Doctors Saving Lives & Growing Potatoes in Russia

Yoshie Furuhashi furuhashi.1 at SPAMosu.edu
Sun Dec 17 11:52:19 MST 2000


On this list, we've discussed the divisions of mental & manual labor,
intellectuals & manual laborers, "conception" & "execution,"
"pleasant work" & "shitwork," etc.  Here's an article on post-Soviet
Russian doctors growing potatoes to survive while still trying to
practice medicine in the public sector.  Russian doctors' salaries
are now so low that many of them also are compelled to extort
"bribes" from patients, making a mockery of still nominally "free"
health care.  At the same time, some doctors have given up on public
medicine, opening private practices; a few of them have become rich
(relative to the rest of the population), but the populace are so
poor that probably most "private doctors" simply function as part of
the precarious "black market" in health care.

While some -- in an idealist & workerist fashion -- may argue for the
virtue of intellectuals like medical doctors becoming acquainted with
the "dignity of manual labor" via growing potatoes, etc., I think
that _a society that cannot support medicine as a profession_ under
the conditions of free health care, with medical supplies, equipment,
pharmaceuticals, etc. always ready at hand, is _a society in dire
straits_.

_Doctors should save lives, instead of growing potatoes for
survival_.  They should also be given sabbaticals, so they can devote
themselves to professional development, always keeping up with the
latest scientific discoveries.

Yoshie

*****   The New York Times
December 16, 2000, Saturday, Late Edition - Final
SECTION: Section A; Page 1; Column 1; Foreign Desk
HEADLINE: Russia's Doctors Are Beggars At Work, Paupers at Home
SERIES: FREEDOM'S TOLL: Saving Lives, Growing Potatoes
BYLINE:  By CAREY GOLDBERG with SOPHIA KISHKOVSKY
DATELINE: KOSTROMA, Russia

Nineteen-year-old Anya, a deaf, blue-eyed china doll of a girl, was
hemorrhaging out of control after giving birth.

Dr. Aleksandr N. Klesarev and his team fought to save her as her
heart stopped three times, as her uterus had to be excised, as she
lost such a river of blood that soon nothing ran in her veins but
transfusions.

Anya and her baby survived, and Dr. Klesarev recalled that recent
case with the joy of victorious battle. Emotionally, acute medical
crisis is the easy part of his job.

It is the chronic crisis that grinds him down, him and the nearly
700,000 other Russian physicians. It is feeling like beggars at work
and paupers at home. It is scrounging for essential medicines in a
system fraying and breaking from poverty even as rising illness and
mortality mean that people need doctors more than ever. It is getting
their trained hands calloused from working in the private vegetable
plots that feed their families.

Soviet doctors never had anything like the status and money of
Western doctors. The medicine they practice was considered to be
below the levels of the West, the system always suffered from
shortages, and the social status of a provincial general practitioner
was akin to a schoolteacher's, respectable, but modest.

That was especially so in provincial centers like Kostroma, an
ancient city of 280,000 on the Volga River known among Russians as
the wellspring of the Romanov dynasty, a city that was in decline
long before the Soviet Union collapsed. But under Communism, doctors
at least lived no worse than anybody else -- and maybe a bit better.

That has changed. Caught between an impoverished government that
cannot afford universal medical care and a deep-rooted Soviet scorn
for medicine-for-profit, many of Russia's doctors, especially here in
the provinces, seem worn thin, out of canteen water but still
marching ahead.

"When everything else took the capitalist road of development, and
medicine was left on the socialist road, we got an imbalance that is
killing medicine," said Dr. Aleksei Golland, one of a handful of
private doctors in Kostroma.

"It's an economic death," he said. "If it continues like this, I see
the murder of medicine in that the masses of quality doctors don't
have ground to stand on. A surgeon has to plant potatoes to feed his
family."

Ask what keeps the government-paid doctors going and the same words
keep coming up: Vocation. Duty. Mercy. Naked enthusiasm.

A hospital department head said he could not afford to buy a suit. A
gynecologist boiled potatoes for lunch in an office teakettle. Some
doctors, city officials say, often walk to work because they cannot
afford to pay the equivalent of a dime to ride a bus.

'They Hope for the Best'

Aleksandr N. Smirnov, until recently the chief doctor of the 900-bed
Kostroma Regional Hospital, recalled that he had to take a string of
vacation days because he needed the salary advance to pay urgent
bills. Doctors and other hospital staff members generally work
six-hour shifts, he said, but so many now extend their hours for
extra pay that the 1,760 jobs in the hospital are filled by just
1,230 workers.

Still, the doctors keep donning the high cylindrical hats that go
with their white coats, keep scribbling diagnoses on flimsy
newsprint, keep trudging to house calls by bus and by foot.

Beg them, "Tell me something good!" and they reply: At least we can
talk freely about this. At least we don't stand in lines anymore. We
have access to Western drugs and technology and literature now,
though rarely the money for them.

Or: For doctors with profitable specialities, life can be better than
it was. And for the population, most medical care is still free, at
least theoretically.

Young people also have not been deterred. There are four or five
applications for every spot at the Yaroslavl Medical Academy, a
school housed in graceful prerevolutionary buildings where many of
Kostroma's doctors studied, said Yuri Novikov, its rector.

Many of the roughly 500 students come from medical "dynasties," he
said, "people who hear about medicine beginning in their diapers,
from their mothers and grandfathers." They know they will not get
rich, but believe that at least a good doctor can always find work.

"Our people have a good trait: They hope for the best," said Marina
Korzina, an 18-year-old student at the academy. "We have enthusiasm.
We can develop without equipment. If you look at the past, we didn't
think about the material side of things."

A few doctors are doing pretty well. There are a handful of legally
private doctors. And there are the doctors who practice a sort of
black-market medicine in which they operate in state facilities, but
charge their own little tolls.

A 1997 national survey estimated that Russian families were charged
some $4.5 billion that year for medical care that was supposed to be
free -- and paid $1.4 billion more in bribes.

No doctor admitted taking such payments, but all acknowledged that
such fees went beyond the old custom of giving doctors gifts -- candy
or liquor, usually -- for good treatment. One Kostroma newspaper
actually published a list of going prices for "free" medical services.

But for many doctors, this is still unthinkable after generations of
providing free service.

"I can't remake myself and take money for a consultation, though some
doctors have foreign cars and live in villas," said Valery Mochalov,
51, a surgeon who heads the hospital's emergency consultation
department. "Why? They take money. We call it 'a bribe.' When they
say, 'We can operate on you, but we have nothing, and I'll find
everything for you, and you pay me.' "

Or worse, he said, "when a surgeon says, 'I can operate on you hungry
and angry, or, if you give me money, I'll be full and happy.'

"That's the kind of extortion that happens, and so the patient pays," he added.

Dr. Klesarev, 41, who helped save Anya, works nearly double time, but
still earns a little more than $115 a month. That is not bad in a
city where the average doctor's base pay is about $30 a month, just
$1 above the poverty line, according to city officials.

But it cannot begin to support him, his wife, Larisa, and two teenage
daughters, Veronika and Nastya, plus a black poodle named Rocky. They
live in one room of his mother-in-law's two-room apartment, with
brown standard-issue Soviet wallpaper in a crumbling Khrushchev-era
building. He and his wife share a fold-out bed; his daughters share
another across the room.

They have no prospects of getting a place of their own. Once,
hospitals built apartments for doctors; not anymore. A rare ration of
milk is the main remaining official perk. With infections on the
rise, they also get a free test for AIDS.

In Dr. Klesarev's home, the television is in his mother-in-law's
room, so he must ask her permission to watch it.

He does not want much. He would like, he said, "to drive in my own
car and lie on my own couch with my own television with my own remote
control -- I can't do that in our apartment."

With his wife, he recently calculated that they need about $50 or $60
more a month to live adequately. Mrs. Klesarev, a bookkeeper, has
worked at several promising jobs lately, but none quite panned out.

So they constantly deny themselves. And like virtually every other
family here, they grow potatoes to save on food bills.

"It's hard," Dr. Klesarev said. "You get tired, and it's not right to
plow the earth with a doctor's hands."

Several years ago, his wife managed to get to America and worked
there for more than a year to build up some savings. In America, she
said, "I cleaned the houses of doctors," adding: "When I said my
husband was a doctor, they looked at me like I was crazy. 'How can
your husband be a doctor and you're cleaning houses?' "

Dr. Klesarev would love to come to the United States but most likely,
he said, his family will return to Crimea in Ukraine, where he worked
for 15 years until 1998, even though Ukraine's economy is worse than
Russia's. At least they own an apartment there. Maybe then, he and
Larisa might pursue her idea of opening a health club for women.

But he is torn.

"I save lives," he said. "That is what I've always done. I don't do
anything else, and I won't, though I'd consider doing something in
parallel, like treating pets. But there is no opportunity for that
right now."

Swarthy, bearded, cigarette constantly nearby, and with the
steadiness of someone who has seen too many real emergencies to
dramatize the mundane, Dr. Klesarev talked about the difficulties of
his life without undue emotion, much as he described amazing cases of
his past: the man cut to shreds when a diving tank he was inflating
ruptured; the camp stove that blew up in the faces of a dozen people,
killing two. (If that happened during the current shortages, he said,
"We'd lose half of them.")

His family is proud of his work as the head of the department of
anesthesiology and intensive care in the hospital's perinatal center.
But he was openly bothered by the humiliations: the begging he must
do from patients, whom he must ask to buy their own needles and
bandages and drugs, and from colleagues.

After the deaf mother, Anya, got through that critical first night,
for instance, Dr. Klesarev had to begin the "getting" that takes up,
he estimates, more than half of his time. He had to hit up colleagues
for drugs from their personal reserves. He had to wheedle blood out
of the nearly empty bank and wangle baby formula to feed Anya
herself. He had to block the use of a Russian-made device for her
tracheotomy, declaring, "Maybe Dr. Pavlov used that kind of
contraption with dogs at the turn of the century!"

In general, Dr. Klesarev said, this is a typical exchange: "I call
the central pharmacy and say, 'I need this,' and they say, 'Oh, we
don't have the money, and you can't get it.'

"So you get the money from the relatives. You summon the relatives
and say, 'We know it's expensive, but if you want a normal relative,
get it.' If they can't get it, we have to replace it however we can."

In Anya's case, he said, there was no money, so he begged as best he
could. A modern tracheotomy tube came from the private reserve of the
head of intensive care, for instance.

Anya ultimately went home with a healthy baby, he said, thanks to the
adage, "If everyone in the community gives a thread, the naked man
gets a shirt."

A Private Revolutionary

A few doctors in Kostroma, some in desperate financial shape or
simply ambitious, are slowly entering private medicine.

But that transition involves wrenching psychological change, as they
reconcile themselves to the idea that it is morally acceptable to
charge for treatment. And opportunities are limited, several said,
among so poor a population.

There is not one full-fledged private clinic here yet. The closest
thing belongs to Bogdan Bilyak, 41, the best-known private doctor in
Kostroma, a back-pain specialist who got into private medicine a
decade ago under Mikhail S. Gorbachev's economic liberalization and
has managed, through a forest of obstacles, to remain private ever
since.

A suite of four rooms, with recorded music piped into the waiting
room and a bright shingle outside, Dr. Bilyak's office would look
ordinary in America. Here, it looks revolutionary.

There is talk that Dr. Bilyak is one of the richest people in
Kostroma, and there are colleagues who envy him, he said, but they do
not understand, nor could they undertake, what is involved: "To work,
not five or six hours a day as in the hospital, but 8, 10, 12 hours a
day, and then go home and not watch TV but open a book."

Moreover, Dr. Bilyak said, when he tries to persuade doctors to start
a private practice, they balk, lacking the marketing and finance
skills they would need. He feels them beginning to change, he said,
but slowly.

"The medical system has not rebuilt itself," he said. "The only thing
being rebuilt is the consciousness of our doctors; poverty is leading
them to seek an alternative."

Dr. Golland, 38, is a newly private doctor. He left public medicine
two years ago, and judging by the black-and-white houndstooth jacket
he was wearing, one very like Dr. Bilyak's, he is doing well.
(Neither would discuss the details of his finances.)

But Dr. Golland is still fighting to reform a system that he sees as
doomed. "It's not underfinanced," he said, "It's a system that eats
up all force; the money disappears somewhere, and it's not clear
where."

These days, Dr. Golland has a small office and private patients he
charges a few dollars a visit. On a recent day, he escorted a patient
who needed a blood test to a nearby laboratory and got her in without
standing in line. He would pay the lab a fee, he said, and the woman
would pay him. That, he said, is the kind of "shadow medicine" that
is thriving these days.

Svetlana Korotkova, a born pediatrician and general fireball, cares
so much about her field that she found it too painful at first to
watch the episodes of the American show "E.R." on Russian TV, she
said. The contrast with Russian medical poverty hurt too much.

The children's clinic where she works opened only four years ago, and
it looks as up-to-date and as well furnished as any in Western
Europe. But Dr. Korotkova complained that there were no sterile metal
tongue depressors and that the clinic is often short of examining
room staples like cotton swabs and alcohol. The cleaning staff had
little money for supplies, and there was no toilet paper in the
bathrooms.

As Dr. Korotkova strode to a series of house calls, she said that in
medicine she felt like a fish in water. She called on a 12-year-old
girl who turned out to have nothing but a cold, and whose parents
would not have to pay for the visit, then walked on to the next stop
and continued her thought.

"Leave? " she said. "A pediatrician has no place to go. But I have
adjusted a bit: I have my own private clientele now." True, they are
just a handful of patients, but a beginning.

"I had to break my conscience to do it, to unlearn what the
Communists taught about free medicine and free education," said Dr.
Korotkova, who is 31. "But I've reached the point that I'm not
ashamed of it anymore. I'm doing what I love."

Just recently, however, she thought, for the first time, about
quitting altogether. She and some fellow doctors had been adding to
their meager incomes by selling nutritional supplements, but the
local government cracked down on such sales by doctors.

"When the decree came out, I thought for the first time of leaving,"
she said. "It's such an abyss, such a swamp."

But Dr. Korotkova is staying, and so are her friends and colleagues,
Aleksei and Anya Furashov, husband and wife doctors, who not only
work full time and raise two daughters but also run an evening club
for pregnant women with Dr. Korotkova. They charge a modest fee to
join.

But even the Furashovs wonder.

"You can't live on naked enthusiasm forever," Aleksei, 35, said. "The
money issue is a powerful issue."

"Why can't I have an apartment and a car, while an illiterate person
can?" he added, referring to street vendors. "And the problem is not
just an apartment and a car; it's bread."

Though so many doctors described themselves as optimists, they are
not short-term optimists. It will take a while, they believe, before
they regain some measure of respect. Today, they know, they are
looked on with pity.

"It will be no sooner than 20 years, maybe 15, when you will meet
someone and they'll say, 'Oh, you're a doctor!" Dr. Klesarev said.

In the meanwhile, he lives on other rewards.

"When you get a patient who is five seconds from being dead and you
get him out of it and 20 days later he walks out," he said, "you feel
like Jesus Christ."

Freedom's Toll

Previous articles in this series examined the reasons for the decline
in life expectancy in Russia since the collapse of the Soviet Union,
looked at a Moscow hospital and gave an account of the spread of
tuberculosis and other infectious diseases in Russia. Later articles
will examine the declining birthrate and the prospects for improving
the health of the Russian people. Articles in this series and related
coverage are available at The New York Times on the Web:
www.nytimes.com


GRAPHIC: Photos: SURGEON -- "A surgeon has to plant potatoes to feed
his family," says Dr. Aleksander N. Klesarev, above and with his wife
and daughter in their garden.; PEDIATRICIAN -- "I have my own private
clientele now," Dr. Svetlana Korotkova says. "I had to break my
conscience to do it." She is shown at left at home in the communal
apartment kitchen that she shares with another family and, below,
tending to the stomach pains of a 9-year-old boy. (Photographs by
Jacqueline Mia Foster for The New York Times)(pg. A10)

Map of Russia highlighting Kostroma: Kostroma, an ancient city, was
in decline long before the Soviet Union collapsed. (pg. A10)   *****





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