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Lessons to learn in both directions
A journey on the Moscow Metro is a rich and mixed experience. The trains are efficient, and many of the stations provide staggering examples celebrating Russian design and architecture across the centuries. At Ploschad Revolyutsil station, bronze statues adorn each corner and alcove. They pay homage to the great ideals of Soviet society; the collective farmworker, the soldier, the athlete, the proud mother of a small healthy family. A search for the depiction of those who care for the sick will be largely unsuccessful. Even in the medical and nursing schools the pictorial displays (mercifully now fading and being cleared away) are of triumphant performances of medically supported troops on the battlefield, as opposed to the care of those who are medically ill.
The Soviet system favoured closely monitored good health from cradle to grave. From the polyclinic (a kind of health centre, each one serving a few thousand people) to the Prikaz (a massive protocol driven tome) the emphasis was on being well and staying well. Collective life meant that the funding and construction of buildings was never a major problem. There emerged in each town a plethora of massive concrete hospitals, each devoted to its own area of medicine. There was often little collaboration across disciplines, and many of these establishments ended up as institutions where the infirm were cared for long term, with a restricted range of therapeutic options.
Funding was never exceptional but always fairly reliable thanks to the collective communist approach. Health professionals, featuring a very high proportion of women, were regarded as distinctly “ordinary” members of society. This was perhaps not so much a demonstration of communism in action, more a manifestation of a difficulty with the acceptance of ill health in a would-be ideal society. This was never more evident than in the time of Stalin, when the drive to produce human perfection carried strong resonances of attitudes in far right Europe.
In the mid-1980s, perestroika turned Soviet eyes seriously to contemplate the outside world. In healthcare it was evident that many of the advances achieved in the 20th century in the West had gone unnoticed, mistrusted, or both. The Soviet health system was held back by a dictatorial hierarchy, non-evidence based protocols, and a progressive paucity of funding. This did not bode well for the forthcoming overwhelming social and political change.
When communism gave way to democracy, along with the collapse of many aspects of former Soviet life, the funding and public image of healthcare suffered further. It is ironic, though to a degree predictable, that in the years that have followed, indicators suggest that standards of health have become lower than previously.1 Alcohol related illness in males has become endemic, and, in direct relation, male life expectancy has decreased from around 68 to 61.2 AIDS has become prevalent, with major attendant difficulties regarding education and treatment. The new, greater mobility of the population, especially in the military, has a strong influence here.
In the early 1980s, longstanding friends of the many Soviet republics saw the problems coming. New charitable, non-governmental organisations, and business based groups were formed anew or modified in order to try to help in the process of change. Examples include Healthprom, International Medical Corps, USAID, and the World Health Organisation. Offering assistance to these countries requires a different approach from that needed in other parts of the world. Here is a huge and diverse society, with a rich and seminal cultural history, not to mention a world leading role in areas of exploratory science. A high degree of “cultural sensitivity” is essential, along with a constant appreciation that learning in this context is a two way process.
An often felt sense of déjà vu accompanies one working with friends and colleagues in Russia, Belarus, Azerbaijan, etc. The same aspirations as we held in the West are held and the same actual and potential mistakes present themselves. One of the main roles of so-called Western experts is continually to confess our own errors, and to try to encourage their avoidance. Specific examples of this in our own field related to safe childbirth include the unnecessary “medicalisation” of normal pregnancy, labour, and delivery. The worldwide verdict on 30 years’ worth of electronic fetal monitoring can perhaps be best summed up as “unsatisfactory and of doubtful overall benefit”, especially in labour. It seems sensible, therefore, that in a country where its use has been uncommon, to discourage its more widespread (and extremely expensive) application, pending the arrival of a more reliable advance, which in this case may be fetal oximetry. Where there is similarity to outside aid in, for example, southern and central Africa, it is in the greater usefulness of low and intermediate technology over and above sophisticated high science. It is understandable that any clinical team would hope to achieve high levels of skill and equipment in ultrasound or neonatal care. But it helps far more mothers and babies at the moment if hand washing techniques are perfected, and simple heated neonatal mattresses are provided.
Coming from our UK setting, where life is ever more governed by pathways and guidelines, it is thought-provoking to encounter a culture whose desperate need is to break away from a protocol driven past. While it is true that the Prikaz (see above) is based more on opinion than evidence, it is significant that our colleagues need to be freed from these strictures in order better to help their patients. Encouraging confidence, lateral thinking, and individualisation of care against this background is proving difficult. There may be an important lesson here for us in the “sophisticated West”.
Both authors are trustees of the charity Healthprom.
Lessons to learn in both directions