The Health System

The glasnost period of the late 1980s first revealed the decay of the Soviet system of socialized medicine, which nominally guaranteed full health protection to all citizens without charge. That system had been installed under Joseph V. Stalin (in office 1927-53) with an emphasis on preserving a healthy work force as a matter of national economic policy. In the 1980s, Russia had a huge network of neighborhood and work-site clinics and first-aid facilities to provide

readily accessible primary care, together with large hospitals and polyclinics to diagnose and treat more complex illnesses and to perform surgery. In 1986 the Soviet Union had 23,500 hospitals with more than 3.6 million beds. Such facilities included about 28,000 women's consultation centers and pediatric clinics, together with emergency ambulance services and sanatoriums.

In the 1980s, the Soviet Union was first in the world in the ratio of hospital beds to population. Behind this system was a huge, multilevel bureaucracy directed from Moscow in consultation with organs of the CPSU. All aspects of health service had nationwide annual programs with complex statistical accounting and goals. Physicians devoted an estimated 50 percent of their time to filling out forms, and every year a large part of the national health care budget went to construction of new facilities.

The structure of the Soviet system, which specified the length of treatment for every disease, often caused people suffering from relatively minor ailments such as influenza to be hospitalized. The result was a serious overcrowding problem in hospitals despite the large number of beds available. Patients preferred hospital treatment because hospitals were better equipped than clinics and because crowded living conditions made recuperation at home difficult. Many large enterprises operated clinics that provided workers health care without requiring them to leave the work site. Such clinics aimed at reducing the incidence of sick leave, which averaged 3 percent of the workforce per day in the 1980s.

The most outdated and abuse-ridden aspect of Soviet health care was psychiatric treatment. That system never advanced from the methodology of the 1950s, which included Pavlovian conditioned-response treatment, heavy reliance on drug therapy, and little practice of individual or group counseling. Therefore, most citizens preferred to suffer rather than submit themselves to treatment. In addition, Soviet psychiatry was at the service of the government to declare dissenters "insane," commit them to psychiatric hospital-prisons, and administer powerful

psychotropic drugs. In the mid-1980s, estimates of the number of political prisoners in such institutions ranged from 1,000 to several thousand, and in 1983 the Soviet Union withdrew from the World Psychiatric Association to avoid censure for its abuses of the profession. In 1988 the special psychiatric hospitals to which political dissidents had been committed were transferred from the jurisdiction of the Ministry of Internal Affairs to that of the Ministry of Health.

In 1986 the Soviet Union had about 1.2 million doctors and about 3.2 million paramedical and nursing personnel. Medical training emphasized practical work over basic research and pure science; only nine medical institutes were attached to universities. In the late 1980s, the average doctor's salary was roughly comparable to that of the average industrial worker. In 1996 the average Moscow specialist made about US$75 per month, and senior doctors made about US$150 per month. Paramedics and nurses needed only two years of training and no scientific background; however, in rural areas, which suffered a shortage of doctors, such individuals often were the only medical personnel available.

Despite the nominally equitable nature of Soviet socialized medicine, the actual system was highly stratified according to location, with far inferior care and facilities available in rural areas, and especially according to political status. The Ministry of Health maintained a completely separate, vastly superior system of clinics, hospitals, and sanatoriums for top party and government officials and other elite groups such as writers, actors, musicians, and artists.

The outline of the Soviet system did not change appreciably in the first half of the 1990s, but quality declined in nearly every aspect except the facilities designated for the elite. In 1992 Russia had 662,700 doctors, a drop of about 32,000 since 1990, and 131 hospital beds per 10,000 population, a drop of 97,000 beds (about 5 percent) since 1990. Among the doctors, 78,600 were surgeons, 77,600 pediatricians, 39,600 gynecologists, 20,300 psychiatrists, and 18,500 neurologists.

In the early 1990s, the public health delivery system in Russia was in crisis. Although the number of doctors and paramedics (парамедик, спасатель, младший медицинский персонал) has remained sufficiently high to ensure the provision of adequate treatment, most such personnel are poorly trained, lack modern equipment, and are badly paid. In 1995 Russia had one doctor for every 275 citizens (compared with one for every 450 in the United States), but about half of medical school graduates cannot diagnose simple ailments or read an electrocardiogram when they enter practice. In 1993 about forty institutions offered medical training, but the quality of training varied considerably. Many medical schools suffer from shortages of instructors, textbooks, current medical journals, contacts with Western experts, and equipment.

Low salaries have made corruption common among medical personnel, who often extract bribes for both materials and services. Thus, although health care is free in principle, the chances of receiving adequate treatment may depend on the patient's wealth. The combination of bribes and authorized charges puts many types of medical treatment beyond the reach of all but the wealthy. Elderly people are hit especially hard by this situation. Meanwhile, a sharp decline in state funding has affected all aspects of medical care, from prevention to emergency treatment. Between 1990 and 1994, state funding declined from 3.4 percent of the national budget to 1.8 percent.

Although Russia pioneered in some specialized fields of medicine such as laser eye surgery and heart surgery, the country's medical establishment is generally deficient in hospital equipment, technology, and pharmaceuticals. For example, preventable infant deaths result from an absence of fetal heart monitors, ultrasound units, and various other equipment for monitoring labor and delivery; needless deaths from heart disease occur because hospitals lack the equipment needed to perform bypass surgery and angioplasty. Facilities for the disabled, of whom about 6 million reside in Russia, also fall far below Western standards. Wheelchairs and artificial limbs are in very short

supply, rehabilitation centers are few, and wheelchair ramps are virtually nonexistent. A 1995 law, On the Social Protection of Disabled Persons in the Russian Federation, provides for a wide range of benefits and services, including equal access to education, employment, transportation, and services. The law requires businesses to set aside at least 3 percent of their jobs for the disabled. However, no funding was available for any of the law's programs in 1996.

The shortage of medicines in Russia is chronic and catastrophic. Soviet-era supplies of materials and drugs have been depleted and are not being adequately replenished. Domestic production has plummeted because of the obsolescence of pharmaceutical factories and shortages of requisite raw materials and supplies. Many of the items produced are ineffective. Russia relies increasingly on imports from former Soviet-bloc nations in Central Europe, which formerly accepted barter transactions and payment in rubles but now demand hard currency (see Glossary), a scarce item in Russia, for their products. The nonconvertibility of the ruble also has hindered Russia's ability to purchase medicines abroad. Even when pharmaceuticals are available in Russia, they often are priced beyond the reach of doctors and patients.

Russia's hospitals and polyclinics are generally old (about 15 percent were built before 1940), and they lack basic amenities. Roughly 42 percent of the country's hospitals and 30 percent of its clinics lack hot water, and 12 percent and 7 percent, respectively, have no running water at all. About 18 percent of hospitals and 15 percent of clinics are not connected to a sewerage system, and only 12 percent in both categories have central heating. Even in the best hospitals, medical personnel do not regularly wash their hands, surgical instruments are not always properly sterilized, and rates of infection are abnormally high.

Aside from shortfalls in Russia's health facilities and the quality of medical personnel, much of the country's public health crisis stems from poor personal hygiene and diet and lack of exercise. Preventive medicine and wellness

programs are virtually nonexistent, as are programs to educate the public about personal sanitation, proper diet, and vitamins. The average Russian does not consume a balanced diet. Vegetables often are scarce in Russia, except in rural areas where they are homegrown, and fruits never have constituted an important element of the Russian diet. Per capita meat consumption also has fallen in the 1990s (see table 6, Appendix).

Russia's government is attempting to equalize the distribution of health care by fragmenting the Soviet-era network of top-level medical facilities for exclusive use of the elite. In the spring of 1993, President Yeltsin signed a decree entitled On Immediate Measures to Provide Health Care for the People of the Russian Federation. The proclaimed goal, which already had been established in the 1980s, was the creation by 2000 of a "unified system of health care" for the entire population. However, economic constraints are likely to stymie achievement of that goal in the near future. In 1995 less than 1 percent of Russia's budget was earmarked for public health, compared with 6 percent in Britain and more than 12 percent in the United States. Experts forecast that such a meager outlay will not address the major shortfalls in Russia's health care system, not to mention the air, water, and soil pollution that continue to contribute insidiously to worsening public health.

In the Soviet era, the state discouraged alternative medicine by arresting practitioners. By 1995, however, the number of such individuals was estimated at 300,000, and as many as 80 percent of Russians needing medical assistance have turned to them, according to a Yeltsin adviser on social policy. Traditional folk healers constitute the largest group of nontraditional practitioners. They offer personalized attention and affordable cures such as birch bark and cranberries to cure a variety of complaints. Russians with access to a plot of land often grow their own herbs, and books describing home cures have become popular. Long-practiced cures such as wrapping oneself in a vinegar-soaked blanket and drinking one's own urine have become more widespread in the 1990s.

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