OSCOW, Dec. 3 — 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."
Tuesday
On his third day here, Mr. Ivanov looks into a mirror for the first time since he
punctured his lung playing with his cat. He is appalled. "Nightmare!" he says.
"To have a face like this, you have to eat a hundred cheeseburgers a day."
He is sitting in bed, a blanket folded beneath his legs to relieve the discomfort of
his thin mattress. A tube juts out of his chest. On a bedside table are a carton of
yogurt, a half-eaten cup of berries and an open pack of Sovereign cigarettes.
Mr. Ivanov is smoking, his oxygen mask dangling at his side. "The doctor says I
could have three a day," he says.
Dr. Aleksandr I. Turchev confirms that. "He can have more if he wants," he
says. "Better for him to stop when he's well."
Smoking in hospitals is a tradition from Soviet times. Virtually all patients smoke. So
do the doctors. A hand-scrawled sign in the intensive-care lounge declares, "No
Smoking." It appears to be a joke.
Dr. Turchev began working here in 1971, just before OPEC's influence swelled and left
the oil- rich Soviet Union flush with funds. From 1970 to 1990, real spending on health
leaped 140 percent. But hyperinflation in 1992, and economic collapse in 1998, reduced
spending drastically, though experts remain uncertain by how much. Dr. Turchev, now 54,
finds himself longing for the old days.
"Sure, in the past we didn't have big possibilities — we had less equipment,
and lower standards," he said. "But if something happened in intensive care when
someone was on duty — a light was out, or one of the systems broke down — it was
an emergency. You could call the main headquarters of the party, and immediately they
would fix everything."
And now? "Two weeks ago, the central vacuum system in the unit was down," he
said, referring to electric pumps and hoses that suction fluid from unconscious patients.
"It took 10 days to fix it." Meanwhile, doctors used an old manual pump.
The paradox of Hospital No. 1 is on full display here in the ill-lit,
institutional-green I.C.U. Each bed has a modern vital-signs monitor and a ventilator for
patients who cannot breathe. In the lab, a sophisticated blood-gas analyzer produces
near-instant readings on blood oxygen and carbon dioxide, otherwise impossible to obtain.
But the blood-gas analyzer often breaks down. The vital- signs monitors cannot be fully
used because attachments to measure blood pressure in the heart and vessels are too
costly.
As for the ventilators — hand- me-downs, like the rest, from a closed German
hospital — they are "just worn out," Dr. Turchev says. Some equipment
cannot be fixed because its Western manufacturers closed long ago or stopped making parts.
Angela Zabrodnaya, the trauma department's wilfully cheerful head nurse, is a case in
point: part of her job is scouring Hospital No. 1's warehouse for that most basic of
supplies, the disposable syringe.
"In the Soviet Union, everything was simpler," she said. "There was
enough for everybody — enough to use, enough to steal. But now, we haven't received a
single disposable syringe all year." Doctors seldom use latex gloves despite the risk
of infection; the supply is largely reserved for surgery.
Intensive-care nurses do not change patients' intravenous catheters without evidence of
an infection. American medical custom is to change catheters every three days, infection
or not.
The giveaway to the unit's state of affairs, however, is its urine- collection system.
From each unconscious or helpless patient, a tube runs over the edge of the bed and
empties into a liter-sized plastic soft-drink bottle hung on a bed rail. An orderly
periodically empties the bottles into a bucket.
Sanitation-obsessed Western hospitals would be aghast. But jury-rigged solutions are
the norm here, for good reason.
"We haven't had any new equipment in five years," Dr. Turchev says.
Wednesday
If there is a yin to Dr. Turchev's dark yang, it is Dr. Yelena Letvena, a 30-something
former professional skier with a parched wit and a burgeoning addiction to L & M's.
Dr. Letvena needed four tries to surmount political and bureaucratic barriers to
studying Soviet medicine. She was told surgery was not a woman's work, and she had the
last laugh: She is now chief of the trauma unit at Hospital No. 1.
Today, Dr. Letvena stops by intensive care to see Mr. Ivanov, who is stubbing out
another Sovereign. His double chin has shrunk to a chin and a half.
She nods approvingly. "He smokes; he drinks; he's O.K.," she says. "If
it continues, I'll bring him up tomorrow."
"Up" is the trauma unit's fifth- floor recovery ward, a sunlit Park Avenue
compared with the Bowery of intensive care. There are 65 beds and, today, only 57 patients
— an infrequent occurrence. A week ago, there were 72.
Truth told, 57 is too many. "There are a lot of patients in Russian hospitals who
could be treated as outpatients," Dr. Letvena says. "Nobody would ever think of
keeping them in hospitals in other places."
Why? "Nobody's keeping an eye on it," she says. That is an understatement. On
one floor, a demented, homeless elderly woman has been a patient for six years.
One reason Russian health care is in desperate shape is that the average patient's stay
approaches 17 days, compared with 5 in the United States. Children may commit elderly
parents to hospitals because they cannot support them. Ordinary people even check in for
long stays — stays that include free meals, laundry, a bed and lots of companionship.
Paradise it is not. Patients bunk four or six to a room, some so debilitated that they
can barely draw sheets over themselves. The ward has but one orderly and, usually, three
nurses. Soviet planners churned out too many doctors but far too few nurses, an imbalance
that has only worsened since 1991.
Someone has to bear the added cost. And in part, it is the genuinely ill patients who
pay more than in Soviet times or endure more Spartan conditions to subsidize roommates.
Consider Room 501, where lies 41-year-old Aleksandr Lebanov, who fell 30 feet from a
Moscow parking garage — "I was drinking wine," he says, not a bit
sheepishly — shattered a thigh and both heels, and has lain in bed four months now.
Too shorthanded to provide full-time care, the ward allows Mr. Lebanov's wife, Galina,
in outside visiting hours. She takes a week off each month from her job in Kostroma, the
couple's home 200 miles east of Moscow, to care for her husband.
She doesn't complain. "If such a thing had happened in Kostroma, I don't believe
they would have saved his legs," she said. "It's not that the doctors there are
bad. It's that their finances are worse."
By week's end, Mr. Lebanov would depart for Kostroma, carried prone in his brother's
little Lada, a passenger seat removed to accommodate his cast. His recovery will be a long
one, thanks to a smoldering infection that settled in shortly after the fall.
"More powerful antibiotics had to be used," Dr. Letvena said, "but we
didn't have them, and there was no way to get them. In the usual situation, we tell the
relatives, and they buy them. But this family did not have the ability."
In Room 518 is 30-year-old Aleksei Belov, who ran his motorcycle full speed into an
illegally turning car. His broken pelvis is held together with a brace that spans his
abdomen like a suspension bridge.
It is $2,000 worth of second- hand steel, bequeathed from patient to patient. On a
doctor's advice, his mother, Valentina Belova, also scoured local stores for a $130 knee
brace and $47 of pain- killing injections.
Ms. Belova spent 30 years as a paramedic, most of it in the Soviet system, when drugs
and equipment were free. One might expect Russia's pay-as-you-go medicine to dismay her.
But she says things look different from the patient's side.
"Before, it was different because there weren't many instruments, not many devices
or drugs," she says. "Now we have much more, but money is the problem. But I
like the chance to be able to go into a drug store and buy whenever my son needs."
Which is why, on an ingenious doctor's advice, she also bought him a $2.30 Looney Tunes
beach ball covered with bright yellow Tweety Birds.
Bedridden Westerners puff into special breathing devices to exercise their lungs and
ward off pneumonia. Mr. Belov inflates his beach ball, to much the same effect.
Thursday
It is moving day for Mr. Ivanov, who has shed his chest tube and seems to be melting
away. But he looks more shaken than happy: The bed next to his is empty.
Dr. Turchev says its occupant, Grigory, a 41-year-old man with a brain infection, died
as doctors were trying to suction fluid from his trachea. "We did manage to start his
heart again, but again it stopped," he says. "And he died."
Grigory had lingered for weeks. Dr. Maksim Strakhov, the young neurologist, suspected
that his infection had ripened into a brain abscess, almost certainly beyond help.
It was hard, however, to be absolutely sure. Many I.C.U. patients arrive with signs of
brain injuries or head trauma that, in a Western hospital, would send them immediately to
the CAT scanner to check for serious brain injuries. But there is no scanner in this
hospital. Instead, Dr. Strakhov decides who needs emergency neurosurgery with his
well-honed instincts, a reflex hammer and a vintage ultrasound machine.
"It was the last word in technology when I tested it, 24 years ago," Dr.
Turchev cracks.
It is not just that CAT technology is too expensive. The major fault lies in the
bizarre municipal health care planning that allocated a CAT scanner to another hospital 40
minutes away, and not to this one, with its constant stream of head injuries.
And so Hospital No. 1 patients who are stable enough to be driven across town get CAT
scans. Desperately ill patients do not.
Oleg V. Rutkovsky, the chief doctor and a former Russian health minister, insists that
patients here do exceedingly well. "We have a 3 percent mortality rate," he
said, "despite the fact that the trauma unit takes some very severe cases." The
1998 rate for American hospitals was 2.6 percent.
"Despite great differences in technology and drugs and insurance systems between
your country and ours, patients in Russia do get better," Dr. Letvena agreed.
"Despite a lack of medicine, nurses and doctors manage to do many things and reach
the same results that American doctors do."
Most patients, like Mr. Ivanov, have uneventful, if uncomfortable stays. But for some
of the other 3 percent, the system breaks under the strain.
Consider Svetlana, a dark- haired, nondescript young woman in her 20's.
She was found early Thursday in a Moscow park. A drug user, if not yet an addict, she
is covered with bruises, and her abdomen is swollen with blood.
After three and one-half hours of surgery on a perforated liver and a ruptured
intestine, she lies in intensive care, unconscious and naked except for a brown bedsheet.
"She's bomzhika," Oleg Klochkov, the night doctor, said, using the word for
homeless woman. "Somebody met her in the park and beat her; her friends, maybe. Her
father came and left. He said he wasn't surprised, because this was her way of life."
Later, Dr. Letvena says Svetlana lost at least half her blood — more than two
liters — in the beating and the surgery. The real problem is her blood type: B-
negative, found in barely 1.5 percent of Europeans.
Svetlana could tolerate a transfusion of the slightly more common O-negative, were any
available. But Moscow's central blood bank has managed so far to deliver only one unit of
either type. She needs four to five.
There are 30 other blood banks in Moscow that might have B- negative blood on hand. But
no single inventory unites them. Nor is there any quick way to canvass them.
"The amount she received, it wasn't enough for her," Dr. Letvena says that
night as she sits in her office, taking a smoking break midway through a 36-hour shift.
"And frankly, I'm not sure how it will end."
Friday
Outside the I.C.U., a group of men in white coats are hunched over a table.
"Scalpel," one barks, and another slaps the flat end of a scalpel into his
palm. He lowers the blade onto its intended target and flicks his wrist once, twice, then
three times.
After enough of this, the screw comes loose, and the surgeon, a 20-ish student from a
medical tech school, lifts the cover off a broken Soviet-era vacuum pump. There lies the
diseased organ: a worn-out washer. Dr. Turchev cuts a new one from a piece of hose; the
students embark on a transplant.
That pump was saved. Two days later, the same determined band was operating on the
spent circuitry of another.
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."
In the intensive care unit this morning, Svetlana's bed is empty. "She died at 3
a.m.," Dr. Turchev says. "At 3:30, they brought some blood for her."
He minces no words as to the cause of death. "Very simple: because of inadequate
treatment," he says. "Because if a patient loses more than two liters of blood,
at least you have to put one liter back in, not just one unit."
"Unfortunately," he adds, "this is a normal practice."
The blood that arrived too late — a single unit — probably would have been
too little to save Svetlana's life. A decade ago, Dr. Turchev says, such a tragedy would
probably not have happened at all.
In Room 502 of the trauma unit, Mr. Ivanov's wife, Tatiana, arrives at his bedside with
a plastic grocery bag full stuffed with pain- killers and other emollients:
Bifidobakterine, $3.10; Bificolum siccum, $1.25; Ketanov, $5.75; Ctadol, $8.35; Tsefakina,
$10.90, and more.
"When I'm free from here," Mr. Ivanov says, "I'll go to the church and
light a candle. Because God saved me."
