michael specter--times--russia's degenerating health

critical condition russia's degenerating health: rampant illness, shorter lives february 19,1995 TULA, Russia--Valery Yermokov's heart stopped beating as soon as he finished the quart of homemade vodka. A drug addict who could not possibly afford heroin, he had also injected a coarser opiate into his veins. By the time they wheeled him into the Semashko Emergency Hospital in this central Russian city, Mr. Yermokov was all but dead: He was breathing once a minute and his skin was cold. The doctors took a look at him and simply shook their heads. But after a few minutes--and a last-hope shot of adrenaline--Mr. Yermokov opened his wide green eyes and clawed his way back to life. "This time he made it," said Valentina M. Lyukovikova, 55, the chief doctor on duty in the hospital poison unit that night. "Next time he won't. You can only save people from themselves for a little while. And in Russia that's not very long." It would be tempting to conclude that Dr. Lyukovikova is a cold woman; she is quite the opposite. Yet working as a doctor in Russia today could turn Hippocrates's heart to stone. The death rates have never been higher in peacetime. Curable infectious diseases like diphtheria and measles have reached epidemic levels unseen since the fall of the Czars, and rates of tuberculosis, cancer and heart disease are higher than in any other industrialized country. It is hard to describe the health of the Russian people today without resorting to lists of despair: Only one child in five is born healthy, according to official statistics, which many experts say understate the problem. Since 1992 the average life expectancy for men has fallen from 62 years to 59 and is still falling--as it is for women, though more slowly. The death rate has risen by 20 percent, an increase with no modern precedent. In St. Petersburg, the country's most majestic and sophisticated city, life expectancy is even lower than the national average. "We don't have the medicine, equipment, training or money to deal with any of this," said Dr. Lyukovikova, leaning in the dusty, poorly lit corridor of this hospital against a cot that 10 minutes earlier had contained the body of a 32-year-old woman who had just died of alcohol poisoning. The case was like many others in Tula, a city with more than 600,000 residents, which in most ways is a perfect demographic slice of today's Russia. "It was never paradise. It was never what they said it should be. But I keep telling myself it can't get any worse. And I am always wrong." Almost half of the 1990 medical school graduating class-- doctors who are practicing throughout Russia today--could not even read an electrocardiogram on the day they got their diplomas, according to the Russian Academy of Sciences. On average, in part because many are women and in part because the medical profession has never had much prestige here, doctors earn less money each month than drivers or baby sitters--about $145. The United States devotes more than 12 percent of its federal budget to health. In Britain the figure is 6 percent. Russia has budgeted slightly less than 1 percent this year, about the same as the poorest African nations. Last summer, the Russian Health Ministry said that half of the country's 21,000 hospitals had no hot water, a quarter had no sewage systems, and several thousand had no water at all. "So you have to ask yourself, what is a hospital and what is a doctor," said Murray Feschbach, a demographer at Georgetown University who has monitored the health of the Russian population for decades. "Can you just hang a sign on any building in Russia and call it a hospital? Is being treated by a doctor any different than not being treated at all? The statistics are all so depressing it becomes impossible to even mention where this will all end up." Diagnosis: A System Crippled By Inefficiencies The despair is unavoidable. Here in Tula, about 100 miles south of Moscow, a special Deputy Health Commissioner does nothing but monitor and attempt to counteract the insidious effects of radiation from the Chernobyl nuclear disaster in 1986. Most of the region is still polluted by the fallout. There is a waiting list to get into a decrepit tuberculosis sanitarium that has neither heat nor hot water. Even the finest hospitals rely on rusty hot plates and ancient pots to sterilize instruments in the operating room. Although drugs are available, they cost far more than the city, the doctors or almost any patient could afford. In Tula, as in Russia as a whole, a third of the population is older than 60. The birth rate has never been lower. And, as in most Russian cities, the hospital system is like the factory system: cumbersome, inefficient and tooled for a world that no longer exists. There are far too many doctors (5,000) and hospital beds (25,000) and far too few nurses (8,500) in Tula to serve the population effectively. "The Russian health care system is essentially set up backwards," said Dr. Thomas L. Hall, an expert in hospital management and economics from the University of California at San Francisco, who has been advising the Government here for the World Health Organization. "They have thousands of gigantic institutions that serve very few people. Money is scarce but it gets wasted on doctors who don't know what they are doing. People spend too much time in the hospital. There is almost no health prevention, and no economic planning." In the United States today the average hospital stay is five days. In Russia, which has far fewer resources for health care, it is 23 days. The number of hospital beds per 1,000 people, considered one of the truest measures of cost efficiency, is twice as high here as in the United States. And while there is one doctor for every 450 Americans, there is one for every 275 Russians. Reasonable attempts to teach proper sanitary habits would save thousands of people from serious illness every year, health specialists say. But such programs are extremely rare. Russians smoke obsessively. But most doctors here do not even bother to try to keep their patients from smoking. They simply recommend that their patients buy American cigarettes, which are more expensive but lower in tar and nicotine than anything made in Russia. Dr. Hall said that personnel costs should account for about 70 percent of medical spending; the rest should go for supplies and equipment. Russia puts 95 percent of its resources into salaries, but usually for doctors who are so poorly trained that they are unable to diagnose the simplest ailments. There seems to be no quick way out of the crisis unless the country changes its priorities. Russia has no money for health, but under the present system more money would almost certainly be poorly spent. Doctors point to a fledgling movement to change the system as the only hope and say they are thrilled that President Boris N. Yeltsin has just decided to ban liquor and tobacco ads and to require anyone who continues to accept these ads to turn any revenues from them over to public health officials. "It sounds trite, but a nation's health is the main indicator of the social welfare of any country," said Dr. Yelena I. Chernienko, the director of Tula's public health system. "We have goods in the shops now and the ability to buy new computers. You can take vacations in Europe and buy color televisions. But who are those things for, I wonder, if we have a life expectancy of 55 in this country? We are dying at a rate that is almost impossible to describe. To me that is the most important fact about the possibilities of the New Russia." Prevention Top Culprits: Diet And Poor Hygiene Despite the complexity of the health problems Russians face, the sources of some of the avoidable illness are easy to trace, and with experience as their guide, it is not surprising that many Russians fear and hate doctors and the health care system. Anyone who undergoes any surgical procedure in Russia has an even chance of catching an infection in the hospital. In public opinion polls, most Russians list health as a major issue, second only to crime. Many big-city operating rooms resemble the clinics of rural 19th-century America in significant ways. There is no attempt at infection control; visitors are not even asked to wash their hands. There are no scrub nurses, truly sterile instruments are rare, blood is washed off the hospital floor with a garden hose. The heavy lights in many operating rooms were discarded in the West 30 years ago. Prevention is the cheapest and most effective way to treat any illness, but the concept has not gained much currency. Few people think about fat or cholesterol. Alcohol consumption, already among the highest in the world, is rising rapidly. Epidemiologists and environmental health specialists say improper treatment of two generations of industrial, conventional and radioactive waste has also begun to take a punishing toll on the population. There are few effective health regulations, and nobody really pays attention to those that do exist. Health specialists say that some of Russia's health problems could be prevented with relative ease and with little money. An inexpensive vaccine that has long been available could wipe out the country's diphtheria epidemic, for example. In the United States, with its population of 255 million, one case of diphtheria was recorded last year by the Centers for Disease Control and Prevention. Preliminary estimates for Russia's 148 million residents suggest there were nearly 50,000 cases, a rate of 31 per 100,000 people. In 1993, Russia had 15,000 cases of diphtheria. It is not yet clear why rates of infectious disease have soared so uncontrollably in the last two years. Poland, by comparison, recorded only a few cases of diphtheria last year; fewer than one resident in a million had the disease. "Our biggest shame is also an opportunity for us," said Dr. Galina M. Perfilyeva, dean of Russia's first graduate nursing academy, the I. M. Sechenov Medical School in Moscow. "We can make dramatic gains in health with even a little effort. We can use trained nurses better, teach people about vitamins, diet and exercise. This alone would save tens of thousands of lives each year." But she acknowledged that "our mentality in Russia is not to protect or prevent." "It hasn't been that long that people could even consider the idea of living a life to a natural end," she said. "But if we don't change soon it will be too late. People will forever believe that faith healers, fake doctors and medicine men are more likely to help them than trained professionals. That feeling makes it impossible to accomplish anything." A Cure: Building 'a Future Worth Living For' But health experts say Russia could improve conditions. Public health officials no longer live in an enforced Communist darkness here. They know what is known in the rest of the world: that bad diets, alcohol and tobacco cause more deaths each year than all other causes. The officials are frightened by the rising rates of infectious diseases, by the health problems of pregnant women and babies, and by the stunning unwillingness of the society to devote more money to health care. "Most of what we see here is inexcusable--it just shouldn't happen," said Evgeny P. Ivanov, chief of emergency medical services in Tula. "Every day people die of alcohol poisoning -- every day. Industrial accidents, too much smoking--these are what kill. There is no attempt at moderation. We are trying to change that but it won't happen overnight." Dr. Ivanov and many other young physicians are spending their free time these days canvassing neighborhoods and talking to people about the simplest medical facts: that washing hands and cleaning bathrooms matter, that alcohol is a poison and homemade alcohol often a deadly drug, that people actually feel better when they eat less. The same attempt at education has begun in Moscow, which even has a few billboards--dwarfed in number by cigarette and liquor advertisements--promoting exercise and healthy food. Private think tanks like the Public Health Research Institute in Moscow are springing up to make computer models of hospital systems that make sense. Confronted with proof that the right way is also the least expensive way, senior officials in the Ministry of Health are finally taking notice. "Twenty percent of our problems are medical and 80 percent are economic," said Dr. Valery E. Tchernayavsky, of the Public Health Institute, which is financed by the Ministry of Health and the World Health Organization. "We have shown people they can succeed cheaply. We are about to go on television with no-smoking ads. We are going to talk about sexual behavior and infectious diseases. One minute at the right moment can do more than a million dollars." "I admit we have a lot of work to do," he said, standing next to a computer model of Russia's most basic health needs for the next 30 years, which he worked up on a laptop computer. "But we are going to do it. These are some bad times--people have little confidence in the future. But things can change dramatically for the better as well as for the worse. We are going to convince Russians there is a future worth living for--and then we are going to show them how to live."



			critical condition russia's degenerating health: rampant illness, shorter lives february 19,1995 TULA, Russia--Valery Yermokov's heart stopped beating as soon as he finished the quart of homemade vodka. A drug addict who could not possibly afford heroin, he had also injected a coarser opiate into his veins. By the time they wheeled him into the Semashko Emergency Hospital in this central Russian city, Mr. Yermokov was all but dead: He was breathing once a minute and his skin was cold. The doctors took a look at him and simply shook their heads. But after a few minutes--and a last-hope shot of adrenaline--Mr. Yermokov opened his wide green eyes and clawed his way back to life. "This time he made it," said Valentina M. Lyukovikova, 55, the chief doctor on duty in the hospital poison unit that night. "Next time he won't. You can only save people from themselves for a little while. And in Russia that's not very long." It would be tempting to conclude that Dr. Lyukovikova is a cold woman; she is quite the opposite. Yet working as a doctor in Russia today could turn Hippocrates's heart to stone. The death rates have never been higher in peacetime. Curable infectious diseases like diphtheria and measles have reached epidemic levels unseen since the fall of the Czars, and rates of tuberculosis, cancer and heart disease are higher than in any other industrialized country. It is hard to describe the health of the Russian people today without resorting to lists of despair: Only one child in five is born healthy, according to official statistics, which many experts say understate the problem. Since 1992 the average life expectancy for men has fallen from 62 years to 59 and is still falling--as it is for women, though more slowly. The death rate has risen by 20 percent, an increase with no modern precedent. In St. Petersburg, the country's most majestic and sophisticated city, life expectancy is even lower than the national average. "We don't have the medicine, equipment, training or money to deal with any of this," said Dr. Lyukovikova, leaning in the dusty, poorly lit corridor of this hospital against a cot that 10 minutes earlier had contained the body of a 32-year-old woman who had just died of alcohol poisoning. The case was like many others in Tula, a city with more than 600,000 residents, which in most ways is a perfect demographic slice of today's Russia. "It was never paradise. It was never what they said it should be. But I keep telling myself it can't get any worse. And I am always wrong." Almost half of the 1990 medical school graduating class-- doctors who are practicing throughout Russia today--could not even read an electrocardiogram on the day they got their diplomas, according to the Russian Academy of Sciences. On average, in part because many are women and in part because the medical profession has never had much prestige here, doctors earn less money each month than drivers or baby sitters--about $145. The United States devotes more than 12 percent of its federal budget to health. In Britain the figure is 6 percent. Russia has budgeted slightly less than 1 percent this year, about the same as the poorest African nations. Last summer, the Russian Health Ministry said that half of the country's 21,000 hospitals had no hot water, a quarter had no sewage systems, and several thousand had no water at all. "So you have to ask yourself, what is a hospital and what is a doctor," said Murray Feschbach, a demographer at Georgetown University who has monitored the health of the Russian population for decades. "Can you just hang a sign on any building in Russia and call it a hospital? Is being treated by a doctor any different than not being treated at all? The statistics are all so depressing it becomes impossible to even mention where this will all end up." Diagnosis: A System Crippled By Inefficiencies The despair is unavoidable. Here in Tula, about 100 miles south of Moscow, a special Deputy Health Commissioner does nothing but monitor and attempt to counteract the insidious effects of radiation from the Chernobyl nuclear disaster in 1986. Most of the region is still polluted by the fallout. There is a waiting list to get into a decrepit tuberculosis sanitarium that has neither heat nor hot water. Even the finest hospitals rely on rusty hot plates and ancient pots to sterilize instruments in the operating room. Although drugs are available, they cost far more than the city, the doctors or almost any patient could afford. In Tula, as in Russia as a whole, a third of the population is older than 60. The birth rate has never been lower. And, as in most Russian cities, the hospital system is like the factory system: cumbersome, inefficient and tooled for a world that no longer exists. There are far too many doctors (5,000) and hospital beds (25,000) and far too few nurses (8,500) in Tula to serve the population effectively. "The Russian health care system is essentially set up backwards," said Dr. Thomas L. Hall, an expert in hospital management and economics from the University of California at San Francisco, who has been advising the Government here for the World Health Organization. "They have thousands of gigantic institutions that serve very few people. Money is scarce but it gets wasted on doctors who don't know what they are doing. People spend too much time in the hospital. There is almost no health prevention, and no economic planning." In the United States today the average hospital stay is five days. In Russia, which has far fewer resources for health care, it is 23 days. The number of hospital beds per 1,000 people, considered one of the truest measures of cost efficiency, is twice as high here as in the United States. And while there is one doctor for every 450 Americans, there is one for every 275 Russians. Reasonable attempts to teach proper sanitary habits would save thousands of people from serious illness every year, health specialists say. But such programs are extremely rare. Russians smoke obsessively. But most doctors here do not even bother to try to keep their patients from smoking. They simply recommend that their patients buy American cigarettes, which are more expensive but lower in tar and nicotine than anything made in Russia. Dr. Hall said that personnel costs should account for about 70 percent of medical spending; the rest should go for supplies and equipment. Russia puts 95 percent of its resources into salaries, but usually for doctors who are so poorly trained that they are unable to diagnose the simplest ailments. There seems to be no quick way out of the crisis unless the country changes its priorities. Russia has no money for health, but under the present system more money would almost certainly be poorly spent. Doctors point to a fledgling movement to change the system as the only hope and say they are thrilled that President Boris N. Yeltsin has just decided to ban liquor and tobacco ads and to require anyone who continues to accept these ads to turn any revenues from them over to public health officials. "It sounds trite, but a nation's health is the main indicator of the social welfare of any country," said Dr. Yelena I. Chernienko, the director of Tula's public health system. "We have goods in the shops now and the ability to buy new computers. You can take vacations in Europe and buy color televisions. But who are those things for, I wonder, if we have a life expectancy of 55 in this country? We are dying at a rate that is almost impossible to describe. To me that is the most important fact about the possibilities of the New Russia." Prevention Top Culprits: Diet And Poor Hygiene Despite the complexity of the health problems Russians face, the sources of some of the avoidable illness are easy to trace, and with experience as their guide, it is not surprising that many Russians fear and hate doctors and the health care system. Anyone who undergoes any surgical procedure in Russia has an even chance of catching an infection in the hospital. In public opinion polls, most Russians list health as a major issue, second only to crime. Many big-city operating rooms resemble the clinics of rural 19th-century America in significant ways. There is no attempt at infection control; visitors are not even asked to wash their hands. There are no scrub nurses, truly sterile instruments are rare, blood is washed off the hospital floor with a garden hose. The heavy lights in many operating rooms were discarded in the West 30 years ago. Prevention is the cheapest and most effective way to treat any illness, but the concept has not gained much currency. Few people think about fat or cholesterol. Alcohol consumption, already among the highest in the world, is rising rapidly. Epidemiologists and environmental health specialists say improper treatment of two generations of industrial, conventional and radioactive waste has also begun to take a punishing toll on the population. There are few effective health regulations, and nobody really pays attention to those that do exist. Health specialists say that some of Russia's health problems could be prevented with relative ease and with little money. An inexpensive vaccine that has long been available could wipe out the country's diphtheria epidemic, for example. In the United States, with its population of 255 million, one case of diphtheria was recorded last year by the Centers for Disease Control and Prevention. Preliminary estimates for Russia's 148 million residents suggest there were nearly 50,000 cases, a rate of 31 per 100,000 people. In 1993, Russia had 15,000 cases of diphtheria. It is not yet clear why rates of infectious disease have soared so uncontrollably in the last two years. Poland, by comparison, recorded only a few cases of diphtheria last year; fewer than one resident in a million had the disease. "Our biggest shame is also an opportunity for us," said Dr. Galina M. Perfilyeva, dean of Russia's first graduate nursing academy, the I. M. Sechenov Medical School in Moscow. "We can make dramatic gains in health with even a little effort. We can use trained nurses better, teach people about vitamins, diet and exercise. This alone would save tens of thousands of lives each year." But she acknowledged that "our mentality in Russia is not to protect or prevent." "It hasn't been that long that people could even consider the idea of living a life to a natural end," she said. "But if we don't change soon it will be too late. People will forever believe that faith healers, fake doctors and medicine men are more likely to help them than trained professionals. That feeling makes it impossible to accomplish anything." A Cure: Building 'a Future Worth Living For' But health experts say Russia could improve conditions. Public health officials no longer live in an enforced Communist darkness here. They know what is known in the rest of the world: that bad diets, alcohol and tobacco cause more deaths each year than all other causes. The officials are frightened by the rising rates of infectious diseases, by the health problems of pregnant women and babies, and by the stunning unwillingness of the society to devote more money to health care. "Most of what we see here is inexcusable--it just shouldn't happen," said Evgeny P. Ivanov, chief of emergency medical services in Tula. "Every day people die of alcohol poisoning -- every day. Industrial accidents, too much smoking--these are what kill. There is no attempt at moderation. We are trying to change that but it won't happen overnight." Dr. Ivanov and many other young physicians are spending their free time these days canvassing neighborhoods and talking to people about the simplest medical facts: that washing hands and cleaning bathrooms matter, that alcohol is a poison and homemade alcohol often a deadly drug, that people actually feel better when they eat less. The same attempt at education has begun in Moscow, which even has a few billboards--dwarfed in number by cigarette and liquor advertisements--promoting exercise and healthy food. Private think tanks like the Public Health Research Institute in Moscow are springing up to make computer models of hospital systems that make sense. Confronted with proof that the right way is also the least expensive way, senior officials in the Ministry of Health are finally taking notice. "Twenty percent of our problems are medical and 80 percent are economic," said Dr. Valery E. Tchernayavsky, of the Public Health Institute, which is financed by the Ministry of Health and the World Health Organization. "We have shown people they can succeed cheaply. We are about to go on television with no-smoking ads. We are going to talk about sexual behavior and infectious diseases. One minute at the right moment can do more than a million dollars." "I admit we have a lot of work to do," he said, standing next to a computer model of Russia's most basic health needs for the next 30 years, which he worked up on a laptop computer. "But we are going to do it. These are some bad times--people have little confidence in the future. But things can change dramatically for the better as well as for the worse. We are going to convince Russians there is a future worth living for--and then we are going to show them how to live."

			Copyright (1995) The New York Times Company. Reprinted by Permission. New York Times material may not be used in any manner except for personal reference without the written permission of The New York Times Company.