The more I have the joy and privilege of talking with younger folks, the more I realize my life experiences are history for them. Just as I wanted my parents, aunts and uncles to flesh out what I learned in history class with their own personal recollections, I continue to share some of my experiences abroad when I was younger.
The following is an article I wrote on September 13, 1998 while teaching as a university lecturer in Ekaterinburg, Russia. I was a visiting American lecturer working through the Civic Education Project, assigned for two years to teach college classes in Ekaterinburg and Tyumen, Russia. I was blessed to live with Russian families. It was a different time in Russia than what folks experience today, and I was a foreigner trying to reflect on what I saw from my outsider’s point of view. I have left the wording exactly as I wrote it back then. It simply captures a moment in time for the sake of history.
At that time, I was passionate about healthcare reform. When I was bit by a rabid dog and also experienced several injuries, I ended up in Russian hospitals a few times. Concerned by what I saw, tremendous areas of need, I picked up the phone and tried to make some noise internationally, asking for help. My cries seemed to fall on deaf ears.
I was told by nearly everyone I talked to outside of Russia that “The Soviet medical system is one of the best in the world.” I tried explaining that the Soviet Union had dissolved, and I was now visiting hospitals in the Russian Republic, in which brilliant doctors did not have the funds they needed, and patients experienced hardships that folks in other countries would find hard to imagine. But I felt like I made no progress. I wrote and circulated this article in the hopes that someone, somewhere would see it and be empowered to make a difference, no matter how small.
I share this article again now for posterity, for someone who is interested in firsthand perspectives on history and/or living abroad. Also, for those who are concerned and trying to help in places where healthcare suffers from lack of funding, I hope these reflections will encourage you not to give up and to continue seeking globally for help. For those who work in healthcare around the world, thank you for all that you do every day.
Russia’s Healthcare Crisis: Money, Medicine, Internet
Ekaterinburg, Russia — September 13, 1998
A three-hour tour of a Russian hospital is not the most pleasant way to spend a relaxing Indian-summer weekend in Ekaterinburg, a city of 1.5 million in the eastern foothills of the Ural Mountains. I came from nearby Tyumen to Ekaterinburg, where I lived the previous academic year, to spend Friday and Monday working with my former students. My plan for the weekend was simply to relax with my friends.
But Friday night I became acquainted with a young Russian medical student, who offered to take me with him on his hospital rounds the next day. Because I am writing a PhD dissertation on the public health system in Russia, and because I am supervising students on public health/ecology projects for the Civic Education Project (CEP) Human Rights Educational Initiative (HREI), I thought this hospital tour would be important.
This was one of the better hospitals in Russia. My first impression upon entering the neurosurgery ward was that this hospital is in such better condition than the nearby polyclinic where I was treated for a dog bite last year. The floors and walls were in reasonably good repair and fairly clean, though nowhere near the standards of a typical US hospital.
The medical student took me to the three nurses’ stations. I noticed the absence of three things: lights, computers, nurses. Someone is always on duty in each wing of the hospital, but the lack of staff was striking compared to a US hospital. The floor seemed almost deserted. Lights were turned on only when necessary. All records and instructions were handwritten. No computers. No monitoring equipment. No emergency call buttons — not that these are necessary, given the setup of the patients’ rooms.
I was struck by what was missing from the patients’ rooms — decent-sized beds, medical equipment, toilets, telephones, carpeting, wall paper — but more struck by what was not missing: people. The smallest number of patients to a room was four, in a space the size of a two-bed US hospital room. Several slightly larger rooms held anywhere from five to eight patients.
Therefore, if a patient has a problem, one of the others can locate help.
The intensive care unit is monitored by hospital staff except when visitors are there. Hospital staff members take care of other responsibilities then, leaving the visitors to watch the patients. Records and X-rays are left lying in a notebook on a small wooden table in front of the glass window.
Beds are assigned ideally based on which surgeon is treating a patient. Each surgeon is allotted several rooms. If those beds are filled, the patient will be put in a nearby room. If all beds in the wing are filled, the patient will be asked to delay surgery until a bed is free. If surgery cannot be delayed, the hospital will find “some place” to put the patient. The patient will not be refused emergency surgery because of a lack of space.
The medical student took me into the pre-surgery wash room, regularly cleaned with a weak disinfectant which does nothing for the rust covering the floor near the tub. He showed me the medicine cabinet in the small room which serves as a laboratory (where blood testing equipment consists of a row of test tubes), supply storage and injection room. The hospital purchases syringes from a German pharmaceutical company and keeps a small supply of inexpensive medications. A shortage of needles requires the staff to use the same needle to mix different injections, though they always use clean needles to give injections.
The more expensive medicines in the supply cabinet were purchased in pharmacies by the patients in advance. Some patients also buy their own syringes and needles. I asked the medical student what happens to a patient who cannot afford the required medicine. He answered that treatment is prescribed based on what the patient can pay. If the patient has little money, either he will try to get money from relatives, or he will receive a cheaper, less effective treatment.
Several of the patients in the neurosurgery ward suffer from seizures. In their medical conditions, convulsions can be life-threatening. The hospital keeps a small supply of medicine to stop seizures. The previous evening, the medical student told me, a patient went into convulsions. But the supply of medicine had run out and had not been refilled. “Why was it not refilled?” I asked, but I already knew the answer. It was the same as the answer to nearly every question I had asked him so far. He smiled and shook his head, because he knew I knew the answer.
“Money,” he said simply. “But in this situation we were lucky. The patient’s convulsions stopped on their own, before any harm was done.”
Money, or the lack of it, is the biggest problem facing Russian hospitals. Funding comes from three sources: government budget, insurance, and payments by patients. The government budget can provide funds no longer; insurance companies are increasingly less able to pay; hospitals depend, therefore, on what little money patients can provide.
Because of this shortage of funds, some hospitals are starting to close, increasing the workload of staff at the remaining hospitals — though without a corresponding increase in pay. Salaries are fixed. Money taken in by the hospitals for treatment is distributed equally to each department for the purchase of new equipment — more precisely, it is used to play catch-up in acquiring equipment which is standard in most US hospitals.
This hospital is better-off than most, because patients come here from surrounding regions and from as far away as Vladivostok, six time zones to the east. The hospital also receives patient support from the wealthier oil region of Tyumen, in nearby Western Siberia. The reason: some of Russia’s top neurosurgeons work here, surgeons as outstanding as those in Moscow and St. Petersburg. The neurosurgery department here is on the European Union’s recommended list.
Despite their talent and high reputations, the surgeons work in one small, crowded office, where they work from 8-5 with alternating overnight shifts. They share two computers and a handful of books among ten surgeons. They live in small flats. Some cannot afford to buy cars. The chief of neurosurgery has been offered positions in the United States several times, but he refuses to leave Russia. It’s a good thing. He and his colleagues have saved and improved countless lives.
“We could do more if we had something as simple as Internet,” said the medical student. I asked why. He explained that for a short time the hospital was able to afford Internet access. One of the surgeons discovered details of a new neurosurgical procedure on an Internet website. He tried the procedure on two seemingly incurable patients. His work was successful and literally saved two lives.
A few months later, the hospital was no longer able to afford Internet access (about US$70 per month), so the connection was cut. Now I know one very simple way to advise my students in developing Human Rights community outreach projects. They can use their university or Soros Internet Center access to surf the Internet for information useful to the Russian medical community.
The lack of technology and financial resources has made the surgeons at this hospital more creative and more in touch with alternative forms of medicine. “They are not dependent on computers,” said the medical student. “They depend on their brains and hands, and this had led to development of their own revolutionary techniques.” He has a point.
The Russian methods of practicing medicine, medical philosophies and organizational structures make sense to some degree. Russian doctors can teach Western physicians as much as they can learn from them. The experience of each is different. Exchange of ideas and experience would be useful and could be used to improve medicine globally. Unfortunately these surgeons do not have the time or money to travel. And their former link to the rest of the world, the Internet, is no longer available to them. They receive offers to visit Western institutions or attend international conferences at their own expense, but this kind of exchange is not realistic for them.
“One of my jobs is to translate such invitations into Russian, so the surgeons here can read them,” the medical student explained. “But usually I laugh when I read them. There is no way financially these surgeons can ever accept invitations to attend conferences halfway around the world at some exclusive resort.”
The medical student continued, “The situation will not improve until the Russian medical system is privatized and the wealthy start supporting local surgeons rather than going to Western hospitals in Moscow or abroad.” The medical student explained, “The money from private practice can be funneled back into the hospitals to treat those who cannot afford private practice.”
“Does private practice exist now?” I asked.
“It does to a small extent,” the medical student answered, “but the extensive paperwork, licensing procedures and costs are prohibitive. To a Russian physician, ‘private practice’ usually means his second job — working in a garage, for example — which supplements his hospital income and helps support his family.”
The current financial crisis in Russia has raised the stakes in reforming the healthcare system. Many patients depend on imported medication. The price of this medicine, already high, rises further every time the ruble falls.
After he concluded his rounds, the medical student took me to see other parts of the hospital. I was shocked by the drug rehabilitation ward in a nearby building. One glance at the hallway, and I thought I was looking at a US hospital floor. The entire wing was newly renovated, walls and doors painted, real door knobs, ceiling lights blazing, using electricity even when no one was out in the hall.
“They receive a lot of money in this department,” the medical student commented, as if that were not already obvious. “Drug rehabilitation treatment is very expensive, and the families are able to pay well.”
It was not until we were halfway down the stairs on our way out that I recognized the discrepancy. I asked the medical student: “Why does this department have so much money? I thought you told me the hospital pools its income and distributes it evenly to all departments.”
The medical student smiled. “I was referring to official income. A lot of the payments in this department are in cash. No one knows how much money they take in. It stays here.”
Clearly if drug rehabilitation treatment is privatized, the country will be further on its way to healthcare reform.
Copyright © 1998, 2021 by Janet Eriksson
Janet Eriksson is an intercessor, writer, and teacher in Dahlonega, Georgia. She loves conversation with friends, front porch swings, sweet tea, and spending time on lakes and rivers. The author of nine books and editor of many more, Janet blogs and teaches at Adventures with God. She enjoys volunteering with Transformations. Janet received her M. Div. from Asbury Theological Seminary.