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Finding a Remedy for Health Care

When anesthesiologist Dmitry Sedykh was called to treat an 8-month-old suffering from heart failure this May, he found no equipment to resuscitate the baby boy.

Sedykh, the only anesthesiologist in the village of Lesnoye in the Kirov region, was summoned to the children's ward of the local hospital to help little Alexei Artemikhin, who was in critical condition because of severe pneumonia.

The boy needed oxygen, but the hospital had no oxygen concentrator, a device used to provide oxygen therapy to patients. Like many small, rural hospitals, this one also lacked a centralized system in which oxygen is shipped through pipes. The hospital did have compressed oxygen in tanks, but because of the decrepit condition of the children's ward, fire inspectors had banned them from being used there.

All Sedykh could find was an antiquated oxygen pillow, a rubberized sac filled with oxygen from a tank. The oxygen passes from the pillow through a plastic pipe to a humidifier, where a nasal catheter then feeds it to the lungs.

"But there was not even a catheter to carry oxygen from the pillow to the baby's lungs. Do you think I am a magician?" Sedykh said by telephone from Lesnoye.

Sedykh took an adult oxygen mask and somehow adapted it to the baby's face. To humidify the oxygen, he filled a 20-gram syringe with wet cotton placed it between the plastic pipe and the mask. After pumping the pillow with his hands for a few minutes, he saw the boy's checks take on a rosy glow. Sedykh called for a nurse.

"I told her, 'Keep pumping this pillow. Maybe we'll be able to take the boy to the district hospital tomorrow,'" he said.

The boy needed a new pillow every 20 minutes. Nurses scurried in and out of the room as they filled pillows with oxygen from the tanks in the adult ward. The process continued day and night for a week before Alexei was finally transported to the larger district hospital in the town of Kirs.

Inventive medical treatments are just the tip of the iceberg of the health care crisis facing Russia. The country ranks a lowly 130th in terms of the effectiveness of its health care system and 127th in terms of its population's health, according to the World Health Organization. This means that the country is not only considerably behind developed Western countries but also the majority of East European and Latin American countries with a similar level of economic development.

At the same time, Russians tend to fall ill much more often than Europeans. In fact, Russians are 30 percent more likely to get sick than Europeans, according to WHO figures.

Like in most industrial countries, Russians suffer mostly from cardiovascular diseases. The number of heart disease patients -- 16 million -- places Russia second in the world, after Ukraine, said Raphael Oganov, the country's chief cardiologist.

Oganov blamed the heart disease on stress linked to the country's ongoing social and economic reforms and Russians' unhealthy lifestyles, which include a higher smoking rate than anywhere in Europe. Combined with the lack of timely medical checks and preventive programs, heart disease kills 1.3 million Russians per year, he said.

"We don't have any infrastructure for all this work like we had in Soviet times," Oganov said in an interview. "In fact, it is virtually true that hi-tech heart surgery centers can only be found in Moscow and St. Petersburg."

During the Soviet era, the state covered all health care expenses, and most of the population had access to medical care regardless of their financial status. This state health care model -- which is implemented in countries like Britain and Canada -- was rejected in 1991 and replaced with a model of obligatory health insurance, or OMC. But it was the state, not the people, who paid into the OMC fund. Although basic care under OMC is provided free to Russians, many procedures are not included in this compulsory plan.

"As a result, almost nothing is guaranteed for those who don't have any money or clout. These people, however, comprise the majority of the population," said Tatyana Chubarova, a senior health researcher at the Russian Academy of Sciences.

Private medical insurance is only held by about 15 percent of population, mostly purchased by big companies to insure their staff, Chubarova said.

Russia allocates 5.2 percent of its gross domestic product to public health -- roughly $561 per person per year. In contrast, the United States spends 15 percent of its GDP, while European countries spend up to 10 percent. This money covers the costs of medical care, including hospital maintenance, doctors' salaries and medications.

An alarming 70 percent of the equipment in regional hospitals is obsolete, but that is only the start of the problem for patients, said Tatyana Siburina, a researcher with the Health and Social Development Ministry.

"Patients are often asked to bring everything from cups to syringes with them when they are checked into the hospital," Siburina said.

Patients with serious diseases such as AIDS, tuberculosis, cerebral palsy, bronchial asthma, multiple sclerosis or Parkinson's disease have the right to receive free drugs in special pharmacies. But when the patients go there, they are often told that the medicine is not available, doctors and other health experts said. Doctors authorized to prescribe medicine to patients eligible for discounted or free drugs must select from those listed on the state-approved "essential drugs list."

"This list is meager and needs to be updated, so doctors do not have much to chose from," Siburina said.

The list is comprised of domestically made or cheap imported drugs.

But with expensive new imported drugs entering the market, some doctors are looking to supplement their meager incomes by effectively acting as distributors for pharmaceutical companies -- and patients end up paying more than they should for what might not be the medicines best-suited for their illnesses, said Rosa Yagudina, a laboratory chief at Sechenov Moscow Medical Academy.

Many doctors, however, seem to have few options if they want to make ends meet on their low pay, which comes from the state. An experienced professional like Sedykh collects 8,000 rubles per month. Nurses are paid 4,000 rubles. Seventy percent of Moscow medical graduates do not work in the public health sector, according to data from Moscow's health care committee. Alexei Artemikhin should count himself lucky that Sedykh was still working in the public hospital, when he could have taken a job in a pharmaceutical company or private clinic where salaries are much higher.

It is common practice for health professionals to accept money and gifts from patients and their relatives for services that are officially free, while many public hospitals earn much-needed cash by charging patients for "extra" examinations and treatments.

A Sickly Population

The woeful condition of health care is not the only cause of the crisis. Unhealthy lifestyles and risky behavior are killing Russians, especially men, whose average life expectancy is 59, one of the lowest in the industrial world. Interestingly, mortality figures have changed drastically for some population groups over the last century. For example, 40 percent of all infants died before the age of 4 in 1897 in Russia, while today almost all of them survive.

But with men aged 30 to 60, the situation has changed little since 1897. In fact, mortality among Russian men has risen by 60 percent since 1991 and is now four to five times higher than in Europe.

Along with heart and lung disease, alcohol consumption is a leading cause of death. Although official figures suggest that alcohol poisoning kills about 30,000 Russians per year, autopsies of people who died as a result of murder, suicide and other unnatural circumstances show that 64 percent of them had alcohol in their blood, said Alexander Nemtsov, a department head at the Moscow Scientific Research Institution of Psychiatry. "The total contribution of alcohol to overall mortality is roughly 50 percent," he said.

Smoking kills 300,000 to 400,000 people per year, and it plays a role in up to 52 percent of deaths blamed on heart disease, according to published studies. More disturbing, Russia ranks fourth in the world in teenage smoking. Some 60 percent of boys and 40 percent of girls smoke, the country's top public health official, Gennady Onishchenko, said in October. Tobacco consumption has increased by 50 percent -- up to 375 billion cigarettes per year -- over the past decade.

Risky behavior is responsible for an alarming growth in HIV cases. While officials say intravenous drug use remains the main way the virus is transmitted, cases of HIV being passed on by heterosexual intercourse are rising quickly. Eighty-six percent of new HIV cases are the result of intercourse, according to the Moscow AIDS Center, suggesting that HIV is now affecting the general population rather than just prostitutes and drug addicts.

More than 110 new cases of HIV are registered every day, adding to the official total of 415,000, according to the latest figures from the Federal Consumer Protection Service. But in reality, the number of those infected is more than 1 million, said Vadim Pokrovsky, head of the Federal AIDS Center.

"If each one of these people passes HIV to another person over the next five years, there will be 2 million HIV sufferers in Russia by 2012," he said in an interview.

HIV-positive people are supposed to get free treatment. However, the state is able to provide antiretroviral therapy to only 35,000 of them, Pokrovsky said.

Social decay is compounding the problem, facilitating the spread of once forgotten infectious diseases such as tuberculosis among low-income people. The WHO groups Russia among 22 countries at high risk for tuberculosis. It said in a report that Russia's plans to provide proper treatment to those with tuberculosis this year and last were not fully funded and that the treatment success rate was low. Russia has Europe's highest tuberculosis mortality rate, 30,000 people per year, or 20 times higher than in the West.

A combination of falling birth rates and rising death rates from chronic and infectious diseases means that by 2025, Russia's population will fall from about 142 million to about 125 million, according to data from the Center for Strategic and International Studies.

What the State Is Doing

The Problem: Health Care
What the Government Is Doing:
Spent 220.3 billion rubles ($9.3 billion) on health care as a national project over the past two years. President Dmitry Medvedev says $15 billion will be spent in revamping health care over the next few years.
Approved legislation, including Russia's recent ratification of the tobacco control treaty, which call for a complete ban on tobacco advertising within five years and higher taxes on tobacco producers.
Formed a commission to draft a strategy to develop health system through 2020.
Possible Solutions:
Create a more effective health care model
Provide adequate, regular funding of the health care system
Expand the state's presence in public health
Tackle social problems
Root out corruption

The government is well-aware of the challenge, making health care one of the four national projects eligible for billions of dollars in state spending in 2006. President Dmitry Medvedev personally oversaw the projects as first deputy prime minister.

Over the past two years, 220.3 billion rubles ($9.3 billion) have been allocated for the health care national project. Much of that money was allocated for the construction of 15 high-tech medical centers across the country, new equipment for hospitals, vehicles, immunization programs and salary raises for family doctors.

Under this program, 7.8 billion rubles were allocated in 2008 for the diagnosis and treatment of HIV and for preventive projects, an amount significantly higher than in previous years, Onishchenko told a United Nations conference in June. Financing will quadruple from 2006 to 2010.

Though designed to support individual sectors of the health care system, the project helped reduce the death rate from 15.2 per 1,000 people to 14.7 last year, Health and Social Development Minister Tatyana Golikova told a Cabinet meeting in March.

Medvedev has also declared it successful. "It has created somewhat better conditions for providing medical aid, but there is huge work ahead here," he said at a Kremlin conference devoted to health care and social development issues in April.

The government will pump about $15 billion into revamping health care over the next few years, Medvedev said during a visit to Italy last year.

In addition to boosting spending, some key legislative initiatives have been undertaken, including Russia's recent ratification of the tobacco control treaty that will implement a range of anti-smoking initiatives, including a complete ban on tobacco advertising within five years and higher taxes on tobacco producers.

Misspent Funds

The government's willingness to spend money is not always translating into better hospitals.

An investigation by prosecutors into Hospital No. 1 in Nizhny Tagil in June 2007 revealed that new equipment worth 8.45 million rubles that had arrived under the national projects program was not being used.

During a visit to the hospital, the prosecutors saw a new X-ray machine broken since February and a colposcope in the gynecology ward that remained unpacked, the Regnum news agency reported, citing prosecutors. The head of the ward explained that there were no doctors trained to work on the machine. Also, patients who needed circulation tests were directed to private clinics while two Doppler ultrasonography units stood in a locked hospital room.

"This situation is not unique. Many of the regions are incapable of making good use of the federal aid," said Siburina of the Health and Social Development Ministry.

Regional newspapers are full of details of the difficulties met by the federal aid. Although almost 60 percent of all ambulances in the Tambov region were replaced with new Gazel vans, the vehicles fell apart on the region's rough roads and spent more time under repair than on duty, the Novaya Tambovshchina newspaper reported in March. The report said emergency services ask for old UAZ jeeps in 76 percent of their calls for assistance.

The government's efforts have actually posed a headache for some regions in terms of finding and training personnel, especially when new high-tech centers were planned.

"When we build a new high-tech center we should consider who will work there," said Konstantin Shatalov, a prominent children's heart surgeon from the Moscow Bakulev Cardiovascular Center. Many of the best specialists have left the country for better-paying jobs abroad, and the low pay discourages many new specialists from entering public health, he said.

More Money, Less Graft

Well-known pediatrician Leonid Roshal is convinced that the national projects are good but that adequate regular funding of the health care system would be even better. Funding for public health should be at least doubled, if not tripled, by 2015, he said at a conference in April.

He said the Public Chamber's health commission, which he heads, had forwarded a report to Medvedev showing that life expectancy and death rates directly depend on funding for the health care system.

Financing is not the only challenge, of course. The government has not had a strategy for health development for the past decade.

The Health and Social Development Ministry formed a commission earlier this year to draft a strategy to develop the health care system through 2020. Everyone -- bureaucrats, the public, doctors -- are invited to discuss it on the web site

As a part of this discussion, experts will have to analyze the national health care model. Officially, the country has an insurance health care model, but in reality, it is funded by taxes. The state insurance fund oversees this money and uses private companies to manage the money as well, said Chubarova of the Russian Academy of Sciences.

"This system is not effective and not transparent, and it is also costing more money," Chubarova said.

All three typical public health models -- state, insurance and private -- have worked themselves out, said Natalya Grigoryeva, head of the Social Policy and Management Center at Moscow State University. There should be a new decision or a new approach to old things, she said.

"Maybe we need to look again at the state health care model, which we once brushed aside, not in order to return to the old Soviet system but to return to state funding and control," she said.

In many Western countries, the state is taking a larger presence in public health, and this is even more reason to replicate the trend in Russia, where most of the population is poor, she said.

"Public health should be an area of state responsibility in a country like Russia," she said.

Alternatively, state money could be offered in tenders among medical institutions, and patients could be fully informed of medical services, said Andrei Demin, head of the Russian Association of Public Health. "This would promote competition in the medical industry and develop the medical institutions properly," he said.

Also, he said, it would be impossible to bring serious improvements in public health without tackling general social problems. Most of the leading national causes of mortality are social.

"I do not know which strategy will win, but I am sure that the decision will be solely political, not based on economic demand," Grigoryeva said.

One of the country's most reputable doctors, however, said the real remedy for the national health care system was rooting out corruption.

"Why do you think Russia has done so well in football lately? Precisely because the coach we hired was not a part of the corrupt system. He did not care about anyone else's interests but his team's," the doctor said.

Dutch coach Guus Hiddink led the Russia team to the semifinals in the 2008 European Football Championship in June.

Corruption siphons off as much as 35 percent of money spent on health care, according to estimates from the Open Health Institute at the Russian Academy of Sciences.

For Sedykh, the anesthesiologist, the most important thing is choosing the right priorities. For one, every hospital should have an emergency room, while the current rules only allow district and larger hospitals to have them, he said. At the same time, rural hospitals have large general care wards that tend to be only half filled.

"In the Soviet era, the most important thing was the number of beds, not the equipment," Sedykh said. "Financing at any hospital still depends on the number of beds."

He suggested reducing the number of beds in general wards and using the money saved to open emergency rooms.

An emergency room would have made it a lot easier for Sedykh to treat Alexei Artemikhin. The doctors who tended to Alexei initially refused to send him to the district hospital in Kirs because of his condition.

Alexei, the son of impoverished parents, survived by a miracle, Sedykh said. The boy now spends his days between the Lesnoye hospital and his home.

"He is still very weak, and at 1 is not able to walk," Sedykh said. "But he is a really cheerful baby. I'm keeping an eye on him."


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