In Russia, medical profession plods toward 21st century

Evidence-based medicine is becoming the Western norm, but it's still a remote concept in Russia. Dr. Vasiliy Vlassov, the Moscow-based editor of the International Journal of Medical Practice, is on a crusade to change this. However, he says he faces a tough task in a country where physicians see nothing wrong with having “romantic relationships” with patients, where medical associations don't enforce ethical standards and where medical school lecturers routinely take cash in exchange for emphasizing specific drugs. Some physicians also accept bribes for providing services — hardly a surprise when surgeons earn the equivalent of about US$100 a month.

Vlassov says evidence-based medicine is finally starting to influence medical practice in Russia, but “physicians don't understand what constitutes reliable evidence.” Today, the term is used more frequently by advertisers than physicians.

The leader of a $3.7-million Canadian International Development Agency (CIDA) project that is attempting to help Russians reform their health care system agrees that the failure to emphasize evidence-based medicine is a problem. Martine Durier-Copp, a Halifax political scientist, says this is one of many issues the Health Policy Reform Russia Project will tackle.

Durier-Copp says the country's hospitals and clinics have deteriorated almost to the point of being hazardous, with “many having no water or heat.” In the decade since the fall of the Soviet Union, she says, health status has declined significantly. Life expectancy for men, for example, has dropped from nearly 65 years in 1990 to 58 years. Women's life expectancy has remained constant at about 71 years.

“The system is not responding to the needs,” says Durier-Copp. Although her team of health professionals, economists and lawyers will try to help Russians do more with their limited resources, Vlassov is aiming to update the medical profession itself. Armed with a computer and research expertise, he says he's doing his best to provoke the country's medical establishment and to encourage the adoption of professional standards for practice, research and publication. He has published more than a dozen articles (J Epidemiol Community Health 2000;54[10]:722-3) and numerous letters (JAMA 1999;279[10]:321-2) on the topic in Russian and Western journals, “but there's no reaction.”

A major obstacle to professionalism and professional clout is the lack of a national medical association within the country. Three associations claim to be the Russian medical association, but none is truly national. And none is offering certification or evaluation or serving the same function as Canada's provincial colleges of physicians and surgeons. This means there are no restrictions in areas such as romantic relationships between physicians and their patients. “Most doctors don't understand what's wrong with it,” says Vlassov.

As for the medical associations that exist in Russia today, he says their “most visible business” is the sale of their names to advertise products such as toothpaste, antibacterial soap or yogurt.

Russia has about 450 physicians per 100 000 people, compared to about 187 per 100 000 people in Canada, but Vlassov points out that there are no family physicians. The point-of-entry polyclinics are staffed by “territorial” physicians who do few diagnostic tests beyond reading patients' blood pressure. They earn about US$50 a month.

This fall, the CIDA reform plan is beginning train-the-trainer projects aimed at developing a family physician program in one region.

The underlying problem is a lack of health care funding. The annual allocation is only between US$20 and $50 per person. “In Russia, everybody is promised the health care he or she needs, but in reality it's available to people who have power or money,” Vlassov says. For example, a Russian with cancer can get surgical care and radiation therapy, but chemotherapy is too expensive and is provided only “as available.”

The CIDA team is looking for simple, inexpensive ways Russians can improve their health status, such as introducing iodized salt and birth control. Today, the average Russian woman has about 6 abortions in her lifetime. Meanwhile, according to WHO, the maternal death rates are 51.6 per 100 000 live births (29.4% of these are due to abortion-related complications).

“The first step is to understand why these sorts of things occur in a population of very bright people,” says Durier-Copp. By 2005, the reform project hopes to have 2 primary health care demonstration projects running.

Notably absent today are the cohesive public health programs that were a cornerstone of the system in the former Soviet Union, and this has led to the re-emergence of diseases such as tuberculosis and an HIV-infection rate that is now doubling annually. “We will have at least 5 million [infected people] in 2 years,” predicts Vlassov.

Internationally, much attention has focused on alcohol use in Russia, with some scientists contending that it has played a major role in Russians' declining life expectancy, but Vlassov says that in a country plagued by rapid change, stress and poverty, it is too simplistic to blame all the decline on alcohol. In Russia, 70% of people live in poverty.