Cardiac Care in Remote Areas
August 16, 2013 | The Russian region of Yaroslavl is investing over 150 million euros in modernizing its healthcare system. One major focus in this initiative is the area’s provincial hospitals, where outdated medical equipment is being replaced. Initial successes are already visible: Mortality from cardiovascular disease has declined by nine percent.
Text: Diana Laarz
Photos: Fabian Weiss
Karabicha is not a village. It’s actually an estate that – according to the stories – Russian poet Nikolay Nekrasov bought at a casino auction in the mid-19th century, bringing new life to the area. One sign of this is the hospital, whose old wing dates back to the period before the October Revolution. The Russian spring is late this year. Outside, on the road leading to the hospital, a couple of men try to fill the huge puddles of snowmelt with sand – a hopeless battle. Inside, Tamara Klokova, MD, wearing her customary slight smile, sits and considers Alexander Nikolayevich Pushkin’s heart.
Just a Couple Towns Down the Road
The beating of the heart rings out with a tinny sound in the treatment room. Klokova guides the transducer of an ultrasound system over her patient’s chest with one hand as the fingers of her other hand move unerringly across the controls. Black and white lines pulse on the screen. “Well, it looks pretty good,” says Klokova, head of the ultrasound department at Karabicha Hospital, nodding encouragingly at the patient. Nine years ago, Pushkin had a quadruple bypass at a hospital in Moscow, almost 300 kilometers to the south. For his annual follow-up appointment, he can now travel just a couple towns down the road. Pushkin, now 72, worked as a driver; his job took him as far away as Algeria. “There’s nothing more romantic than being on the road,” he says. Klokova smiles again. She takes off her dark-framed glasses and says softly, “You can get dressed, Alexander Nikolayevich; everything is fine.” Having the chance to talk to patients, Klokova says, is what she likes most about her specialty - ultrasound imaging.
A Hospital for All
Karabicha might be a small place, an unprepossessing dot on the vast map of Russia, but the same cannot be said of its hospital. The rural part of the Yaroslavl region rings the famed capital city of Yaroslavl, once the seat of the Russian tsars and today home to a city center listed as a UNESCO World Cultural Heritage site. All of the rural district’s 52,000 residents, from both sides of the Volga River, come to Karabicha if they need hospital treatment. The facility has 160 beds and units covering various specialties, from pediatric surgery to physical therapy.
A Passion for Medicine
Tamara Klokova is 64 years old. She actually retired a couple of years ago, but she still comes to the white stone building at the center of the village every day – both to earn extra money to supplement her meager pension and because she is a part of the hospital the same way the birch forests are a part of the Yaroslavl landscape. Klokova studied in Yaroslavl before moving to Karabicha in the 1970s – for good. She looks younger than her age, with short, untamed blonde hair. She knows the countless stories surrounding the old building, but also all the issues facing a hospital in the Russian provinces.
A Salary of 360 Euro Is Not Enough
As at many rural hospitals in Russia, most of the equipment used at the facility in Karabicha is outdated. There is also a lack of staff. The average monthly salary – 15,000 rubles, or about 360 euros – is not enough to attract any doctor, much less bring one to a remote and seemingly desolate place like Karabicha. The ultrasound unit where Klokova works employs four physicians – and no nurses. All of the unit’s work, from accounting to actually examining patients, falls to Klokova and her colleagues. As a result, adult patients sometimes have to wait as much as a month for a routine ultrasound examination. It is no wonder Klokova’s otherwise calm voice rises, after 40 years in the job, when she talks about Russia’s national program to modernize the medical sector.
About Five Billion Euros in Added Investment Funding
Progress has been made in the field since March 2011, when Vladimir Putin, then the country’s prime minister, declared healthcare to be the Russian government’s top priority. Reforming the healthcare system is one of the Russian government’s four major “National Priority Projects” - alongside activities focusing on housing, education, and agriculture. The Russian constitution guarantees all citizens free basic medical care. This principle - which has remained from the Soviet era - is the reason why Russia has a relatively large number of hospitals and doctors per capita. On the other hand, those hospitals have been underfunded for decades. According to calculations by Germany Trade and Invest, the volume of financing in the Russian healthcare sector in 2010 was equal to about 4.1 percent of GDP. That is only half as much as in Western countries.
The Modernization Program
The Healthcare Modernization Program for the Yaroslavl region is scheduled to run from January 1, 2011, until mid-2013. The program focuses on various fields, including oncology, neurology, cardiology, obstetrics, and pediatrics. There are also plans to introduce digital patient files throughout the region. About 150 million euros are available to put the plans into action, half from the regional budget and the other half in the form of grants from the Russian federal government. The program is also intended to increase pay for doctors and nurses by as much as 30 percent. Yaroslavl Governor Sergey Vahrukov drew an initial positive conclusion about the efforts back in early 2012. According to Vahrukov, between 2011 and 2012, child mortality decreased by eight percent and mortality from cardiovascular disease was down nine percent.
For the last two years, however, the government has become more serious. Budgets have been beefed up, with about five billion euros in additional funding available for investments each year. In addition, faced with pressure from the health ministry, all 83 of Russia’s top-level political divisions, the federal subjects, had to establish programs to modernize healthcare within their regions. The Yaroslavl region was one of them, investing almost 150 million euros over the past two years. One result of these activities was that 38 Siemens ACUSON X300™ ultrasound systems, Premium Edition (PE) arrived in Yaroslavl in late December 2012. The equipment was distributed to 35 regional hospitals following the New Year holiday. One of the units went to Karabicha, and to Tamara Klokova. The old ultrasound unit is still in the examining room, but is no longer used for cardiac exams. “The quality difference is huge. I don’t even want to think about working without the new system anymore,” Klokova says.
“This Program Is a Miracle”
The head of diagnostic ultrasound for the Yaroslavl region, Sergey Lavlinsky, MD, doesn’t hold back when describing the modernization program, calling it “a miracle.” Life expectancy in Russia is still relatively low. This is especially true of men, who reach an age of just 64.3 years on average. The most common causes of death include cancer, trauma due to accidents, and alcoholism. But the most common cause of death – affecting nearly 57 percent of Russians – is heart attack or other cardiovascular disease. “Myocardial infarction in a patient in his mid-30s does not surprise us,” Lavlinsky says. That is exactly where the new ultrasound units are supposed to help. “With them, we will be able to identify cardiac disease much earlier and then treat it more effectively.”
Klokova learned how to use the newly purchased equipment properly straigt away, during a three-day course held at the hospital in Yaroslavl in early January. Under the leadership of a Siemens employee, participants also took part in hands-on activities as doctors from all of the regional hospitals examined each other. “When you can clarify all the questions that arise right away, getting accustomed to something new is no problem at all,” Klokova says.
Full Attention for the Patients
The next patient is now in position on the table. Sixty-five-year-old Sergey Vladimirovich had two heart attacks in 2010, and since then he has been coming to Karabicha regularly for treatment. Today is the first time he will be examined using the new ultrasound system. Klokova turns her full focus to her patient, oblivious to any distractions around her. She gives him a comforting smile and says, “Well, Sergey Vladimirovich, let’s see how your heart looks.” Not long afterward, a tinny pulse echoes through the room again.
Diana Laarz is a correspondent in Moscow. She has been a journalist since 2006, writing reports for German-language journals and magazines.