Billionaire financier and philanthropist George Soros never has been one to retreat from an intractable health problem.
Since 1979 Soros has contributed millions of his personal wealth to some of the world's poorest nations. Last year he invested $2.3 million to improve maternal and child health and medical education in Hungary. His network of foundations in 31 countries will provide $15 million to $17 million in grants and donations to health and medical programs this year.
Now, at age 67, the Hungarian-born money manager is upping the ante. In his largest gift ever, Soros will spend $500 million over three years in Russia (See related story in the international section, p. i34). Roughly $100 million of that will be invested in public health projects, exceeding the United States' own $95 million total foreign-aid contribution to the former Soviet republic last year.
Soros' goals are lofty: He wants to cure Russia's menacing tuberculosis epidemic and begin repairing the country's tattered public healthcare infrastructure.
In an interview with MODERN HEALTHCARE, Soros said he is intervening now because Russia's healthcare system faces a "crisis" and needs immediate rehabilitation. "The authorities are not in a position to do enough about it because the state itself is in disarray," he said.
Over the next three years, Soros' philanthropic arm in Russia will fund several projects, with an emphasis on maternal and child health. That's because children, he said, "are the future of the country, and they are also in very bad shape."
Seeking open societies. Soros' benevolence is influenced by the writings of 20th-century philosopher Karl Popper. Popper introduced the concept of an "open society," characterized by, among other things, a democratically elected government, moderation in politics and respect for diverse opinions. Soros' New York-based Open Society Institute promotes the idea by supporting educational, social and legal reforms and exploring alternative approaches to complex problems. The fall of the Soviet empire in 1991 presented Soros with a framework for helping build an open society there.
Soros, who lives in New York's West-chester County, acknowledges some personal reasons for focusing on Russia. His father was imprisoned in a labor camp there during World War I.
"Yes, I have some emotional ties, but I'm not in any way favoring Russia to the exclusion of other countries," Soros said.
Once the Russian reforms are in place, Soros plans to move on to other targeted healthcare projects around the globe.
"This is only a temporary measure on my part until the (Russian) authorities are able to get their act together," he said.
Beginning in 1998, foundation leaders have proposed spending $7 million over three years to expand general practice and family medicine training in Romania. The country suffers from a lack of generalists, Soros said. His philanthropic advisers also are assessing needs in Georgia and Mongolia. Those programs will begin in 1998 as well, although specific funding amounts have not yet been determined.
Sources in the international aid community said the amount of Soros' gift to Russia is substantial, but the nation's healthcare needs are larger. Whether it will make a difference depends on how the money is spent, they said.
If it's used to leverage other commitments of money and manpower, then it can have a much larger impact, said Christopher Harris, vice president for emerging issues and international programs at the Council on Foundations, Washington.
Soros can get the most bang for the buck by concentrating on small projects, working with schools and hospitals to share medical knowledge, for example, added a spokeswoman for the U.S. Agency for International Development.
At times his brand of humanitarianism has riled critics. This summer, for instance, Soros donated $1 million to make sterile needles available to U.S. drug addicts at risk of contracting HIV. And last fall, he supported ballot initiatives in California and Arizona aimed at legalizing the medical use of marijuana.
Simple measures. In comparison, the Russian initiative seems relatively noncontroversial. His goal is to replicate and expand existing pilot projects in three areas: maternal and child health, medical education and information, and health promotion and disease prevention.
Much of it boils down to "simple, basic low-tech intervention," explained Abbey Gardner, a regional director for Russia at the Open Society Institute.
Gardner said one possibility is to expand local projects in which maternity ward physicians have been trained to encourage breast feeding, dramatically improving infant health. A lack of funding has prevented the model from being replicated, she said.
Russian women lack even up-to-date, basic information on what to expect when they are six months pregnant and how to care for a 5-month-old baby.
"Some people are using Dr. Spock if they can get their hands on it, which is obviously out-of-date American information that doesn't work in 1997," Gardner said. One solution, she said, is to commission a textbook author to fill the gap.
Soros and his staff have met with key leaders in Russia's Ministry of Health to garner their comments and approval. "Without the ministry's support, it would be impossible to successfully implement the program," Gardner said.
Officials hope to launch the Russian initiative within the next several months. Right now, they are busy canvassing the globe for an executive director to oversee the project.
Health targets. Soros already has written a $3 million check for the Russia project. The money, part of a $12 million grant, will go for a three-pronged attack against Russia's rampant tuberculosis epidemic and poor infection-control practices. Later, at least $6 million will be devoted to eradicating TB in Russia's prison population. It is estimated that 8% to 10% of the nation's 1 million inmates are infected with the disease, he said.
The TB project will be headed by Alex Goldfarb, a researcher at the Public Health Research Institute in New York. Goldfarb's team of researchers will begin by collecting sputum samples in Russian jails. If those specimens show that prisoners will respond to drug therapy, then clinical researchers will begin training prison personnel to administer "directly observed treatment" programs.
According to the World Health Organization's 1997 report on TB, having health workers watch patients take their anti-TB medications is cost effective, cures patients and stops the spread of TB. Yet it is still not widely used. Between 1991 and 1994, TB case rates in Russia climbed 42% and death rates soared 87%, the report said.
If the sputum samples collected in Russia's prisons show a high incidence of multiple drug resistance, "then we have a real disaster on our hands," Goldfarb acknowledged. Treating a single drug-resistant case requires expensive drugs and isolation.
A second leg of the TB project focuses on reforming treatment in the general population. Russians still rely on old X-ray diagnostic procedures and long hospitalizations to treat the disease, and they lack the drugs that have been shown to work. In the long run, Russia could save a lot of money on TB treatment, Goldfarb said, but first the old system needs to be dismantled.
"There's no point in throwing good money on introducing (directly observed therapy) protocols on top of an inefficient system," he said.
Goldfarb hopes to spend money on two or three pilot projects demonstrating the effectiveness of nonhospital, community-based treatment. "If we were able to help the Russians plan the transition from the traditional hospital-based system of TB control to the community-based (directly observed therapy) program that is recommended by the (World Health Organization) . . . then I think we would accomplish something," he said.
The final $1 million of the $12 million grant targets Russia's poor hospital infection-control practices. The money will pay for a state-of-the-art laboratory where technologists and clinicians will be trained in modern microbiology.
Small steps. Foundation officials measure Soros' philanthropic success one program at a time.
One of their proudest achievements is a partnership with the city of Cluj, Romania, where they established "the first baby-friendly hospital in Romania," said Srdjan Matic, director of network medical programs at the Open Society Institute. He said the city donated the building and spent $1 million on reconstruction. Soros' foundation in Romania spent $200,000 to $250,000 on equipment and supplies and introduced the idea of integrated medical teams, in which nurses, physicians, midwives and technicians coordinate care. The hospital offers privacy during labor and delivery, and newborns get to stay in their mothers' rooms.
But in his classic shoot-from-the-hip style, not even Soros can say for sure whether he'll be able to make a difference in Russia.
"I don't believe in being able to calculate these things too closely, and we haven't made any profound needs assessment studies," he said nonchalantly. "We just recognize the need is there. We'll do the best we can."