]]]]]]]      SOVIET HEALTH CARE'S CRITICAL CONDITION      [[[[[[[[[[[ 
                  By Kenneth M. Prager [, M.D.]             (9/29/88)
   [Dr. Prager is on the faculty at Columbia College of Physicians
  and  Surgeons  in  New  York and  is  a  specialist  in pulmonary
                          medicine.]
       From The Wall Street Journal, 29 January 1987, p. 28:3
                [Uploaded by Freeman 10602PANC]
   As a physician on a private visit to Moscow and Leningrad last
spring, I  had a  unique opportunity  to learn  about the current
[1987]  state  of Soviet  medical  care.   As soon  as  my Soviet
acquaintances  learned  that  I  was  an  American  doctor,  they
organized makeshift clinics in various apartment houses so that I
could examine patients and  dispense medical advice.  Even though
I expected Soviet medicine to  be below American standards, I was
appalled by what I saw.
   The Soviet medical-care  system is decades  behind the West in
technology  and stresses  little more  than  keeping the  mass of
Soviet workers  happy and on  the job.   It is a  system that can
adequately care  for simple  and self-limited  health problems of
its ordinary  citizens, and it  offers the  privileged among them
such amenities as resortlike sanitariums  where they can bathe in
mineral  waters  and  rest.   But  the  level  of  sophistication
necessary to properly attend to such chronic and complex ailments
of modern  society as cancer  and cardiovascular  disease is what
one  would expect  of  a developing  nation  and not  one  of the
world's great powers.

Waiting Lists for Wheelchairs

   My impressions of  Soviet medicine were  reinforced by my care
of  refusenik  David Goldfarb,  who  arrived in  the  U.S. aboard
Armand Hammer's jet  last October [1986].   After languishing for
four months in  several Soviet hospitals,  Prof. Goldfarb finally
received  definitive  treatment  for  his  multiple  medical  and
surgical problems in New York.   He is currently learning to walk
on a modern prosthesis.   The fact that he  did not use his heavy
and  crudely  made  Soviet prosthesis  since  losing  his  leg at
Stalingrad  in  1942 speaks  volumes  about Soviet  care  for the
disabled.  Long waiting lists  for wheelchairs further testify to
Soviet disregard for the needs of the handicapped.
   One of my first patients on my visit was an 80-year-old man in
severe pain  because he was  unable to urinate.   His bladder was
remarkably distended and  he obviously needed  to be catheterized
immediately.  The  urologist who  had been  summoned to  his home
complied  with  my request  for  a  rubber glove  to  examine the
patient's prostate  gland.  After  examining him,  I was startled
when the  physician requested  that I wash  the glove  so that it
could be reused.   She then relieved the  patient of his distress
by passing  her only,  reusable catheter  into his  bladder after
lubricating it with  butter.  She had  sterilized the catheter by
boiling it in a pot of water in the patient's kitchen.
   There  is  a  virtual  absence  of  such  disposable  items as
syringes, needles, catheters and  intravenous tubing in hospitals
and  clinics.  Patients  pay a  considerable price:  Reused items
increase  rates  of  infection,  while  intravenous  needles  and
scalpels  that have  become dull  as  a result  of wear  and tear
increase pain and discomfort.
   That  this  elderly   man  adamantly  refused  hospitalization
pointed  to  another feature  of  Soviet medicine:  The  aged are
afraid  of  being  hospitalized.  In  a  medical  system  that is
chronically short  of the  most basic  supplies, the  elderly are
considered expendable and will be the  first to feel the brunt of
such shortages.
   Another  patient   I  met  was   a  28-year-old   man  with  a
well-documented  heart attack  two  years earlier  who  was still
experiencing  chest pain  when  he exerted  himself.   His entire
evaluation by Soviet physicians consisted  of an ECG stress test,
and his only  medication was nitroglycerin to  be taken as needed
for chest pain.  A coronary angiogram, which might have disclosed
a surgically  correctable reason  for his  premature heart attack
and  persisting  angina,  was never  suggested,  and  he  was not
treated with  any of  the potent  cardiac medications  that might
lessen his pain, and possibly increase his longevity.
   The  case  of   this  unfortunate  young   man  discloses  the
unavailability of coronary  angiography and surgery  to all but a
select few  in the  U.S.S.R.  On  a much  more fundamental level,
however, it  reveals how  few modern  medicines are  available to
patients with serious  problems.  The tremendous  strides made in
the  past  two decades  in  development of  potent  and effective
medications in all  areas of internal medicine  seem to have made
little impact in the U.S.S.R.  New medications are either totally
unavailable from  pharmacies or  are in  such short  supply as to
make them ineffective in treating chronic illness.
   Such staples of modern medical  treatment as Tagamet [brand of
cimetidine] for ulcer disease, Sinemet [brand of a combination of
carbidopa  and  levodopa]  for  Parkinsonism,  beta  blockers and
calcium  channel  blockers  for   angina  and  hypertension,  and
antihistamine-decongestant preparations for  the relief of common
cold  symptoms  are  extremely hard  to  come  by.   Other useful
medications, such as anti-asthma  drugs and multivitamins, are of
such poor  utility as to  discourage their  use.  Liquid antacids
are completely  unpalatable.  While I  was in Moscow,  I was told
that a drug such as Tagamet could sell for a small fortune on the
black market.
   A major health  problem facing Soviet women  is the absence of
reliable  measures for  birth  control.  Birth-control  pills are
impure and produce  intolerable side effects,  and diaphragms are
poorly fitting and of low quality; condoms are crudely made.  The
result is that abortion in the major method of birth control used
by  non-Moslem Soviet  women.  A  conservative estimate  based on
Soviet statistics is that the  average Soviet woman undergoes six
abortions in her lifetime.  It is  not uncommon to meet women who
have had 10 or even 15 abortions.
   And   this  primitive   health  system   is  far   from  free.
Hospitalized Soviet  patients frequently  bring a  roll of rubles
with them if they  want to make sure  that they obtain such basic
nursing  care   as  linen   changes  and   reliable  delivery  of
medications.   Their families  must bring  them meals  from home.
Payments to physicians in the form of cash, goods or services are
often necessary to ensure proper  treatment or a skilled surgeon.
Even more money is needed to obtain scarce medications.
   Faced with a  medical system that is  too often ineffective in
treating  disease, Soviet  citizens  turn with  desperation  to a
variety  of quack  medical  practitioners.  Starvation  diets are
commonly  resorted  to  in  treating  chronic  illness,  with the
unintended result  of weakening  an already  debilitated patient.
Psychic healers with a variety of potions abound, and amulets and
other magical devices are frequently used.
   Not  everyone in  the U.S.S.R.  must put  up with  these gross
deficiencies of  the medical  system.  The  "classless" Communist
utopia  has a  very rigid  hierarchy of  medical-care facilities.
The  Fourth  Department of  the  Ministry of  Health  consists of
hospitals, sanitariums and clinics that are available only to the
Communist Party  elite and  other notables.   These hospitals are
stocked with  the most advanced  medical technology --  all of it
made abroad.   It is  to these  flagships of  the Soviet hospital
fleet that groups  of visiting foreign  physicians are taken when
the occasion arises.  The  unsuspecting doctors leave the country
with a totally  distorted impression of the  true state of Soviet
medicine.

A Matter of Priorities

   Why does  one of  the world's  two great  superpowers tolerate
such primitive conditions  in so much  of its health-care sector?
The  answer  is  that modern  medicine  is  very  expensive.  The
Soviets have chosen to spend their limited resources on missiles,
heavy  industry and  space technology  rather than  on disposable
medical equipment,  modern drugs and  costly life-saving devices.
Excellence in medical care  is simply not a  high priority in the
Soviet system.   The best  estimates available  indicate that the
Soviets allocated 9.8%  of the gross  national product to medical
care in 1955, but only 7.5% in 1977.  The trend is clear.
   Whether  Mikhail  Gorbachev's  attempts  to  modernize  Soviet
society  will  include  an overhaul  of  the  medical-care system
remains  to   be  seen.   Unremitting   Western  publicity  about
human-rights abuses in the U.S.S.R. has sensitized the Soviets to
this  issue,  and  there  seems   to  be  some  movement  on  Mr.
Gorbachev's part  to try to  mollify his  Western detractors with
conciliatory moves,  however few.  If  the sorry  state of Soviet
medicine  becomes a  focus of  concern in  the West,  perhaps the
Soviets will be similarly instigated into carrying out some badly
needed reforms to bring their medical system into the second half
of the 20th century.

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