Russia Is Taking First Steps to Deliver Its Health-Care System Out of Chaos

FORT LAUDERDALE, Fla--Imagine a country where a cancer diagnosisis never revealed to a patient, where few have ever heard of screeningmammography or breast self-examination, and where most men donot live long enough to get clinically evident prostate cancer.

"This is a portrait of the United States in the early decadesof this century and also a portrait of Russia today," saidBarrie Cassileth, PhD, in her talk at the second annual Industries'Coalition Against Cancer conference.

Dr. Cassileth has traveled in Russia and actively encouraged modernbreast cancer education among Russian physicians. She noted thatdecades of neglect have left the Russian health-care system disjointedand inadequate, while pollution, alcoholism, smoking, and poornutrition have led to a major public health crisis. Russia, forexample, has the lowest life expectancies of any industrializedcountry--59 years for men.

Universal access to free medical care was achieved in Russia bysacrificing quality of care for quantity, she said, and the idealof equal access was subverted by a three-tiered system: At thetop, "show hospitals" created for the government elite;for the masses, poorly equipped regional hospitals; and for ruralareas, physician assistants called feldshers.

In her talk, Dr. Cassileth, adjunct profession of medicine (oncology),University of North Carolina, cited some dismaying statisticsabout the primitive regional hospitals where the vast majorityof patients in Russia receive care: 24% lack plumbing; 19% lackcentral heat; 45% lack bathrooms or showers; 49% lack hot water;and 15% have no water.

She said that the government began reform efforts in 1992 witha goal of reducing the number of physicians while increasing thequality of hospitals and training. Entrance requirements for medicalschool have been tightened, but continuing education and qualityassurance programs are still lacking or inadequate.

"Developing quality assurance is a crucial step," shesaid, "to help counteract the widespread mistrust and lackof respect in Russia for medical care and physicians." Partof the mistrust stems from the oath taken by physicians in theold Soviet Union to defend the interest not of the patient butof the state, and of the tradition of protecting patients fromknowledge of any potentially fatal illness.

Because of this mistrust, patients often refuse hospital admissionand decline needed surgery. A survey of patients in oncology departmentsthroughout the Vinnitsa region who refused surgery for stomachcancer revealed that many had guessed their diagnosis and decidedthat treatment was useless.

"There is, in fact, deep pessimism concerning the value ofcancer treatment," she said, not only among patients butalso among physicians. In a survey of all 234 fourth- and fifth-yearmedical students at Tver Medical Institute, questioned after completingan oncology course, half said they considered cancer preventionineffective and distanced themselves from cancer patients. Some10% viewed cancer as contagious.

Not surprisingly, many patients turn to bizarre forms of faithhealing. "Millions of Russians place bottles of liquids andcreams in front of their TVs daily to be infused with curativepowers through the screen by a TV faith healer," she said.Dr. Cassileth believes the government will have difficulty enforcinga recent law prohibiting "mass healing events."

She also thinks that it may take a long time for Russian physiciansto become comfortable with the 1993 law that mandates patients'right to know their illness. This law also grants patients, forthe first time, the right to confidentiality, to see their testresults and other medical documents, to select their doctors,to request consultations, and to refuse treatment.

On a brighter note, Dr. Cassileth said that the Russian Academyof Science and other groups are urging adoption of US and Europeanstandards for clean air to deal with the serious pollution problems.

"Once problems such as these begin to be addressed, I thinkwe will be able to look to some important changes that will allowthe development of cancer programs in Russia, as we have hereand in other countries," she said.