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In Russia Ill and Infirm Include Health Care Itself

By: Michael Wines with Abigail Zuger
The New York Times, December 4, 2000

In the intensive-care unit at Hospital No. 1, there are 12 beds for the near-dead. One morning 10 unfortunates lay there, mostly unconscious and virtually naked beneath tobacco-colored sheets.

The first had ignored an earache that grew into a raging bacterial infection of the brain. The second, third and fourth shattered their bodies in auto accidents. The fifth, sixth and seventh bloodied their brains in mostly drunken falls.

The eighth had his skull fractured in a beating. The ninth had been run down by a car.

The 10th is Yuri Ivanov. He was felled by a 20-pound cat, a fat black Persian he had been playing with. ''I was walking backward and stumbled on the stairs and fell,'' the 46-year-old businessman said through his oxygen mask. ''That night I went to sleep. When I woke up at 6 the next day, my body was all swollen -- my neck, my shoulders, my hands, my belly -- everything.''

Still more harrowing, his skin crackled like bubble wrap whenever he pressed it.

So he drove 50 miles to a doctor who instantly sent him by ambulance to the emergency room here. The diagnosis: two broken ribs and a punctured lung. The escaping air had inflated Mr. Ivanov like a beach toy.

Almost anywhere, a trip to the hospital is an unsettling experience. But Mr. Ivanov had cause to be nervous: In Russia these days it can be a life-threatening one.

Russian hospitals -- almost all of Russian health care, in fact -- are in a perilous state. Drugs are in short supply; if available, they are often too costly for the average citizen to afford. By one 1999 estimate, at least 20,000 cancer patients die annually because they cannot afford medicine. By another, some 200,000 diabetics are unable to get insulin, even though the government guarantees a free supply, because local and regional governments cannot afford to buy it.

With life expectancy falling, there is rising concern here and in the West that Russia is struggling to preserve the well-being of its people. Should it fail -- and health care is one determinant of success -- American and other experts say Russia faces a grim future, and could even require an international rescue effort.

Doctors and nurses are astonishingly underpaid, as much as a third below the national average. The best leave for better jobs. Those who stay battle a lack of money, medicine and equipment.

The problem is not just that Russia's health care system is ancient (one in 10 hospitals was built before 1914) or ill equipped (one in five hospitals have no running water). Nor is it that it is huge and inefficient (12,000 hospitals and 20,000 clinics).

That was true when Soviet leaders ruled. The new problem is that there is no health care system, not like there was before.

''In the Soviet Union, we used to have a good system of health care,'' said Rafael G. Oganov, director of the government's National Center for Preventive Medicine. ''The quality wasn't good, of course, but the system was accessible to everyone and free. When the Soviet Union collapsed, they began reforms. These reforms have mostly destroyed what existed before, and nothing has replaced it.''

But not for lack of trying. Since 1990, Russia has decentralized its Soviet health bureaucracy, then tried to recentralize it; thrown the door open to private health insurers, then moved to close it; guaranteed free medicine to those who needed it, then limited free medicine to the neediest. Eight different health ministers have tried to run the system during the last 10 years.

''In typical Bolshevik fashion, they decided that this major reform had to be introduced overnight, with no training and no funds to support it,'' said Christopher Davis, an Oxford University economist who has studied Russian health care.

Russia's near-depression in the early 1990's, which decimated tax revenues, delivered the coup de grace. ''If you have inadequate funding,'' Mr. Davis said, ''you try to put it in the most crucial areas -- pay the wages of doctors and nurses, get the most vital drugs. You can't spend a lot of money on supporting reforms.''

In theory, doctors have more technology and training than ever, and yet they yearn for the days when basic drugs were always in stock and when equipment, however outmoded, at least worked. Patients detest bribing doctors and buying medicines , yet cherish the freedom to choose better, if costlier, treatments.

The system seems destined to linger in this economic purgatory unless Russia's leaders give it more money and attention.

Soviet health spending ran between 3 and 3.5 percent of the gross domestic product for decades, barely a third of the rate in Europe generally. Russia now spends perhaps 5 percent of a gross domestic product vastly shrunken from Soviet days. In 1995, that amounted to $148 a person, 25 times less than was spent on the average American.

''Funding for health care was always poor; in the last 10 years, it's really gone to hell in a hand basket,'' said James Smith, executive director of the American International Health Alliance, which has worked on Russian medical care for a decade. ''There's not much infrastructure in the United States or anywhere else that can sustain that for very long. It's cumulative, and it shows.''

Indeed it does inside the trauma ward at N. I. Pirogov Municipal Hospital No. 1, a rambling 1,500-bed institution on the edge of downtown Moscow.

Today it is a Russian version of New York's Bellevue: Moscow's biggest public hospital, taking all 35,000 comers a year, some rich but most poor. Last year's budget was about $4.1 million, somewhat more than it sounds, as it was spent largely on cheaper Russian products and salaries.

Differences in American and Russian health care make comparisons risky. Still, Catholic Medical Services in Brooklyn, a complex of four hospitals with a similar number of beds -- 1,584 -- spent $565 million last year to treat 38,000 patients.

A newcomer could be forgiven for failing to realize that Hospital No. 1 is a very well-regarded research and teaching hospital, head and shoulders above most public hospitals outside the capital and St. Petersburg.

''The people who work here are fanatics,'' an X-ray technician said. ''Either that, or they're fools.''

It is unclear how much a collapsing health-care system contributed to Russia's soaring death rate during the 1990's.

Demographers and experts like Mr. Oganov, the preventive-medicine expert, say not much: those dying young in Russia -- alcoholics, victims of heart-attacks, homicides -- needed help long before they reached an emergency room.

Others like Mr. Davis, the Oxford economist, dispute that. And in fact, scattered data suggests that some indicators of health care, like the percentage of cancer patients who die within a year of diagnosis, have worsened since the Soviet demise.

''If you cut health-care funding,'' he said, ''and then introduce all these reforms that aren't implemented, I'd say the impact could be substantial.''