While Congress participants steadily stream in, members of the Society's committee meet with the local conference organizers in the magnificently furnished reception room. The mahogany table is covered with sakuski—cold meats, fish, eggs, and gherkins. To drink (even so carly in the morning), we are presented with a choice of Moldovan champagne, vodka, tea, or instant coffee. The dignitarics of the Yekaterinburg health authorities soon arrive: young executive-types in elegant, well-cut, dark-blue suits and white shirts who sharply contrast the soberly dressed professors and hospital consultants.

The general discussion focuses on the serious problems that face this city of more than a million inhabitants, located at the eastern foot of the Ural Mountains on the border between Europe and Asia. Until only a few years ago, it was called Sverdlovsk after one of the earliest Bolshevik revolutionaries. Perestroika prompted the restoration of its original name, Yekaterinburg (after Catherine I, tsarina 1725-1727), and removed its designation as a so-called closed city. Because it was the site of giant armaments factories, no foreigner had been allowed to visit Sverdlovsk.

In 1992, the city's name hit the western press when President Yeltsin admitted that an accident had occurred there on 2 April 1979 at a factory manufacturing weapons for biological warfare. Large quantities of Bacillus anthracis spores had been released into the atmosphere. In a roughly oval-shaped area extending to the southeast across the city (there had been a northwesterly wind that day), 77 people contracted anthrax; 66 of them died. Details of the disaster came to light only 2 years ago [1]. A few hundred kilometers south of Yekaterinburg is the site of another environmental catastrophe, the region near Chelyabinsk surrounding the Mayak nuclear reactor that manufactured plutonium for weapons. Here, between 1949 and 1956, 76 million cubic meters of highly radioactive liquid waste were released into the Techa River. Along a 150-km stretch, the population takes its drinking water from the river and uses it to irrigate the land. Together with their Russian counterparts, U.S. scientists are currently investigating the effects on health of this heavy radioactive contamination, which has led to a sharp increase in the incidence of various malignant diseases [2]. In addition to these spectacular environmental disasters, Yekaterinburg has been and still is affected by the constant emission of fumes and effluent from its heavy industry: The city is also a center for processing of the rich yields of minerals and ores from mines in the Ural Mountains. The ubiquitous pollution assails the senses even when one is strolling along the wide boulevards; Yekaterinburg is dusty and polluted. Indeed, many chimneys are now cold because armaments factories and other plants have ceased to operate. Unmistakable signs of this can be seen in the many young men who loaf around on the park benches all day, playing cards and drinking vodka.

Yekaterinburg also achieved somewhat dubious fame earlier this century when the last Russian tsar, Nicholas II, and his family and attendants were shot on the night of 16 July 1918. The Ipatiev house, where the executions took place, was torn down a few years ago when Boris Yeltsin was party secretary in Sverdlovsk. On the roughly leveled site, a temple is being built "on the blood of the royal family, to the glory of all the saints and the Russian earth."

In the meantime, the auditorium of the conference hall has filled mainly with young physicians; women are far and away in the majority. They have traveled from almost all corners of this huge country to broaden their knowledge during these 2 days. The conference is dedicated to the famous Russian nephrologist Eugene Michailovitch Tarcev (1895-1986) on the 100th anniversary of his birth. A lengthy address in his honor, given by the chairman of the Russian Society of Internal Medicine, opens the conference. Then, as a foreign guest of the Congress, I am warmly welcomed. I have been invited to present a paper in Russian on "AIDS [the acquired immunodeficiency syndrome], the situation in 1995." Everyone listens with great interest because infection with the human immunodeficiency virus (HIV) in Russia is veiled with taboos and equated with promiscuity. Precise figures on the prevalence of the infection in Russia are not available, and they probably do not even exist [3]. Representatives of the Ministry of Health speak of some 100 cases in a country with a population of 150 million. A Russian colleague cynically remarks that there is a low prevalence of AIDS in Japan because that country is already living in the 21st century, whereas there are few cases in Russia because it is still back in the 19th. He points out that many people refuse to be tested for HIV because they do not trust the laboratory equipment or are afraid that they may become infected with the virus if their blood is collected with a reused, inadequately sterilized needle. In 1988, several hundred children were infected with HIV in this way in the Kalmykia Republic of the Russian Federation [4]. The same colleague further explains that the fear of dirty needles is also an important reason for the diminishing use of vaccines in the population, which has led to a rapid spread of diphtheria.

The large number of prostitutes hanging around in bars, restaurants, and hotel foyers, waiting for customers who can pay in dollars or German marks, makes it abundantly clear that the danger of rapid spread of HIV in Russia should be taken seriously. Abuse of intravenous drugs does not stop at the Russian border, either [5].

After the lecture, I give guidelines for HIV prophylaxis. These guidelines are warmly received, but some colleagues shrug their shoulders resignedly and explain that even the most simple preventive measures often cannot be carried out because of the lack of necessary materials. Apart from the dearth of equipment, Russian physicians today have a scarcity of information about advances in medical knowledge. Few institutes and hospitals can afford to subscribe to the leading medical journals, and the language barrier, which particularly affects the older generation, presents a substantial problem. The dean of a Russian faculty of medicine points out that in the former Union of Soviet Socialist Republics, any physician who learned English, German, or French was immediately suspect. Young students now enthusiastically learn foreign languages to enable them, for the first time, to make contact with the rest of the world.

This year's Congress has the theme Emergency Situations in Internal Medicine. One state-of-the-art lecture follows another, most given by senior leaders of Russian medicine. In comparison with the annual meetings of the American College of Physicians, where most papers are presented by young, dynamic research workers and clinicians, the higher average age of the lecturers here in Yekaterinburg is immediately obvious.

A.P. Golikov from Moscow, speaking on management of hypertensive crises, warns of compromising the cerebral blood flow through a too-rapid decrease in blood pressure and recommends nimodipine as the treatment of choice.

A.V. Tuev from Perm presents a study intended to show the antiarrhythmic effects of antioxidants. The author has already filed this method of treatment with the Russian Patent Office and tells us the patent number.

E.P. Kamisheva from Nizhni Novgorod, speaking on emergencies in patients with diabetes mellitus, shows impressive statistics on comatose patients seen in the emergency department of her hospital. Of these cases, 56.2% were in a diabetic coma, 26% were in a coma resulting from alcohol intoxication, and 17.8% were in a coma because of other causes. Among other things, these figures indicate the scale of the alcohol problem in Russia.

L.A. Leshinski describes a randomized trial of patients with unstable angina pectoris in which endovascular laser irradiation of the blood, in combination with tocopherol, turns out to be superior to conventional treatment. Details of the technique are not given, but circulating blood in a peripheral vessel was apparently exposed to a laser beam for 15 minutes during 7 or 8 treatment sessions.

In Yekaterinburg, the close collaboration between the University Institute of Mathematics and the Faculty of Medicine is of great scientific importance. A.V. Lirman lectures on the development of mathematical models and algorithms for the diagnosis and treatment of medical conditions. In a round of discussions held in the maths-institute before the Congress, one of the mathematicians told me that since many armaments factories have closed, his institute now has more time to solve formulated medical questions. Considering the high standards of Russian mathematics, this is a promising development for the future.

Between the lectures, representatives of pharmaceutical companies are given the opportunity to address the delegates and commend the virtues of their products.

Most speakers read their papers straight from the script, an approach does not, of course, enthrall the listeners. The slides shown on the antiquated projector are often difficult to read, mainly because the writing is too small (a problem with which we have to contend time and again at our medical meetings). Discussions at the end of the lectures are remarkably polite and disciplined. The questioners show great respect for the eminent authorities on the rostrum. This is also a notable difference from western congresses, where pleasure is often taken in trying to lead the speakers onto thin ice. As mentioned, most of the physicians in the auditorium are women; most of the speakers, however, are men. The senior positions in hospitals, professional associations, and the Ministry of Health are also held by men—not very different from the situation in western countries. Talking to female Russian physicians, one repeatedly hears of the extremely heavy workload they have to bear. In addition to full schedules in hospitals or outpatient departments for low salaries, they have to do all the domestic chores on their own and collect the children from daycare centers and supervise their homework. In Russia today, all this is still more labor-intensive than it is in Europe or the United States.

Lunch is offered to the speakers and the organizing committee in the house restaurant. The menu consists of solyanka, a well-seasoned soup, followed by blinis, small meat-filled pancakes. The accompanying beverage of cranberry juice causes the academics to turn up their noses—there is a saying in Russia that not even a dog eats blinis without vodka. A large bottle of the national spirit immediately appears on the table, and the drinking beings. As usually happens in such circumstances, toast after toast is proposed: to friendship, to international cooperation, to the women (in general), and so on. A visitor from the West is predictably obliged to join in, and it is as well to be prepared for this: One need not be a physician to see that far too much drinking still occurs in Russia. In fact, the problem is so serious that many people emphasize that they are teetotalers when applying for a job.

On my way back to the airport, a dazzlingly white Cadillac limousine, occupied by four grim-looking characters wearing dark glasses, overtakes us at high speed. The limousine is closely followed by an equally pristine U.S. jeep with oversized wheels and two flashing blue lights on the roof. In the front sit two bodyguards, also in dark glasses; in the rear, a large, fearsome bloodhound is enthroned. The underworld is on its way to work.

A version of this manuscript originally appeared in Schweizerische Aerztezeitung under the title "Der Jekaterinburger Kongress."