While some -- in an idealist & workerist fashion -- may argue for the virtue of intellectuals like medical doctors becoming acquainted with the "dignity of manual labor" via growing potatoes, etc., I think that _a society that cannot support medicine as a profession_ under the conditions of free health care, with medical supplies, equipment, pharmaceuticals, etc. always ready at hand, is _a society in dire straits_.
_Doctors should save lives, instead of growing potatoes for survival_. They should also be given sabbaticals, so they can devote themselves to professional development, always keeping up with the latest scientific discoveries.
Yoshie
***** The New York Times December 16, 2000, Saturday, Late Edition - Final SECTION: Section A; Page 1; Column 1; Foreign Desk HEADLINE: Russia's Doctors Are Beggars At Work, Paupers at Home SERIES: FREEDOM'S TOLL: Saving Lives, Growing Potatoes BYLINE: By CAREY GOLDBERG with SOPHIA KISHKOVSKY DATELINE: KOSTROMA, Russia
Nineteen-year-old Anya, a deaf, blue-eyed china doll of a girl, was hemorrhaging out of control after giving birth.
Dr. Aleksandr N. Klesarev and his team fought to save her as her heart stopped three times, as her uterus had to be excised, as she lost such a river of blood that soon nothing ran in her veins but transfusions.
Anya and her baby survived, and Dr. Klesarev recalled that recent case with the joy of victorious battle. Emotionally, acute medical crisis is the easy part of his job.
It is the chronic crisis that grinds him down, him and the nearly 700,000 other Russian physicians. It is feeling like beggars at work and paupers at home. It is scrounging for essential medicines in a system fraying and breaking from poverty even as rising illness and mortality mean that people need doctors more than ever. It is getting their trained hands calloused from working in the private vegetable plots that feed their families.
Soviet doctors never had anything like the status and money of Western doctors. The medicine they practice was considered to be below the levels of the West, the system always suffered from shortages, and the social status of a provincial general practitioner was akin to a schoolteacher's, respectable, but modest.
That was especially so in provincial centers like Kostroma, an ancient city of 280,000 on the Volga River known among Russians as the wellspring of the Romanov dynasty, a city that was in decline long before the Soviet Union collapsed. But under Communism, doctors at least lived no worse than anybody else -- and maybe a bit better.
That has changed. Caught between an impoverished government that cannot afford universal medical care and a deep-rooted Soviet scorn for medicine-for-profit, many of Russia's doctors, especially here in the provinces, seem worn thin, out of canteen water but still marching ahead.
"When everything else took the capitalist road of development, and medicine was left on the socialist road, we got an imbalance that is killing medicine," said Dr. Aleksei Golland, one of a handful of private doctors in Kostroma.
"It's an economic death," he said. "If it continues like this, I see the murder of medicine in that the masses of quality doctors don't have ground to stand on. A surgeon has to plant potatoes to feed his family."
Ask what keeps the government-paid doctors going and the same words keep coming up: Vocation. Duty. Mercy. Naked enthusiasm.
A hospital department head said he could not afford to buy a suit. A gynecologist boiled potatoes for lunch in an office teakettle. Some doctors, city officials say, often walk to work because they cannot afford to pay the equivalent of a dime to ride a bus.
'They Hope for the Best'
Aleksandr N. Smirnov, until recently the chief doctor of the 900-bed Kostroma Regional Hospital, recalled that he had to take a string of vacation days because he needed the salary advance to pay urgent bills. Doctors and other hospital staff members generally work six-hour shifts, he said, but so many now extend their hours for extra pay that the 1,760 jobs in the hospital are filled by just 1,230 workers.
Still, the doctors keep donning the high cylindrical hats that go with their white coats, keep scribbling diagnoses on flimsy newsprint, keep trudging to house calls by bus and by foot.
Beg them, "Tell me something good!" and they reply: At least we can talk freely about this. At least we don't stand in lines anymore. We have access to Western drugs and technology and literature now, though rarely the money for them.
Or: For doctors with profitable specialities, life can be better than it was. And for the population, most medical care is still free, at least theoretically.
Young people also have not been deterred. There are four or five applications for every spot at the Yaroslavl Medical Academy, a school housed in graceful prerevolutionary buildings where many of Kostroma's doctors studied, said Yuri Novikov, its rector.
Many of the roughly 500 students come from medical "dynasties," he said, "people who hear about medicine beginning in their diapers, from their mothers and grandfathers." They know they will not get rich, but believe that at least a good doctor can always find work.
"Our people have a good trait: They hope for the best," said Marina Korzina, an 18-year-old student at the academy. "We have enthusiasm. We can develop without equipment. If you look at the past, we didn't think about the material side of things."
A few doctors are doing pretty well. There are a handful of legally private doctors. And there are the doctors who practice a sort of black-market medicine in which they operate in state facilities, but charge their own little tolls.
A 1997 national survey estimated that Russian families were charged some $4.5 billion that year for medical care that was supposed to be free -- and paid $1.4 billion more in bribes.
No doctor admitted taking such payments, but all acknowledged that such fees went beyond the old custom of giving doctors gifts -- candy or liquor, usually -- for good treatment. One Kostroma newspaper actually published a list of going prices for "free" medical services.
But for many doctors, this is still unthinkable after generations of providing free service.
"I can't remake myself and take money for a consultation, though some doctors have foreign cars and live in villas," said Valery Mochalov, 51, a surgeon who heads the hospital's emergency consultation department. "Why? They take money. We call it 'a bribe.' When they say, 'We can operate on you, but we have nothing, and I'll find everything for you, and you pay me.' "
Or worse, he said, "when a surgeon says, 'I can operate on you hungry and angry, or, if you give me money, I'll be full and happy.'
"That's the kind of extortion that happens, and so the patient pays," he added.
Dr. Klesarev, 41, who helped save Anya, works nearly double time, but still earns a little more than $115 a month. That is not bad in a city where the average doctor's base pay is about $30 a month, just $1 above the poverty line, according to city officials.
But it cannot begin to support him, his wife, Larisa, and two teenage daughters, Veronika and Nastya, plus a black poodle named Rocky. They live in one room of his mother-in-law's two-room apartment, with brown standard-issue Soviet wallpaper in a crumbling Khrushchev-era building. He and his wife share a fold-out bed; his daughters share another across the room.
They have no prospects of getting a place of their own. Once, hospitals built apartments for doctors; not anymore. A rare ration of milk is the main remaining official perk. With infections on the rise, they also get a free test for AIDS.
In Dr. Klesarev's home, the television is in his mother-in-law's room, so he must ask her permission to watch it.
He does not want much. He would like, he said, "to drive in my own car and lie on my own couch with my own television with my own remote control -- I can't do that in our apartment."
With his wife, he recently calculated that they need about $50 or $60 more a month to live adequately. Mrs. Klesarev, a bookkeeper, has worked at several promising jobs lately, but none quite panned out.
So they constantly deny themselves. And like virtually every other family here, they grow potatoes to save on food bills.
"It's hard," Dr. Klesarev said. "You get tired, and it's not right to plow the earth with a doctor's hands."
Several years ago, his wife managed to get to America and worked there for more than a year to build up some savings. In America, she said, "I cleaned the houses of doctors," adding: "When I said my husband was a doctor, they looked at me like I was crazy. 'How can your husband be a doctor and you're cleaning houses?' "
Dr. Klesarev would love to come to the United States but most likely, he said, his family will return to Crimea in Ukraine, where he worked for 15 years until 1998, even though Ukraine's economy is worse than Russia's. At least they own an apartment there. Maybe then, he and Larisa might pursue her idea of opening a health club for women.
But he is torn.
"I save lives," he said. "That is what I've always done. I don't do anything else, and I won't, though I'd consider doing something in parallel, like treating pets. But there is no opportunity for that right now."
Swarthy, bearded, cigarette constantly nearby, and with the steadiness of someone who has seen too many real emergencies to dramatize the mundane, Dr. Klesarev talked about the difficulties of his life without undue emotion, much as he described amazing cases of his past: the man cut to shreds when a diving tank he was inflating ruptured; the camp stove that blew up in the faces of a dozen people, killing two. (If that happened during the current shortages, he said, "We'd lose half of them.")
His family is proud of his work as the head of the department of anesthesiology and intensive care in the hospital's perinatal center. But he was openly bothered by the humiliations: the begging he must do from patients, whom he must ask to buy their own needles and bandages and drugs, and from colleagues.
After the deaf mother, Anya, got through that critical first night, for instance, Dr. Klesarev had to begin the "getting" that takes up, he estimates, more than half of his time. He had to hit up colleagues for drugs from their personal reserves. He had to wheedle blood out of the nearly empty bank and wangle baby formula to feed Anya herself. He had to block the use of a Russian-made device for her tracheotomy, declaring, "Maybe Dr. Pavlov used that kind of contraption with dogs at the turn of the century!"
In general, Dr. Klesarev said, this is a typical exchange: "I call the central pharmacy and say, 'I need this,' and they say, 'Oh, we don't have the money, and you can't get it.'
"So you get the money from the relatives. You summon the relatives and say, 'We know it's expensive, but if you want a normal relative, get it.' If they can't get it, we have to replace it however we can."
In Anya's case, he said, there was no money, so he begged as best he could. A modern tracheotomy tube came from the private reserve of the head of intensive care, for instance.
Anya ultimately went home with a healthy baby, he said, thanks to the adage, "If everyone in the community gives a thread, the naked man gets a shirt."
A Private Revolutionary
A few doctors in Kostroma, some in desperate financial shape or simply ambitious, are slowly entering private medicine.
But that transition involves wrenching psychological change, as they reconcile themselves to the idea that it is morally acceptable to charge for treatment. And opportunities are limited, several said, among so poor a population.
There is not one full-fledged private clinic here yet. The closest thing belongs to Bogdan Bilyak, 41, the best-known private doctor in Kostroma, a back-pain specialist who got into private medicine a decade ago under Mikhail S. Gorbachev's economic liberalization and has managed, through a forest of obstacles, to remain private ever since.
A suite of four rooms, with recorded music piped into the waiting room and a bright shingle outside, Dr. Bilyak's office would look ordinary in America. Here, it looks revolutionary.
There is talk that Dr. Bilyak is one of the richest people in Kostroma, and there are colleagues who envy him, he said, but they do not understand, nor could they undertake, what is involved: "To work, not five or six hours a day as in the hospital, but 8, 10, 12 hours a day, and then go home and not watch TV but open a book."
Moreover, Dr. Bilyak said, when he tries to persuade doctors to start a private practice, they balk, lacking the marketing and finance skills they would need. He feels them beginning to change, he said, but slowly.
"The medical system has not rebuilt itself," he said. "The only thing being rebuilt is the consciousness of our doctors; poverty is leading them to seek an alternative."
Dr. Golland, 38, is a newly private doctor. He left public medicine two years ago, and judging by the black-and-white houndstooth jacket he was wearing, one very like Dr. Bilyak's, he is doing well. (Neither would discuss the details of his finances.)
But Dr. Golland is still fighting to reform a system that he sees as doomed. "It's not underfinanced," he said, "It's a system that eats up all force; the money disappears somewhere, and it's not clear where."
These days, Dr. Golland has a small office and private patients he charges a few dollars a visit. On a recent day, he escorted a patient who needed a blood test to a nearby laboratory and got her in without standing in line. He would pay the lab a fee, he said, and the woman would pay him. That, he said, is the kind of "shadow medicine" that is thriving these days.
Svetlana Korotkova, a born pediatrician and general fireball, cares so much about her field that she found it too painful at first to watch the episodes of the American show "E.R." on Russian TV, she said. The contrast with Russian medical poverty hurt too much.
The children's clinic where she works opened only four years ago, and it looks as up-to-date and as well furnished as any in Western Europe. But Dr. Korotkova complained that there were no sterile metal tongue depressors and that the clinic is often short of examining room staples like cotton swabs and alcohol. The cleaning staff had little money for supplies, and there was no toilet paper in the bathrooms.
As Dr. Korotkova strode to a series of house calls, she said that in medicine she felt like a fish in water. She called on a 12-year-old girl who turned out to have nothing but a cold, and whose parents would not have to pay for the visit, then walked on to the next stop and continued her thought.
"Leave? " she said. "A pediatrician has no place to go. But I have adjusted a bit: I have my own private clientele now." True, they are just a handful of patients, but a beginning.
"I had to break my conscience to do it, to unlearn what the Communists taught about free medicine and free education," said Dr. Korotkova, who is 31. "But I've reached the point that I'm not ashamed of it anymore. I'm doing what I love."
Just recently, however, she thought, for the first time, about quitting altogether. She and some fellow doctors had been adding to their meager incomes by selling nutritional supplements, but the local government cracked down on such sales by doctors.
"When the decree came out, I thought for the first time of leaving," she said. "It's such an abyss, such a swamp."
But Dr. Korotkova is staying, and so are her friends and colleagues, Aleksei and Anya Furashov, husband and wife doctors, who not only work full time and raise two daughters but also run an evening club for pregnant women with Dr. Korotkova. They charge a modest fee to join.
But even the Furashovs wonder.
"You can't live on naked enthusiasm forever," Aleksei, 35, said. "The money issue is a powerful issue."
"Why can't I have an apartment and a car, while an illiterate person can?" he added, referring to street vendors. "And the problem is not just an apartment and a car; it's bread."
Though so many doctors described themselves as optimists, they are not short-term optimists. It will take a while, they believe, before they regain some measure of respect. Today, they know, they are looked on with pity.
"It will be no sooner than 20 years, maybe 15, when you will meet someone and they'll say, 'Oh, you're a doctor!" Dr. Klesarev said.
In the meanwhile, he lives on other rewards.
"When you get a patient who is five seconds from being dead and you get him out of it and 20 days later he walks out," he said, "you feel like Jesus Christ."
Freedom's Toll
Previous articles in this series examined the reasons for the decline in life expectancy in Russia since the collapse of the Soviet Union, looked at a Moscow hospital and gave an account of the spread of tuberculosis and other infectious diseases in Russia. Later articles will examine the declining birthrate and the prospects for improving the health of the Russian people. Articles in this series and related coverage are available at The New York Times on the Web: www.nytimes.com
GRAPHIC: Photos: SURGEON -- "A surgeon has to plant potatoes to feed his family," says Dr. Aleksander N. Klesarev, above and with his wife and daughter in their garden.; PEDIATRICIAN -- "I have my own private clientele now," Dr. Svetlana Korotkova says. "I had to break my conscience to do it." She is shown at left at home in the communal apartment kitchen that she shares with another family and, below, tending to the stomach pains of a 9-year-old boy. (Photographs by Jacqueline Mia Foster for The New York Times)(pg. A10)
Map of Russia highlighting Kostroma: Kostroma, an ancient city, was in decline long before the Soviet Union collapsed. (pg. A10) *****