Posted on Mon, Oct. 16, 2006
Russian health care is ailing Good treatment available -- to the few who can afford it
By KIM MURPHY Los Angeles Times
KARABASH, Russia - He was 40 when he had his first heart surgery, a quadruple bypass to correct damage caused by the poisons of the ancient copper smelter where he worked.
But that was a decade ago, when the decrepit Russian health-care system still provided low-cost care to those who could wait.
Now, Mikhail Lychmanyuk has been told he will die unless he has a second heart operation. This time, it will cost him $5,000.
It might as well be a million.
''I'll wait for the end,'' he said, sitting in an empty playground in this desolate industrial town about 1,000 miles east of Moscow.
Russia's steep population decline in the 15 years since the collapse of the Soviet Union has many causes, but the end of the Soviet health-care system and the debut of free-market medicine have made matters worse.
In the new Russia, millions are born sick. Many succumb to poisons in the air and water, or are slowly killed by alcohol, cigarettes or stress. Most are too poor to buy back their health.
Medical care still is nominally free; in practice, all but the most basic services are available only to those able to pay hefty fees.
Bribes, the cost of superior treatment even in the Soviet era, are a feature of nearly every successful medical transaction, including being admitted to a decent hospital and the sense of well-being that comes with knowing that your doctor will perform his most diligent work.
For the well-off, mostly foreigners and those who struck it rich in Russia's transition from communism, there are gleaming ''European medical centers'' with modern equipment and foreign-trained physicians who charge $100 a visit. The rest are relegated to foul-smelling infirmaries with stained sheets and no food that often lack equipment as basic as a functioning X-ray machine. Doctors work for as little as $140 a month.
The Scientific Center of Children's Health, a branch of the Russian Academy of Medical Sciences, estimates that 45 percent of all Russian children are born with ''health deviations,'' including problems in the central nervous system, faulty hearts, malformed urinary tracts and insufficient birth weight.
Heart disease and strokes have increased by as much as 36 percent in the last five years for those under 40, said Dr. Yevgeny Chazov, personal physician to most Soviet leaders since the Leonid I. Brezhnev era, and head of the Russian Cardiological Center in Moscow.
Russian President Vladimir V. Putin has responded, pushing health care to the top of the nation's priorities. This year, his government is spending $24.6 billion to more than quadruple some doctor's salaries, build new hospitals, buy ambulances and equipment, pay for more surgeries, vaccinations and AIDS treatment, and subsidize medicines for children and pregnant women.
''It finally took Putin himself to understand what was happening,'' said Murray Feshbach of the Woodrow Wilson International Center for Scholars in Washington, who has long studied health and demographics in Russia. ''But it's very late.''
Nowhere is the health-care crisis more pronounced than here in Karabash and other poisoned cities of the Soviet-era industrial belt.
A legacy of chemical and heavy metal emissions and radiation leaks -- including one worse than Chernobyl -- earned the Karabash region a reputation in the 1990s as the most polluted spot on Earth.
The looming smokestack of Karabash's blister-copper smelter has been venting into the air as much as 180 tons a year of sulfur dioxide and metal particulates since 1910, before the Bolsheviks came to power.
The particles from ''the torch'' have settled over every yard, rooftop and doorstep for a mile or more. The hillside along the road into town, once a forest, is bare earth. Hardly a blade of grass grows next to the smelter, where an estimated 1,200 to 6,000 people live.
By 2000, deaths in Karabash were exceeding births by 3½ to 1. Although Karabash is subject to the same poverty and social ills as the rest of Russia, residents have no doubt why they're dying.
''No one in this town isn't sick. Not a single one. If they don't have bronchitis, they have problems with their stomach. If it's not the stomach, it's the heart,'' said Alevtina Nazarova, 40. ''It's all because of the gas. You walk in the street, you come home and you cough like a madman.''
The environmental problems became so apparent that the Soviet government shut down the plant in 1990. Everyone expected massive infusions of aid to remedy the pollution and help residents find new jobs. But nothing happened. And when the plant reopened in 1997 under private management, hardly anyone objected.
''We lived eight years when the plant wasn't functioning,'' Sharando said. ''The ecology started to pick up, the air was fresher. Trees started to grow on the mountains. It was a good period, but it was also a depression. There were no salaries, people were unemployed. And our town was faced with a dilemma: Either we need to continue breathing the gas, or have no chance of any kind of passable life. We decided in favor of the gas.''
The health-care crisis that accompanies Russia's demographic decline is a fact of life not only in rural areas, but in cities as well. It affects the middle class as well as the poor.
The 8.8 million people who ride the Moscow subway every day are exposed to nearly 1 1/2 times the maximum safe level of carbon monoxide and other dangerous gases, the government reported.
A hepatitis-A outbreak traced to bad beer hospitalized 600 people in the Tver region last summer, and about 500 others were sickened with the same illness in November in Russia's third-largest city, Nizhny Novgorod. Cases of hepatitis-A and typhoid fever climbed 20 percent in the first half of 2004, the Health Ministry reported.
But neither alarms health officials outside Russia as the growth of AIDS and tuberculosis, a common secondary infection of AIDS.
Russia and its neighboring former Soviet republics are experiencing the fastest-growing epidemics of AIDS and tuberculosis in Europe. Russia sees at least 120,000 new TB cases a year, 10 times the number in the U.S., which has double the population. Last year, about 32,000 Russians died of the disease.
Tuberculosis, unlike AIDS, can spread through casual contact with people with compromised immune systems, sparking fears that Russia could become an ''epidemiological pump'' for spreading the disease to the rest of Europe and North America.
While tuberculosis and AIDS are becoming front-line priorities for Russia's health-care system, hundreds of hospitals continue to languish.
Doctors struggle with unequipped laboratories and surgical instruments 20 to 30 years old. Equipment donated by foreign aid organizations is broken down. There is no money to fix it, or the money budgeted for repairs has evaporated in the web of corruption that strangles public spending everywhere in Russia.
Alexander Naryshkin, whose job as head of neurosurgery pays $350 a month, said he and his colleagues pooled their money to buy a piece of equipment to close blood vessels during brain surgery after hospital management refused.
Most serious brain surgery cases are transferred to other hospitals, but in an emergency or if patients can't afford to go elsewhere, they end up at City Hospital 23. The death rate for brain surgery here has climbed from about 40 percent, when the hospital had a functioning neurological intensive care unit, to about 80 percent.
Twice during one recent month, Naryshkin lost patients who needed surgeries because the St. Petersburg blood bank had no blood, and there were no relatives to donate.
He has lost others, he said, because families can't afford the $35-a-day medicines essential to post-surgical survival.
''If a patient has relatives who are able to afford buying the medicines, then this patient has more chance to recover,'' he said. ''If not, naturally, the chances of surviving a very hard skull trauma are close to zero.''
Slowly, the court system and patient advocacy groups are gaining a foothold in health care.
In Moscow, the Patients' Protection Association is gathering anecdotal data on hospitals and preparing to distribute on the Internet a list of hospitals to avoid.
In St. Petersburg, bookkeeper Irina Vladimirova recently won one of the first major medical malpractice judgments in Russia. She was awarded about $7,100 in a judgment against the maternity hospital where she delivered a son who died two weeks later.
Hospital officials refused to discuss the case. But Vladimirova's version resembles other horror stories told by patients of Russian hospitals.
Vladimirova said she had started bleeding and suffering severe abdominal pains after a routine vaginal examination shortly before her due date, but waited all day and night at the hospital to be examined again.
By the next morning, Vladimirova said, she was ''screaming with pain'' and bleeding on the floor, but was told by doctors that she needed to wait. Doctors apparently believed she was suffering normal labor pains, despite the bleeding, she said.
The baby stopped kicking. Suddenly, the doctors became ''very busy'' around her, listening for a fetal heartbeat. They gave her injections to induce labor. It was too late.
Her infant son died 13 days later, joining the growing population of the cemetery outside town.