation leaves one more open to HIV.
The major increase in HIV in central and eastern Europe has not come about simply through sexual transmission; it has come about because of the enormous increase in the drug problem in that part of the world and the massive increase in HIV among intravenous drug users. I recently received figures which showed that the incidence of HIV among intravenous drug users in one part of the Ukraine rose from 1.7 per cent. in January 1995 to 56.5 per cent. in December; that is, 11 months later. So in a period of less than a year the incidence of HIV among intravenous drug users in one city had gone from 1.7 per cent.—almost nothing—to cover well over half of the intravenous drug users. We know that the incidence of intravenous drug abuse has massively increased in the former Soviet Union. That is not just because of availability. It is because many people have turned not to legitimate capitalism but to illegal organised crime.
We all know that organised crime in any part of the world involves itself in money laundering, in threats and intimidation, in the drug trade and in the sex industry. Of course, the latter is an important link in respect of 1514 all these diseases. I raise the point because, when it comes to the question of what we in this part of the world might fear and do as a result, there are important implications not only in health terms but also in terms of the control of organised crime. The freedom to travel makes it much more likely that travellers from this part of the world who are foolish enough may find themselves contracting infections when they visit the countries of central and eastern Europe. Similarly, those who visit us from central and eastern Europe may bring such infections with them. Indeed, that is a serious issue and a serious health problem.
There is also the danger to all of us not only through the development of a serious pool of infection in central and eastern Europe, which might then spread to the rest of us, but also through the development of a massive pool of organised criminal activity—for example, peddling sex and drugs. That is a major threat to us, because those who are intent upon making a profit out of organised crime and drugs will not be satisfied merely to keep their activities to those countries. We already know that there have been attempts to expand such activities to this part of the world. Of course that is a serious matter.
It is a matter of considerable disappointment to note—as the noble Lord, Lord Kilmarnock, did—that when the task force was established as recently as February this year the European Union was not represented on that occasion despite being invited. I hope that in his reply the Minister can advise us why that was the case and can assure us that during our presidency of the European Union that kind of neglect simply will not be allowed to continue, and that in approaching this question we shall not simply restrict ourselves to public health measures such as the provision of condoms, needles, syringes and the provision of an educational campaign. We have achieved success with our campaigns and we can transmit that success to others.
I hope the Minister can assure us that the criminal side will be taken into account and that there will not merely be collaboration by health and preventive health agencies but also co-operation between police organisations, the Home Office and ministries of justice in other places. I hope that that side of the matter will be given serious consideration and that there will be co-operation between security agencies and health agencies. That is the big link between all these different diseases whether they are sexually transmitted, or transmitted in even larger numbers in central and eastern Europe through the use of intravenous drugs. I look forward to the Minister's response.
§ 2.45 p.m.
My Lords, I, too, am grateful to the noble Lord, Lord Rea, for initiating this debate and for the help that the noble Lord was able to obtain for me from Dr. Renton, who has also been most helpful to me. I extend my congratulations to the noble Lord, Lord Whitty, on his appointment as a spokesman with responsibility for sexually transmitted diseases. I hope he will find that post a healthy one!
1515 As many speakers have said, what these countries of eastern Europe are facing is a change of system and a breakdown of the old controls that used to keep these diseases suppressed, and a consequent epidemic. As has been said, syphilis has increased by a factor of 200 and has reached levels which might truly be called epidemic. We are looking at about one quarter of 1 per cent. of the population being actively infected. That might translate into half a dozen Members of your Lordships' House. I think we would recognise that as an undesirable number.
I do not share the worries of the noble Lord, Lord Rea, about "tarts" bringing syphilis into this country. I think the arrangements we have here for dealing with syphilis keep it very much under control. I do not think there is any danger of an epidemic starting or spreading here. Nonetheless we should consider whether we can help the former Soviet Union overcome the problems it faces.
As regards AIDS, although increases have been dramatic, the level of AIDS in the former Soviet Union and eastern Europe is much lower than it is in western countries. In Russia it is about a hundredth of the level that it is in the UK. Therefore we are not facing an epidemic, but from what has been said today it is clear that we are facing a potential epidemic. As the current level of the disease is low, we have the opportunity to move fast now to do something about it and to prevent it reaching the stage that it will undoubtedly reach if we do nothing about it.
What can be done? I think President Museveni was correct in attributing AIDS and all sexually transmitted diseases to a change in people's practices and habits. That is the root of the problem. The way forward must be through education and through providing examples of how systems can work. Russia faces enormous problems, not least that of raising taxes with which to pay doctors to treat sexually transmitted diseases. I hope the noble Lord, Lord Whitty, will confirm that there is not scope for us to spend large sums of money trying to solve these problems, which relate fundamentally to major structural problems within Russia and the other countries of the former eastern bloc. Those problems have to be solved by those countries themselves, perhaps with the aid of other streams of help from us. For us simply to throw money at the problem will be nothing but counter-productive.
I hope that the noble Lord, Lord Whitty, will be able to confirm that the new emphasis of DfID on poverty elimination will not prevent it from helping with this problem in what is fundamentally one of the richer countries of the world. As the World Bank and the European Union have acknowledged, market mechanisms cannot deliver effective control of such an epidemic in the Soviet Union because those most affected are those with the least resources. It is effectively the poor within those countries, who do not have access to such wealth as would be available in a country like the United Kingdom to deal with the problems they face. I hope that the noble Lord will allay one of my long-term fears about DfID's new policy: that we shall still feel able to devote resources to this sort of problem.
1516 There are several things that the UK should do. First. as has been said by several speakers, we should support the WHO task force. I hope that we shall have a clear and unequivocal statement from the noble Lord on that. Secondly, I hope that the Government will promote awareness of the issue within the European Commission. Many speakers have raised the problem. The European Union spends many millions on projects in Africa and Asia to promote sexual health but seems to have no mechanism to do the same in eastern Europe. That may account for the absence of those from eastern Europe from the opening session of the WHO task force. I hope that the Minister will confirm that we are determined to do something about that during our presidency of the European Union.
The HIV epidemic is at an early stage when it would respond well to intervention. We and the Europeans have a great deal of expertise in that area. It is clear that those involved in the former Soviet Union would much prefer to work with representatives from the European Union. From their cultural backgrounds, they would have a better understanding of life in the former Soviet Union and its culture than the Americans who already work there. It would be a shame if we were not able to participate because of some structural technical deficiencies within the European Union.
Thirdly, I hope that the noble Lord will enlarge on what DfID is doing to help. The noble Lord, Lord Rea, gave some examples. My noble kinsman Lord Carlisle praised the work of the British Council. I hope that we shall hear more from the Minister on what is being done. Projects led by DfID to enhance the health of local populations, to serve as models for wider development, and to support the case for reforms within the system, would be an excellent way forward. The United Kingdom is particularly good at delivering low cost but highly effective and widely accessible STD services. We have struck an excellent balance between high and low-tech services. In Russia doctors may be more concerned with the latest diagnostic test than in using the available resources in a modest but effective way. Health promotion and education activities are often neglected as they have no high-tech appeal. We can show that our model, which does not rely on a high-tech but a more down to earth public health approach, is highly effective.
We are also good at working with hard to reach, marginalised and sometimes criminalised groups in society. That would apply in particular in Russia to sex workers, migrants, homosexual men and drug users, all groups with which we have had considerable success in this country. We have strong experience in local rapid public health research to develop tailored local intervention strategies. Such a structure is not in place in the Soviet Union. Some seedcorn from us would help a great deal.
We can help, too, in developing humane medical practice which shows respect for patient confidentiality and human dignity. That was not a feature of the old regime in the Soviet Union. I am sure that we can do much to encourage it.
I look forward to the reply of the Minister. I hope that he will give encouragement to us all.
§ 2.55 p.m.
§ Lord Whitty
My Lords, this has been a serious and sombre debate. We should thank the noble Lords, Lord Rea and Lord Kilmarnock, and others who have taken a deep interest in this area, and the organisations with which they have been involved and the experts to whom they themselves paid tribute during the course of the debate. To be honest, I was not fully aware of this area before I undertook the briefing and research for this debate. I have been further enlightened by the contributions from your Lordships.
This is an immensely serious problem on the doorstep of Europe, and one which adds to the serious tensions within the countries of the former Soviet Union (if I may briefly use that term) and beyond. It behoves the authorities within those countries, and those in western Europe who are in a position to help them, to give greater priority to this issue. As the noble Earl, Lord Carlisle, indicated, the Estonian authorities are now aware of the problem. I am informed that the Russian authorities have only recently updated the statistics referred to by the noble Lord, Lord Alderdice.
The figures given by the Deputy Minister for Health, Gennadi Onishchenko (at least, I believe he is still the Deputy Minister for Health—I am not sure what President Yeltsin has done with him) indicate that the rate of notification of syphilis is almost 300 per 100,000 of the population as of February this year. That is a significantly higher rate than in Britain before the application of penicillin. It is also significantly higher than the rate in many of the very poor countries in Africa where there are serious problems of STD. The overall rate is higher in certain areas—in Siberia for example—and in cases of young people, particularly young women.
Those notification rates are continuing to increase in almost all the countries: Russia, Ukraine, central Asia and the Baltics. Admittedly, as has been stated, the rate of HIV infection is relatively low in those countries at the moment; but the rate of syphilis and other STDs indicates the very real possibility that HIV transmission in the region will rise very rapidly over the next few years.
I assure the House that Her Majesty's Government share the concern of noble Lords about this appalling situation. The Department for International Development and the Department of Health are taking serious steps—both bilaterally and in collaboration with multilateral organisations—to help governments reduce the transmission of STDs and HIV/AIDS. They are also assisting them to provide cost-effective treatment to those already infected.
DfID's main channel for bilateral assistance—the Know-how Fund—is helping the Russian Government develop a co-ordinated, public health strategy for STD control throughout the Federation, and is helping Samara Oblast to establish a more effective "model" STD service. We are also working with the health department in Sverdlovsk Oblast to develop a strategy to prevent the transmission of HIV among intravenous 1518 drug users. As noble Lords rightly said, that is the main means of transmission at present. That assistance will, it is to be hoped, make STD and HIV prevention services more accessible to poor and marginalised groups (the homeless, unemployed and migrants) who experience a particularly high incidence of STDs and HIV.
Elsewhere in the region, the Know-how Fund is supporting efforts by international organisations to improve reproductive health services. Support extends from Latvia, to improve the availability of contraceptives through social marketing, to Kazakhstan and Kyrgystan in central Asia, where national governments use British know-how to develop sex education strategies, particularly for adolescents.
In addition to British Government efforts, the World Health Organisation has a vital role to play. The Department for International Development is supporting the task force referred to by noble Lords. It not only funds participants in the task force, but will also provide financial support to the secretariat. I shall say more about some of those initiatives in a moment.
The noble Lord, Lord Kilmarnock, asked: is it our business? He clearly answered the question—yes, it is our business. The problem is already affecting western Europe and the UK. Dr. Alexei Gromyko, who is the WHO's adviser in STDs and Aids for the European region, has recommended that the countries of the European Union support concerted public education campaigns for the whole of Europe, western as well as eastern Europe. We shall be pursuing that.
There is already evidence that a proportion of western Europe's cases of infectious syphilis are associated directly with transmission in Russia and elsewhere in eastern Europe. A recent report on syphilis infection in England and Wales between 1994 and 1996 states that 20 per cent. of UK cases were already associated with transmission from the former Soviet Union. Moreover, there are long-term implications for eventual increase in HIV transmission from the same source. We know from our own Landmark research in Tanzania, which was supported by the British Government and the European Union, that the presence of STD greatly increases the risk of HIV transmission, by a factor of three to five, and prompt and effective treatment of sexual infections can lead to a reduction in HIV transmission.
The incidence of HIV is increasing dramatically, from a fairly low level. In the Russian Federation there were 3,841 official notifications in 1997, but in January 1998 alone there were 6,378—in other words, twice the previous year's level in one month. The deputy minister for health said that he feared an AIDS surge in Russia. He implied, moreover, that the actual number of new cases could be as much as 10 times higher than official notifications and that we should not be deceived by the relatively low reported levels.
Noble Lords have referred to the reasons for this in Russia and central Asia: the enormous social and economic changes; migration; sexual mores; and, as the noble Lord, Lord Alderdice, stressed, the nexus of prostitution, crime and drugs in those unhappy parts of the world. Changes have been very rapid and have 1519 undoubtedly increased the tendency to unprotected sex and casual treatment of relationships and are associated in many cases with casualisation of life, migration, alcoholism, suicide, crime and divorce. Those are all part of the same problem—namely, the disintegration of much of society in Russia.
Another part of the problem relates to the state of health services within Russia. A relatively substantial provision not only has been discredited but is also not being used by the population. Historically, the level of STD surveillance was centred around a nationwide clinical service controlled by the ministry of health which was fairly draconian in terms of its identification and treatment. That has largely been rejected by the Russian population, who are no longer willing to subject themselves to stigma, sanctions and archaic and painful treatment. This has led to a rapid growth in poor quality, private sector STD treatment and also in self-medication, much of which is totally ineffective.
The noble Lord, Lord Lucas, asked whether we would throw money at the problem. It is clear that substantial resources in Russia are still being spent on health, but they are being spent ineffectively. Expertise, technical advice and capital help from both public and private sources is in many cases the most important way in which we can help, expertise perhaps being more important than money.
In terms of the British Government's response to this crisis, there are clearly some things we can do on our own and much that we can do through the WHO and the UN and potentially through the EU. We have substantial experience and technical qualifications. We have the experience of our AIDS education process and the STD services and information to which the noble Lord, Lord Alderdice, referred. Much of that is relatively easily transferred to other countries provided we can establish the networks and the willingness to learn and listen.
Starting from scratch, at the beginning of this year as we became increasingly aware of the crisis, the Department for International Development now expects to invest up to £1 million in helping the Russian Government to develop a comprehensive strategy for combating sexually transmitted diseases. That will include some of the projects to which I referred. It will also include assistance to health departments in various parts of Russia and help to develop strategies for preventing the spread of HIV among intravenous drug users. That will comprise primarily a health promotion campaign aimed at intravenous drug users, peer group counselling and the development of targeted health services, of all of which we have substantial experience in this country. It could serve as a model for other cities in Russia and other countries where HIV transmission through intravenous drug users is the most serious problem.
There may be other areas in which we can help. I was taken with a reference by the noble Lord, Lord Alderdice, to the supply and price of condoms, which is an obvious but important aspect of the control of the transmission of these diseases. We are already helping in both Latvia and Moscow to try to develop the social marketing of condoms and we should perhaps 1520 look at developing that area in association with some of our partners. The Know-how Fund, to which I referred, is already providing substantial assistance in Russia, in St. Petersburg in particular, and in Kazakhstan, and elsewhere is providing sex education. In Latvia the social marketing of contraceptives is being supported. The Know-how Fund is not a money fund: it is primarily a fund which provides expertise and technical help.
There is also the whole question of research and knowledge generation and new technologies and innovative health approaches are needed. We are making a significant contribution in those areas as well. We are supporting the MRC's action in search of an HIV vaccine and we are also supporting work at the London and Liverpool Schools of Hygiene and Tropical Medicine.
In terms of the work that is being done with the World Health Organisation, the DfID representatives are fully engaged in that work, and British expertise will be used. The task force to which noble Lords referred recommended urgent action for the control of potential STD epidemics in the region. It focused on prevention and health promotion designed particularly for at-risk groups and implementing a public health strategy for controlling STDs, with stress on access, confidentiality and the integration of STD care with primary and family planning sectors. The World Health Organisation is clearly the main multilateral organisation for transmitting those efforts.
A number of noble Lords criticised the lack of activity within the European Union on this matter. My honourable friend the Minister for Health. Tessa Jowell, has taken on board the problems within this area and agrees that some consideration at European Union level will be taken; whether or not the 30th April Council meeting is the appropriate point is not clear. It is not at this point on the agenda. She has certainly undertaken to pursue that issue with her colleagues.
It is true that the powers of the European Union are relatively limited in this area under the article in the Maastricht Treaty referred to by the noble Lord, Lord Kilmarnock. They will be extended slightly under the Amsterdam Treaty, but that has not yet been ratified. Much will depend on the efforts of member states acting collaboratively rather than through the European Union itself. Nevertheless, we agree that the issue should receive greater prominence in the public health strategy of the European Union in conjunction with other activities which are being pursued under the British presidency. These relate particularly to the drugs trade, the trafficking in women and other sex trades and other international crime. These are issues which my friends in the Home Office and elsewhere are pursuing with their colleagues in our war on international crime during the British presidency. Much of that relates to the problems that arise in this area. In addition, noble Lords referred to the UNAIDS programme, in which we are participating fully and trying to mobilise both agency, NGO and private sources in order to tackle the problem.
1521 We sometimes forget in this country that we are in a privileged position in that our free and open access to genito-urinary medicine and clinics ensure that confidential information, testing and treatment for all sexually transmitted diseases is readily available to us and to visitors. That was not the case under the old Soviet Union and it is not the case in the newly independent states. We also carry out national and local health promotion campaigns for HIV and other sexually transmitted infections. We are committed to transferring 1522 this experience to partners in eastern and central Europe. We are working with WHO and UNAIDS to support national governments as they develop effective public health responses to these threats. If I have not answered points raised by noble Lords, I shall check Hansard and write to them. However, I think that what I have said indicates our concern about these epidemics and our determination to ensure that we use all means to help those countries to tackle the serious social and medical problems that they face.
House adjourned at eleven minutes past three o'clock.