On Location – Russia
By Thomas Pezzella, MD (October 2007)
Russia is the largest country in the world (17,075,400 sq
km) with a population of 142.4 million that has decreased in recent years (1) (Figure 1,
Russian countryside). It has a storied history, with a proud culture and an
educated population (Figure 2,
Orthodox Church). Over the past 100 years, Russia has experienced three major
forms of government--- monarchy, communism, and now democracy. The transition
periods have been at times turbulent and violent. The population has suffered
through two major wars of the 20th century with a massive loss of
people (20-30 million combined military and civilian). Yet its contributions in the arts, sciences,
technology, and engineering have been and remain numerous and noteworthy. The
political and economic progress of Russia has increased in recent
years, as evidenced by an average 7% yearly increase in GDP, mainly related to
oil and gas revenues (2).
As with the majority of present day countries, health,
social services, and education receive less attention and financial support
from the central or federal government. Yet the Health Development Index (HDI)
is 74.1 (1). The health care spending in Russia is 5.6% of GDP, compared to
the world average of 10.2%. However,
healthcare spending has increased over the past few years as part of a national
priorities project (3).The demographics continue to change, especially the
decreasing life span of males( 58.7 years), and an increasing elderly
population ( 12.5% over 65 years of age) (Figure 3, Russian
woman).
The incidence of chronic illness is rising in Russia,
especially cardiovascular and cancer diseases. The double burden of
communicable diseases, especially tuberculosis, diptheria, syphilis,
brucellosis, and HIV/AIDS, has made the access and availability of both
preventive and curative strategies a challenge (4). The transition over the
past 16 years from a totally socialized system to a hybrid of government
funding, insurance, and self-pay continues to be a challenge and source of
frustration, and oftentimes despair. The rise in violence, alcohol consumption
(160-180 half liters vodka/ year for adult males), smoking (70% of men; 30% of
females), unemployment (despite a decreasing workforce), and drug addiction
have accelerated the increase in the incidence and prevalence of chronic
disease, trauma (both violent and accidental), mental illness, and suicide.
Denisov (5) has outlined three themes that characterize the healthcare transition
since the collapse of the USSR (CCCP) since 1991: collapse of geographic and
administrative relationships; changing demographics and migration; and internal
political conflicts, along with imbalance in economic growth.
Despite these somewhat pessimistic facts, the healthcare
structure or system continues to evolve in a progressive manner. Initially, the
fully funded socialized system was designed to preserve a healthy workforce as
part of national economic policy (4). With the democratic transition, the centrally
controlled system gave way to fragmented initiatives in the 89 federal
republics or regions (“oblasts”) (6). This resulted in decreased funding,
bureaucratic allocation of resources and money, and resultant increased “out of
pocket” financial burden to cover pharmaceuticals and supplies, not to mention
under the table compensation. In May 2000, President Putin combined the 89
regions into seven federal regions to allow for more inter-regional
coordination and implementation of policy (7). A new Ministry of Health and
Social Development was established. This ministry will also assume
responsibility to oversea medical education.
The medical education system has not changed appreciably
(8). The system of “free standing” medical institutes (about 54) still
prevails. They are separate from the academic universities. This system
advocated early specialization and empirical clinical training. Following
primary and secondary school, the medical institute duration is six years. At
23-24 years of age, specialized training includes a mandatory one-year
internship (internatura). Another year or two (ordinatura) is followed by a
three residency in the specialized area (residentura). Of the 86 academic
centers in Russia,
about five offer specialized training in cardiovascular surgery. The premier
academic center for cardiovascular (CV) training is the Bakoulev Scientific
Institute in Moscow (Figure 4, Bakoulev Scientific Center). The majority of CV
surgeons in Russia
have received part or all of their training at the Bakoulev institute. The
pathway to achieve Academician is a much longer and arduous process.
There are 75 centers in Russia with cardiac care services
(9). Seventy-three centers perform open-heart surgery. Thoracic surgery is a
separate specialty. It is estimated that there are about 1,000 cardiac surgeons
practicing in Russia.
There is no national registry to document the exact number, or board to refer
to. The training system remains the traditional German pyramid system with many
residents progressing to junior attending level and remaining in that position
for varying lengths of time. It is clearly the professor/ apprentice model.
Hard working, dedicated, technically talented surgeons progress at an
accelerated rate in this hierarchal system. It is reminiscent of the original
Halstead system at Johns Hopkins, prior to the evolution of the “rectangular”
system in the USA following
World War II, as championed by ED Churchill at Massachusetts General Hospital
(10).
The burden of cardiovascular disease in Russia is high.
The Soviet Union did not report vital
statistics to the World Health Organization (11). Yusuf et al. (12) has
illustrated the stages of epidemiological transition for cardiovascular
diseases (CVD) (Figure 5,
Russian epidemiologic transition). Russia is in stage 5, with >35%
annual mortality secondary to CVD. Unger (13) has presented a survey of
worldwide annual cardiac surgery procedures (Figure 6, Worldwide cardiac operations). Russia is estimated at 37 million
population. This has changed in recent years. In 2005, 23,257 open-heart
procedures were performed in Russia
at 73 centers (9). The average yearly increase from 2002 is 2,000 per year. The
incidence and prevalence (backlog) of cases is difficult to determine, but
clearly, there is a need to increase the annual caseloads. The limiting factors
include well-trained surgeons, access geographically (especially east of the
Urals in Siberia), and funded centers with
capable teams/systems/equipment/ supplies. Congenital heart surgery remains the
major operation with valve surgery second, and coronary bypass surgery rising.
It is doubtful that Russia
will develop a standardized, time fixed cardiovascular residency program. As in Western programs, the market forces
will dictate transition
It is difficult to assess the contributions of Russia in CV
surgery since most of the work was recorded in Russian and largely unavailable
during the Soviet era. This has changed dramatically in recent years, as more
abstracts and manuscripts are being presented and published in English. As an
example, 50 abstracts from the Bakoulev institute were presented at the May
2007 meeting of the European Society for Cardiovascular Surgery. Historically,
many original contributions in CV surgery came from Russia (14).
Professor
Nikolai Petrovich Sinitsin from Nizhny Medical Institute conducted early
experimental heart transplants in the early 1940’s (15). Professor Vladimir Demikhov also contributed
to early cardiac transplantation in the 1940’s, as well as experimental
internal mammary artery bypass anastamosis in the early 1950’s (13, 14).
Professor V I Kolessov is credited with the first mammary artery – coronary
bypass in 1967 (16); ( J. Thorac Cardiovasc Surg 1967; 54: 535-544). The
largest series of contemporary surface cooling operations for congenital heart
problems was pioneered in Novosibirsk
(17). This operation is still being performed in Mongolia. The first successful
caval-pulmonary operation (popularized by Glenn) was performed by Professor E N
Meshalkin in April 1956 (15). It has historically been referred to as “the
Russian Operation”. Presently, more Russian scientific contributions are being
published in Western journals (18-20).
In recent years, centers in Western Europe have reached
out to their colleagues in Eastern Europe and Russia. Hans Borst has reported on
the initiatives of the European Association for Cardiothoracic Surgery to help
support programs and offer further observational and fellowship training in
selected Western European centers (21, 22). In 1998, Professor Borst visited 11
centers in Russia.
He commented that the economic/political constraints were momentary and that
the enthusiasm, optimism, ability, and hard work of the Russian cardiac
surgeons would prevail. He did, however, highlight that the opportunities for
the younger surgeons needed to improve.
Following a trip to Pushkin
City in 1992, with a group from the Worcester MA/ Pushkin, Russia
Sister city program, to evaluate healthcare at the community hospital level, a
second trip was taken by this author to Russia in August 2003. This
included a train trip from Helsinki, Finland to Shanghai,
China over a
2-month period. Six Russian CV centers were visited in St
Petersburg, Moscow, and Tomsk, Siberia. A recent
one-month trip to Russia in
August/September, 2007 was made to the Bakoulev institute in Moscow. This afforded the author the
opportunity to get an insight into the status of CV surgery in Russia, as well
as to interact with the local doctors and staff.
The Bakoulev Scientific Center
for Cardiovascular Surgery—Russian Academy of Medical Sciences is one of the 86 academic
centers in Russia.
It is the major center for CV care and surgery in Russia. Headed by Professor Leo A
Bockeria (Figure
7, Professor Bockeria), the center performed 4,158 open-heart operations in
2005, with over 3,000 for congenital heart disease. The institute is divided
into departments, each with a chief and team. These departments include
congenital neonatal (< one year); congenital (one to three years);
congenital (> three years); and adult acquired disease (Figure 8, Russian
pediatric ICU). The organization and flow of care is highly efficient (Figure 9,
Organization scheme). The operative aspects are standardized and kept
simple, with cost efficiency a primary goal (Figure 10, Mitral
valve repair). Advanced technology
was evident. One example includes an operative sterilizer that utilizes ozone
technology (Figure 11, Russian
sterilizer). (www.orion-si.ru, in
Russian). Western cardiac valves were used, as well as the lower cost Russian
tilting disc MIKS valve. The Bakoulev also produces a mechanical heart valve,
as well as its own homograft and heterograft material. The team approach to perioperative care
combines Anesthesia, Surgery, Perfusion, Cardiology, and Intensivists. A weekly Tuesday afternoon conference reviews
the previous week cases, as well as morbidity/mortality discussions (Figure 12, Russian
conference). Detailed and accurate statistics for all the Russian programs
are maintained (8).
In
summary, the Russian CV surgery programs are progressing at a pace only limited
by economic/political constraints. The
future challenges include increased awareness of the CV disease burden, access
to care, a planned strategy to educate and train future CV surgeons, well-equipped/
staffed centers, and financial support. The openness and bluntness of our
Russian colleagues is balanced by their congeniality and willingness to learn,
as well as share there proud legacy in CV surgery.
There is nothing more
difficult to plan, more doubtful of success, nor more dangerous to manage than
the creation of a new order of things.
Niccolo Machiavelli
References
1.
The
Economist- Pocket World in Figures 2007 edition. Profile Books, Ltd. London, UK.
P. 202-203; 244-245
2.
Dempsey, J. Sick
Man of Russia?
The Average Citizen. International Herald Tribune,
September 7, 2007
3.
McAdams, L.
Russia Readies Radical Health Care Reform. http://www.voanews.com/english/archive/2006-05/2006-05-01-voa31.cfm.
(Accessed 9/10/07)
4.
Russia-Health. U.S.
Library of Congress. http:// countrystudies.us/russia/53.htm
. ( Accessed 9/10/07)
5.
Denisov, IN. Health and Health Care in Russia: Issues
and Solutions. Comparitive
Economics Seminar, February 14, 2002. Davis Center for Russian Studies, Harvard
University, Cambridge, MA.
6.
Vienonen,MA, Vohlonen, IJ. Integrated Health Care in Russia: to be or not to be.
International J. of Integrated Care 2001;1:1-7
7.
Danshevski, K, McKee, M. Reforming the Russian health-care
system. Lancet 2005; 365: 1012-1014.
8.
Barr, DA, Schmid, R. Medical Education in the Former Soviet Union. Academic Medicine 1996;
71: 141-145.
9.
Bockeria, LA, Goudkova,
RC Cardiovascular Surgery- 2005.
Official Cardiac Surgery Registry, Russian Federation. A.N. Bakoulev
Publishing House, Moscow
Russia
10. Grillo,HC. Edward
D. Churchill and the “rectangular” surgical residency. Surgery 2004;
136: 947-974.
11. Cooper, RS. Epidemiologic Features
of Recent Trends in Coronary Heart Disease in the Soviet
Union. JACC 1983; 3: 557-564.
12. Yusuf, S, Reddy, S, Ounpuu, S, Anand, S. Global Burden of Cardiovascular Diseases Part I:
General Considerations, the Epidemiologic Transition, Risk Factors, and Impact
of Urbanization. Circulation 2001;104:2746-2753.
13. Unger, F. Worldwide Survey on
Cardiac Interventions 1995. Cor Europaeum 1999; 7: 128-146.
14. Bockeria, LA. History of Cardiovascular Surgery.
Publishing House of the Bakoulev Scientific Center for
Cardiovascular Surgery, RAMS, Moscow
1998, p 97- 107.
15. Shumacker, HB. The Evolution of Cardiac
Surgery. Indiana University Press, Bloomington, Indiana.
1992. p. 81-82; p.140; p.316-336.
16. Westaby, S, Bosher, C. Landmarks in
Cardiac Surgery. ISIS Medical Media. Oxford,
UK. 1997. P. 197.
17. Karaskov, AM, Kitchlu, CS, Lomivorotov. VN. Cardiac Surgery under perfusionless
hypothermia: Siberian Experience. Asian Cardiovasc.
Thorac Ann 2002; 10: 3-7.
18. Bockeria, LA,
Gorodkov, AJ, Dorofeev, AV,
Alshibaya,
MD, the RESTORE group. Left ventricular reconstruction in ischemic cardiomyopathy patients with predominantly hypokinetic left ventricle. Eur J
Cardiothorac Surg 2006; 29: S251-S258
19. Bockeria, LA, Podzolkov, VP, Makhachev, OA, et. Al. Surgical
Correction of Tetralogy of Fallot
With Unilateral Absence of Pulmonary Artery. Ann
Thorac Surg 2007; 83: 613-618
20. Bockeria LA, Golukhova, E, Dadasheva, M, et. Al. Advantages and disadvantages of one-stage and two-stage surgery
for arrythmias and Ebstein’s
anomaly. Eur J Cardiothorac Surg 2005; 28: 536- 540.
21. Borst, HG. Editorial: Cardiac Surgery Beyond the Urals. Europ J. Cardiothorac Surg 1998; 14: 223-228.
22. Borst, HG. The Hammer, the Sickle,
and the Scalpel: A Cardiac Surgeon’s View of Eastern Europe. Ann Thorac
Surg 2000; 69: 1655-1662.
Figure Legends
1.
Russian
countryside
2.
Russian Orthodox
Church
3.
Elderly Russian
woman
4.
Bakoulev
Scientific Center
5.
Epidemiological
transition figure
6.
Graph of
worldwide cardiac surgery
7.
Professor Bockeria
8.
Russian ICU
9.
Russian
Organization scheme
10. Operative mitral valve repair with superior septal
approach
11. Russian Ozone
operative sterilizer
12. Russian Weekly
Tuesday afternoon CV surgery conference
