An inadequate health-care system provides good care only for those who can pay
For the Sick, No Place to Turn
The population decline can be blamed in part on the broken-down healthcare system. If you're seriously ill, only serious money can help.
Karabash, Russia — He was 40 when he had his first heart surgery, a quadruple bypass to correct damage caused by the swirling poisons of the ancient copper smelter where he worked. But that was a decade ago, when the decrepit Russian healthcare 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 $1 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. "What can I do without money? Wait for the end."
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 healthcare system and the debut of free-market medicine have added to the slide.
In the new Russia, millions are born sick. Many succumb to poisons in the air and water around them, or are slowly killed by alcohol, cigarettes or stress. Most are too poor to buy back their health.
The overwhelmed healthcare system can't help much. Although 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. They can ensure that a patient will be admitted to a decent hospital and increase the chances that a doctor will be diligent.
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. Everyone else is relegated to foul-smelling infirmaries with stained sheets, no food and a dearth of equipment as basic as a functioning X-ray machine. The 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% of Russian children are born with "health deviations," including problems of the central nervous system, faulty hearts, malformed urinary tracts and low birth weight.
Heart disease and strokes among those younger than 40 have increased by as much as 36% in the last five years, said Yevgeny Chazov, who heads the Russian Cardiological Center in Moscow and was personal physician to most of the Soviet leaders since the Leonid I. Brezhnev era.
Russian President Vladimir V. Putin has responded to the problem, pushing healthcare to the top of the nation's priorities. This year, his government is spending $24.6 billion to more than quadruple some doctors' salaries, build 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 healthcare crisis more pronounced than 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 that 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 as much as 180 tons of sulfur dioxide and metal particulates into the air annually since 1910, before the Bolsheviks came to power.
Lychmanyuk knew he was slowly killing himself every time he stepped inside the smelter oven, where it was too stifling to even wear a gas mask.
"The stove is stopped for 24 hours. It gets a little cooler, and you go inside and start cleaning," he recalled. "But five minutes in there, and your clothes and felt boots start catching fire."
He started having pains in his chest and trouble breathing. His bypass surgery alleviated the problem for a while.
Outside the smelter, the particles spewed from what residents call "the torch" have settled over every yard, rooftop and doorstep for a mile or more. The hillside along the road into town, once a dense forest, is bare earth. Hardly a blade of grass grows in the yards near the smelter.
By 2000, deaths in Karabash were exceeding births 3.5 to 1. Although Karabash is subject to the same poverty and social ills as the rest of the country, residents have no doubt about 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."
Natalya Sharando, the chief physician at Karabash City Hospital, said she saw an endless parade of patients with ulcers, breathing problems, cancers and heart disease.
One of them was Anatoly Fomin. When the hospital could no longer treat his lung cancer, Irina Bespalova took her 56-year-old brother home to die.
At first glance, it appeared that no one was in his small room. But Bespalova moved a jacket to reveal Fomin huddled in a fetal position. "No, it's cold, " he whimpered, clutching at the jacket, as he lay on a metal bed frame. She had had the mattress removed, she said, because there was no running water to keep him clean.
Sharando noted that "three or four generations have grown up breathing this gas and smoke. That's why, even if you employ very intensive health improvement measures ... they will not bring any positive results," she said.
The environmental problems caused by the plant became so apparent that the Soviet government shut it down in 1990. Everyone expected massive infusions of aid to address the pollution and help residents find new jobs. But nothing happened.
When the plant reopened in 1997 under private management, hardly anyone objected. Recently, a filter was installed that significantly reduced plant emissions. Still, in June 2004, an accidental discharge sent a poisonous cloud over the town, killing 250 acres of forest and 600 private gardens and yards. Sulfates, iron, zinc and copper have been measured in the groundwater at levels as high as 115 times the legal limits.
"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 Smallest Victims
In a dim living room in Chechnya, a small shape on the sofa was distinguishable mostly by cries, low moans and occasional sharp shrieks. The toddler clenched and unclenched his tiny fists, legs trembling like a bird's wings.
"His spine and his head hurt badly," said Svetlana Shaipova, a nurse and friend of 2-year-old Askhab Dzhamulayev's family, "but his mother didn't want to keep him drugged asleep all the time with painkillers."
A year ago, Askhab was toddling energetically around the apartment and starting to talk. "Mama." "Give." "Bring." Then one day, he developed a fever and cramps in his legs. That was followed by a seizure, then a coma. When he awoke, he was partially paralyzed, and doctors don't know why.
Even when Russians can get a foot in the door of the healthcare system, the result often is unsatisfactory. Doctors came up with one diagnosis after another for Askhab: encephalitis, meningitis. None of them have been certain.
The family traveled to the nearby city of Makhachkala for a better hospital, but there weren't enough diagnostic instruments available to doctors there either.
Just go home, they said. Askhab probably would live, in pain and barely functioning, for 20 to 30 years.
But they suggested an alternative.
"'Why don't you think of something else?'" the child's grandmother, Leila Dzhamulayeva, recalled a doctor telling her. "'Why don't you put him to sleep? That would be better for him, and for you.'"
Another Chechen mother pushed for answers all the way to Moscow. Rossita Magomedova of Grozny, a 31-year-old psychology teacher, didn't believe the doctors who said the mysterious swelling in the jaw of her 3-year-old son, Anzor, was a complication from the mumps.
She drove him to the neighboring republic of North Ossetia, where she had to fight to get a doctor to see her son. He said the child had a tumor and needed immediate surgery.
"I'm holding my son in my arms," Magomedova said. "The doctor told us every second counts, and he had no time for anesthetic. So we open his mouth, and without any anesthesia at all the doctor takes a pair of scissors from the bottle and snips, snips on the tumor. He was cutting it like a piece of meat. And the horrible thing is, you have to trust this doctor, not with your own life, no, but with the life of your child."
When the tumor was found to be malignant, Magomedova bundled Anzor in blankets and flew with him to the best children's hospital in Moscow. She headed straight to the office of the deputy chief physician.
"I put Anzor on the table. I said, 'A doctor like you gave him three days to live, and this is the third day. Let's watch him die.' He immediately called in another doctor, and they admitted him."
The hospital gave Anzor top-flight medical care: chemotherapy and enough radiation treatment to shrink the tumor. But not long after the boy was admitted, a new tumor was detected in his belly.
Week by week, Magomedova watched her son's life dim like dusk, flickering out on May 6.
The healthcare crisis that accompanies Russia's population decline is a fact of life not only in far-flung regions and rural areas, but also in major cities. And it affects the middle class as well as the poor.
The 8.8 million people who ride the Moscow subway system every day are exposed to nearly 1 1/2 times the maximum safe level of carbon monoxide and other dangerous gases, the government reported.
An outbreak of hepatitis A 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% in the first half of 2004, the Health Ministry reported.
But neither disease is as worrisome to health officials outside Russia as the alarming growth of AIDS and tuberculosis, a common infection associated with AIDS.
Russia and its neighboring former Soviet republics are experiencing the fastest-growing epidemics of AIDS and TB in Europe. Russia is seeing at least 120,000 new tuberculosis cases a year, 10 times the number in the United States, which has double the population. Last year, about 32,000 Russians died of the disease.
Tuberculosis, unlike AIDS, can be spread through casual contact with people who have compromised immune systems, sparking fears that Russia could become an "epidemiological pump" for spreading the disease to the rest of Europe and to North America.
"The worse off you are, the more likely you are to have tuberculosis," said Mikhail Perelman, director of Moscow's Phthisio-Pulmonary Institute, once a hospital for Napoleon's troops. Its dark, arched hallways are haunted by shuffling tuberculosis patients, many of them quarantined for months on end.
Tuberculosis has flourished in the airless confines of Russia's severely crowded prisons, and it seeps into the general population with the tens of thousands of convicts released each year. In a growing number of cases, the disease has mutated beyond the reach of drugs commonly used to treat it.
Russia has accepted international help to begin a serious fight, developing aggressive programs to make sure patients complete their treatment. In addition, $480 million a year has been allocated for expensive "second-line" treatment for the estimated 30,000 cases of drug-resistant TB.
But as with those who have AIDS, many TB patients outside Moscow have no access to the latest drugs.
Sergei Shelkovnikov, a 34-year-old fuel engineer who works for TNK-BP, British Petroleum's joint venture in Russia, was spending three months in the Moscow institute for treatment of drug-resistant tuberculosis. He thinks he caught it on the subway.
"All I know is, I had a persistent cough. It sounded like bronchitis to me," he said. "It lasted for about a month, and when I went to the doctor, a lung X-ray revealed I had tuberculosis."
Studies have shown that stress and general ill health increase susceptibility to tuberculosis. People may be exposed repeatedly but don't catch it until their resistance breaks down.
Galina Sokolova, chief physician at the Phthisio-Pulmonary Institute, cited the case of a well-educated 43-year-old man with two small children. When his wife died of cancer, he had to work as a security guard, and eventually came down with tuberculosis.
"This happens time after time," Sokolova said. "A state-owned enterprise is closed down. People lose their jobs. And they become our patients."
The office of the head of neurosurgery at St. Petersburg's City Hospital 23 is at the end of a medieval-looking corridor with bare wires and peeling paint. Stuffing and springs are falling out of a sofa in the corner.
Doctors drink tea and chain-smoke at a tiny table etched with scratches. Their ancient electroencephalogram machine looks like something out of a horror movie.
Although tuberculosis and AIDS are becoming front-line priorities for the healthcare system, hundreds of hospitals continue to languish.
Doctors struggle with poorly equipped laboratories. Expensive equipment donated by foreign aid organizations may have 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 across the country.
"The CAT scanner we have at our hospital has not been working for a year — for a whole year," said Alexander Naryshkin, head of neurosurgery. Hospital management said that it provided $80,000 to buy replacement parts for the scanner, which served an entire district of the city, but the money disappeared. So this $1-million piece of equipment is standing useless, and nobody seems to care,"
The doctors work with surgical instruments that are 20 to 30 years old. Naryshkin, who makes $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 to make the purchase.
Most serious neurosurgery cases are transferred to other hospitals, but if there is an emergency or patients can't afford to go elsewhere, they end up at City Hospital 23. The death rate for brain surgery patients here has climbed from about 40%, when the hospital had a well-functioning neurological intensive care unit, to about 80%.
Twice during one recent month, Naryshkin lost patients who needed surgeries because the St. Petersburg blood bank was empty, and there were no relatives to serve as donors.
He has lost others, he said, because their families couldn't buy 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."
A Legal Remedy?
Slowly, the court system and patient advocacy groups are gaining a foothold in healthcare.
In Moscow, the Patients' Protection Assn. is gathering data on hospitals and preparing to distribute on the Internet a list of hospitals that should be avoided.
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 case 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 had to wait. Doctors apparently believed she was suffering normal labor pains, despite the bleeding, she said.
She recalled that the baby stopped kicking. She thinks she must have nearly passed out.
Suddenly, the doctors became "very busy" around her, listening for a fetal heartbeat. They gave her several injections to induce labor. It was too late.
Danila Vladimirov died 13 days later, joining the growing population of the cemetery outside the city.