Russia, Take Heart

Russia’s health care system is in crisis. The safety net of free medical care is gone. Doctors, patients and medical centers are all struggling to survive with little or no government aid. Against this backdrop, Russian Life Executive Editor Mikhail Ivanov visited the prestigious Bakulev Cardiovascular Center in Moscow. He talked with doctors and nurses about what the current health crisis means for this one hospital. The diagnosis is sobering. Particularly since, as the writer Ivan Turgenev once wrote, “if this is the cream, what about the milk...?”

"Oh you, great shadow, how lucky your are not to be among us. We live in a country where the state is everything and the man is nothing "

Ivan Petrovich Pavlov, the world famous physiologist, addressing the portrait of the late physician, Ivan Sechenov, at the commemoration of Sechenov's 100th anniversary in 1929.

Wearing a long, dark blue, extra-large Indian wool sweater, cardiovascular surgeon Sergei Ambatiello walks down the long corridor of the Moscow-based Bakulev Center for Cardiovascular Surgery. He greets patients along his way and pats anxious relatives on the shoulder, offering a reassuring smile which cannot hide his fatigue. In spite of his effort to look cheerful, the bags under his eyes betray him.

The long line of patients and the endless pleas and requests from patients’ relatives waiting in the corridor is a sign of the respect and renown Ambatiello has built in his 12 years as a doctor of medicine, making him one of the center's leading research fellows. He may not yet be a Renat Akchurin (the heart surgeon who operated on President Boris Yeltsin), but, at 36, Sergei Ambatiello is known and respected in his professional world. More importantly, he is highly regarded by his patients, who continually return to express their gratitude and to refer him to relatives and friends.

Rising Health Care Costs

In his office, Ambatiello replaces his sweater with a common, light-blue surgical coat. The change, he said, helps him recapture the feeling of being "a God in the eyes of the people who know you can help them and therefore pin all their hopes on you." It was this feeling which made him decide to become a doctor some twenty years ago.

But there are costs... Ambatiello’s fatigued smile and baggy eyes are the result of just coming off a 24-hour night watch -- he had to stay up all night with an critical patient he had operated on.

Interestingly, Ambatiello’s Indian sweater is a souvenir of his not-so-distant involvement in shuttle business. Not so long ago he would travel once or twice a year to India to buy sweaters in bulk, reselling them at Moscow's infamous tolkuchkas (wholesale markets where shuttle traders sell their goods). "After prices were freed in 1992, my family income plummeted,” recalled Ambatiello, who is married and has a 12-year old son. "So I had no other option but to work as a chelnok (shuttle trader) a couple of times a year, spending my vacation on it."

The part-time shuttle trading allowed him to afford good food, decent clothing, and his lifelong dream -- a private car (a white, Lada-5). What is more, he was even able to save enough money to take his wife Lali and son Misha to the US -- his father-in-law had emigrated there in the late 1980s.

When the government imposed heavy tariffs on shuttle traders last summer, Ambatiello quit the business (he had never quit cardiovascular surgery, however) and sought out other ways to supplement his meager income. An alternative was soon found... With a heavy heart, he decided to rent his nice, two-room apartment, located in a gorgeous, Stalinesque building in down-town Moscow, to a foreign couple. Like most Russian surgeons, he is a bit of a handyman and had renovated the apartment himself.

Renting the apartment has allowed Ambatiello to carry on his work as a cardiovascular surgeon, to keep driving his car, to fill it regularly with gasoline and fresh motor oil, and to dress and feed his family well enough. In exchange, he and his family have to resign themselves to a tiny, one-room apartment in a humble panel house. The business scheme is simple -- get a higher rent there, pay a much smaller one here, and live on the difference.

Why does a top-rate surgeon at Russia's leading cardiovascular center have to go through such trials and tribulations to attain a decent living standard? Because, after more than 10 years of hard work at the Bakulev Center, Ambatiello’s salary, with all bonuses and premiums included, barely makes the equivalent of $250 a month. Which is just slightly more than the official, average monthly salary. Research by independent social services long ago estimated that Moscow’s minimum monthly subsistence salary per capita (one of the world's most expensive cities) is some $200.

Still, why go through such tricky and time-consuming job combinations? Would it not be easier to resign oneself to living on $250? After all, millions of Russians live on much less.

"Well, I know well what a cardiovascular surgeon is worth in America, having visited there recently,” Ambatiello said. “As far as I know, it's a minimum of $100,000 -$150,000 a year. So I don't even bother comparing it to my salary, so as not to get upset. What's the point anyway? I have no hard feelings. Our countries are too different historically and economically. But I can't lower myself to a substandard level... To keep working as a cardiovascular surgeon, I need to eat well. I want to go on vacation with my family. I need to drive a car, so I can respond to my patients within 20-30 minutes. It is too bad they can't pay me what I want -- but that's not a reason to quit. Everyone like me who has decided to stay here no matter what has his own private scheme to survive."

What about taking money ‘under the table’ for medical help -- a common practice. "I can't take money under the counter from my patients,” Ambatiello said. “So I know I’ll never achieve the compensation level of my US colleagues."

Ambatiello later admitted that, at times, he can’t help wishing he had a much easier, more lucrative job of being a "simple" head doctor at a Moscow hospital -- the one with access to budgetary money and with power to sign for the purchase of imported equipment. "I tell you,” he remarked, “all these doctors walk around flanked by a minimum of two bodyguards."

According to unofficial data circulating in Russian medical circles, such signatures typically cost about 10% of the contract value -- often millions of dollars.

In a recent interview published in the Russian press, Health Minister Tatyana Dmitrieva said that an investigation into the distribution of budgetary money disbursed by the Health Ministry uncovered cases where low-quality pharmaceuticals were purchased with government funds and one case of direct embezzlement. In the latter instance, a state enterprise under the Health Ministry’s purview spent government funds on clothing and on receptions for foreign delegations in expensive restaurants.

Status & Svyazi

Doctors never ranked high on the national payroll scale in the former Soviet Union. In Soviet days, a young medic graduating from an institute received a salary of 95 rubles per month. A junior research fellow got 125 rubles. Surely not a lot, but, at that time, enough to feed oneself decently and even set a little money aside, since there were not many goods to spend money on anyway. When there was a need to supplement income, young medics would work 24-hour shifts in different hospitals around the city. With ten, 24-hour shifts per month (the most any medic can endure) this supplemented one’s salary nicely. Nurses and matrons would also work full-time at two or three places. A combination of several workplaces was a common practice for medics back then.

But doctors had a great incentive to climb up the scientific ladder. When Ambatiello defended his Ph.D. dissertation in 1990, his salary rose to 275 rubles, well above the national average at the time. And there was incentive to do still better. A Doctor of Medical Science received 400 rubles a month and a Professor, the head of a hospital department, got 500 rubles, which was quite good by Soviet standards. With metro fares fixed at a stable 5 kopeks and bread less than 20 kopeks, 500 rubles was a fortune.

There is also a certain prestige that accompanied the profession, even down to the level of medics. In the 1970s and 1980s there were 20-30 applicants for each free spot in medical institutes. But it was not all about prestige. The medical profession offered important material side benefits. At a time when quality consumer goods and services were nowhere to be found, medics used their connections to get many things done, or purchased. No GAI (traffic police) officer would ever fine a medic.

Ambatiello recalled numerous real-life anecdotes he heard from his older colleague and teacher, the late Lev Klioner. In particular, there was the story of a doctor from a kolkhoz (collective farm) who complained to the kolkhoz chairman about a shortage of sour cream and cucumbers. The next morning, the doctor was awoken up by the roar of a kolkhoz truck -- full of cucumbers and a metallic barrel with sour cream... At that time, doctors, both in rural areas and in major cities, were kings. For, in the Soviet era, the prestige of a profession was not measured by money along. In fact, sometimes it was judged least of all by the salary it garnered. Connections (svyazi) were everything -- they would free you from perennial queues and other inconveniences of daily life.

Meanwhile, the Soviet Constitution guaranteed free health care to all. Which meant that no medical professional would ever directly accept money from patients, for fear of legal reprisals.

«The degree of human gratitude,» Ambatiello noted tongue-in-cheek, using administrative cliches, «was commensu-rate with the doctor’s title and the gravity of the patient’s disease.» Yet gratitude was not to be expressed with money, but with in-kind payments. «Just try and stop a patient from giving you flowers,»  Ambatiello said. «Some colleagues even received special gifts — for female doctors it was usually much-coveted French perfumes.»

Males doctors, especially surgeons, were usually given top-class liquors, most typically cognacs. Hence the famous surgeon’s proverb: «A surgeon who buys his drinks in a liquor store is complete rubbish.»

The Current Crisis

Now the ‘svyazi factor’ is subsiding. And so is the use of cognac in lieu of cash. Not that it is not accepted, it is just not enough anymore. With an ever-widening range of available goods and services, only one criteria of well-being, prestige and remuneration is valid in today’s Russia: money.

And it is a shortage of money which has led Russia’s health care system into a situation of deep crisis. Yet, for some, even ‘crisis’ seems to be too mild a description for the condition in which domestic cardiovascular surgery finds itself. In late 1996, the Third All-Russian Congress on Cardiovascular Surgery said that the field, «is not even in a crisis, but rather has come to an impasse.»

The fact that Russian surgeons conducted a successful quintuple bypass operation on Russia’s president last November doesn’t alter this severe diagnosis one iota. True, world-renowned heart surgeon Michael DeBakey, who consulted on the surgery, praised Russian surgeons highly for their level of professionalism. And all who saw the vigorous, rosy-cheeked Boris Yeltsin at the March, US-Russia summit in Helsinki, can testify that Renat Akchurin and his team did a good job.

But how many other patients are waiting in line to undergo such heart bypass surgeries — by now an almost routine operation in many industrialized countries? How many can actually afford it? What Boris Yeltsin or any top Russian politician can take for granted, too many other Russians cannot.

Shifting Gears

Starting January 1 of this year, due to chronic underfinancing from the state budget, the Bakulev Center no longer offers free surgery. Patients from CIS countries have had to pay in full for surgery for some time, but up until this year, Russian citizens were operated on for free. «Before January 1, more than 50% of our patients were operated on for free,» said Ambatiello. «On the other hand, it was ludicrous — under the law, we could not even charge ‘New Russians’ if they were Russian citizens, though for them $6,000 or $8,000 is a ridiculous sum.»

Now all patients must go through the Bakulev Center’s commercial department, which sets prices at between R28 mn to R47 mn ($5,000-$8,000), depending on the type of operation.

Those who cannot pay must queue up in the ‘free line’ — the so-called lgotnaya ochered. These patients are operated on only as the center receives money from the state budget. This line, created for Chernobyl victims, war veterans and families with low incomes, is now hundreds of patients long. But only ten patients from the lgotnaya line were operated on at Bakulev this year — that is all the Center received money for.

What with constant complaints about excessive individual and corporate taxation in Russia, one would expect there to be more money from the government for such social services. Sadly, this is not evident. The so-called OMS, the Fund for Mandatory Medical Insurance, set up in the early 1990s, is a case in point. The fund is sustained by a 3.6% gross wage and salary deduction at companies. The problem is, it is not clear where all this money ends up.

«In my view,» said Ambatiello, «the system of Mandatory Medical Insurance has been mechanically copied from the US prototype, where private doctors prevail and where a highly developed insurance system exists. Here, nobody knows which insurance company this money goes to. Part of it goes to pay for city polyclinics. But the only tangible change for now is that most of these clinics have undergone superficial physical renovations. As far as treatment itself goes, nothing has substantively changed since Soviet times.»

In any case, OMS does not cover such things as heart bypass operations.

This sad situation results in sad statistics. The Congress on Cardiovascu-lar Surgery stated that Russia presently satisfies only 2.3-4.3% of demand for bypass interventions. (In 1995, only 15 such operations per million citizens, vs. the 350-650 actually needed. Compare this with the US, where there were 1,800 operations per million persons in 1995).

The situation with infants with congenital heart defects leaves no room for optimism either. The Bakulev Center’s Sergei Popov, who specializes in such infants, said that, in all of Russia, only 200 operations on these infants are carried out per year, while demand for such opera-tions is estimated at some 16,000  per year. «You can easily deduce what happens to the rest,» Popov said.

Popov and Ambatiello aver that cardiovascular surgery is one of the best litmus tests with which to judge a country’s technological development. Perhaps this is why Yeltsin’s surgeon, Renat Akchurin, told the Russian press he was «ashamed to admit that they had to bring an artificial left ventricle from America — just in case.» The develop-ment of analogous medical devices at Russian research institutes, Akchurin said, «is on its knees. All they can do is come up with new ideas, but it never goes beyond the creation of prototypes.»

And yet, prior to the advent of the market economy, Soviet medical engine-ers were often at the cutting edge of medical research. For instance, the famous apparatus for artificial blood circulation was designed by the Soviet scientist, Sergei Brukhonenko. Soviet researcher Vladimir Demikhov made a great contribution to heart transplanta-tion. US surgeon Christian Barnard came to the USSR to study Demikhov’s expertise prior to conducting his world famous heart transplant in 1967. The list of such achievements is endless, but they belong to the glorious past.

In point of fact, technological backwardness is only the tip of the iceberg. The most arduous task in curing heart patients is not the operation itself — it is the rehabilitation.

«But look at our conditions,» Ambatiello said. «We have three to five patients per room — way too many for patients of our type, only one toilet per floor and three bathrooms for the whole center. They would not even consider operating on Yeltsin or someone of his level in our center, which is the leading institute of this type (we did 1,840 operations on open heart in 1995, vs. 129 at the Chazov Center, which traditionally operates on Russian VIPs). They have a much more attractive and suitable environment — nicely renovated rooms, marble all over the place, etc.»

Changing Minds

So, what is the poor Russian patient to do? Send letters to President Yeltsin? This is what one reader of Trud did recently, urging the president «to honor the constitutionally guaranteed right — the right to live... You have just undergone a complex heart surgery. You cannot allow this right to be provided only to the rich...» Or maybe one can only rely on therapy? Or gobble pills? More likely, as the Trud letter writer wrote, «you pay if you can, and if you can’t, you just suffer...»

Popov offered a realistic, if somewhat cynical, answer to these uneasy questions. «It’s the people’s mentality that you need to change in the first place. Our people have been living with the idea that they will be treated for free. But I don’t see any alternative to paid health care. People should try to live with it. It’s a long way to go before our insurance system develops into something palatable. I personally don’t believe in it. The state keeps robbing us every day. And what with multi-month wage arrears, how can patients believe in the Mandatory Medical Insurance?!»

Ambatiello agrees, saying that health has to stop taking a back seat in people’s list of priorities. «We receive our patients in much harder conditions than our Western colleagues. We all knew here that Yeltsin’s operation was long overdue. But instead, he was trying to deceive the electorate on stage or was out playing tennis. This is like so many of our patients who come to us only as a last resort. Starting from the age of 16, many of them are chain smokers — so why should the state pay for their heart operations?»

Promoting a healthy way of life is tough, but still much easier than changing the mentality of Russia’s elderly, who grew up under state-managed health care. «They have all been living with this Soviet idea of self-immolation,» Popov adds. «Okay, we lived badly, so let our kids live better... So, instead of trying to save their lives, they sacrifice themselves, they sit on their savings, not even considering disbursing $5-8,000 to pay for an urgent heart operation.

«Let’s just take Moscow. People do have money here, even ordinary people. Look at the number of cars. Look at the number of VCRs or TV sets people are carrying on the street. It’s just that material things — of which they have been deprived for so long — for now take the lead. So they would rather bequeath the money hidden in the mattress to their kids. ‘I have lived enough, whatever God gave me is fine,’ that’s their philosophy. Okay, some people don’t have anything in savings, but they can sell stuff. They have apartments, so they can move to smaller ones. They have dachas. In the final analysis — what is better — to live or die?»

For Nikolai Lyubimov from Tula region, even selling stuff seems to offer no solution. Writing in to a national newspaper, he said he has a daughter who needs an urgent operation that will cost R10 mn ($2000). «I have collected only R3 mn,» he wrote. «I don’t know where to get the rest from. We do have a cow to sell, but even if I sell it, it won’t be enough, and I can’t live without a cow. I am about to settle accounts with life.»

And in such difficult times, what is the doctor to do to survive? Switch to business? Sell beer in street kiosks? Popov and Ambatiello answer with a resounding «No.»

«Cardiovascular surgery is like a diagnosis,» Ambatiello says. «Once you have gotten into it, you can’t quit. Former colleagues who switched to business keep calling, and we can hear jealousy in their voice — for all the money they earn, they miss the Center.»

So why not emigrate to the West, where the pay is demonstrably higher? Ambati-ello, whose last name echoes the bouquet of nationalities in his roots (Polish, Greek, Jewish, Russian), offers an explanation. «It’s tough to start from scratch abroad, where emigres have to retake difficult exams in basic disciplines – and this in a foreign language. Plus you have to build prestige, a name, from a clean slate. It’s hard to do low-qualification work once you have reached a certain level. And, last but not least, I feel pride in being a Russian doctor. This goes back to the old traditions of zemsky [village] doctors I read about who could cure with just their hands and a stethoscope. I feel from my practice I can do the same — that’s the strongest trait of Russian doctors who have traditionally been forced to work at low technological levels.»

Pride and hope for the better is all Russian doctors seem to have left. Which is also the case with 23-year old Natasha Kazachok, who has been working as a registered nurse at the Bakulev Center since 1992, the year which saw the most dramatic drop in medics’ income. She said she came to the center because it’s her calling... «Here you feel the result of your work immediately,» she said. «You alleviate pain of other people and nothing can beat this feeling.» She is also determined to continue her medical education and is planning to enter the evening faculty of a medical institute — even though it will take her six years to finish while working days at Bakulev.

Kazachok receives just R400,000 ($70) per month. The bulk of it goes to pay for her two hour long commute from Podolsk (Moscow region) to Leninskiy prospekt (where Bakulev Center is located). Her parents, in their mid 50s, support her both morally and financially, and encourage her to pursue her medical career by any and all means.

«I believe that some day it’s going to get better,» Kazachok said. «Now that we have switched to commercial operations, my salary goes up to R600,000 occasionally» [just over $100]. At this rate, Natasha may soon pass the Moscow minimum subsistence salary. Yet, on such a salary, she could surely not afford an operation at Bakulev Center’s new commercial rates. Luckily, for now at least, local doctors operate on their colleagues for free.