Are doctors civil servants in Russia

Russia

Judy Twigg

To person

Dr. Judy Twigg is Professor of Political Science at the Virginia Commonwealth University in Richmond, Virginia and an advisor to the World Bank, the Center for Strategic and International Studies in Washington, DC, and several other institutions. She is currently writing a book on health care reform in Eurasia.

The Russian health system is facing a challenge in the coronavirus pandemic. What are the requirements and what measures have been taken?

Beds and medical equipment in the newly built COVID-19 hospital in Moscow. The vertical command structures in Russia allow a relatively quick diversion and mobilization of new resources. (& copy picture-alliance, Russian Look)

Summary

Although Russia has a relatively moderate number of cases of Covid-19 sufferers in coping with the coronavirus pandemic by international comparison, the real challenges that the country has to overcome are enormous. The handling of the number of cases, the procedure to contain the virus and the nature of the health system seriously raise doubts about the efficiency of the so much vaunted vertical of power.

Bad numbers

With regard to the coronavirus, Russia currently faces fewer challenges compared to other countries. The government reported the first confirmed case on March 2, and on March 15, the first case that the virus spread to a region without traceable introduction. As of April 5, 5,400 Russians were reportedly infected, out of almost 700,000 tests that were carried out. The number of new infections reported daily had leveled off at a fixed level in the past week. The epidemic seems to affect a relatively large number of young people in Russia: 80 percent of the confirmed infected are between 18 and 60 years old (as of April 5).

However, there are many reservations about the reported figures. It is unclear what the quality and scope of the tests are. There are many individual reports that people who came to the hospital with pneumonia or other severe respiratory problems and were not tested for the virus even though the symptoms clearly indicated a possible infection. The actual number of Covid-19 cases in Russia is certainly higher than the officially reported one. The existing system of incentives in the Russian bureaucracy means that officials at the local government or health facility level are better off not bringing bad news. Many hospital directors are now experiencing very contradicting impulses: They urgently need additional resources in order to be able to cope with the existing or potential Covid-19 case numbers. On the other hand, they don't want to attract negative attention either. In this context, the video conference between Putin and the governors of the regions was something extraordinary because of their signals. Putin repeatedly stressed the importance of his subordinates telling him the truth, providing him with real data and following the instructions. Putin would not have emphasized this so forcefully if the reality, i.e. the way things usually work, were different: Subordinates keep lying about what the situation is like on the ground and how they intend to deal with it. Effective action against an epidemic requires comprehensive and accurate data as well as strict adherence to the health-related guidelines that have been formulated on the basis of this information. The level of obfuscation, mistrust and inaction within the Russian system that results raises the serious question of how effective the much-vaunted "power vertical" is in this situation.

The spread (contain)

As of April 5, the greatest load of Covid-19 cases was, unsurprisingly, in the largest metropolitan areas, in Moscow and the Moscow region, as well as St. Petersburg and the Leningrad region. Smaller local outbreaks have also been reported from other regions, such as the Komi Republic, Nizhny Novgorod, the Sverdlovsk Region and Krasnodar. The cases in the Komi Republic are said to have been traced back to a doctor at a city hospital who recently traveled to Europe (or whose children had traveled). A freely accessible model using data from the travel portal "tutu.ru" states, based on the movements of plane, train and bus passengers in April 2020, that the epidemic in many Russian cities will last at least until September. The large number of sprawling urban and sparsely populated areas in Russia makes the task of physical distancing easier if the right policies are followed and enforced in a timely manner. The highly centralized transport system - with half of all flights going through the five cities of Moscow, St. Petersburg, Krasnodar, Simferopol and Sochi - concentrates many passengers in relatively few places (which favors the spread of the virus); but it also makes it easier to intervene quickly to stop the spread of the disease. As everywhere else, the centralized traffic flows make the inhabitants of large cities more vulnerable to the epidemic.

The capital Moscow recently issued extensive distance requirements that are intended to flatten the spread curve. There were early reports that isolating Moscow from other parts of the country was being discussed. However, it is unclear whether Russia has the necessary human resources to implement such a measure. The Chechen Republic, which has followed its own strict course against the pandemic from the start, was the first region within Russia to close its borders (effective April 5). It is unclear whether others will independently follow suit. Other regions have issued contact bans with different levels of strictness. Tatarstan has copied the system proposed in Moscow (but not implemented across the board) with mandatory QR codes or other IDs that are required when residents want to leave their homes. The Siberian regions of Krasnoyarsk, Norilsk and Tomsk introduced a fortnightly quarantine for all visitors from Moscow with effect from April 6th. Belgorod residents are now fined for driving privately. However, as in the case of the US, the lack of uniform nationwide action may increase the extent and length of time that the epidemic has persisted in Russia. Different regions could experience epidemic climaxes over a number of months, depending on when contact bans and other control measures are put in place and how strictly they are enforced.

President Vladimir Putin's reaction to the corona crisis was initially poor at best. His address to the nation on March 25, through which the Russian government signaled for the first time that it understood the severity of the threat posed by the virus, was strangely meek. He also spoke almost exclusively about the economic consequences and not at all about the kind of measures society should take to contain the epidemic. His original announcement of a week's paid work vacation was a huge mistake in containing the epidemic: people took it as a vacation announcement, and many traveled from Moscow to other parts of the country. The consequences of this mistake may not become apparent for 7 to 10 days, but this step could be responsible for the virus spreading to smaller cities and rural areas, where medical facilities could quickly be overwhelmed.

The capacities of the health system as a solution

In terms of the health care system's ability to cope with the epidemic, there are two important questions: 1) How well equipped are the country's two largest cities, Moscow and St. Petersburg, to handle a wave of patients with moderate to severe cases of shortness of breath? ? and 2) Will there be significant expansion to other cities or even small towns and villages where health care is less developed and would collapse quickly? Overall, the Russian healthcare system has several advantages. They are largely based on the legacy of the production-oriented Soviet system, which placed quantity over quality. The health system has many doctors, nurses, and other staff. According to the OECD, there are 4.04 doctors per 1,000 population, over 50 percent more than in the United States (2.6 doctors) and 70 percent more than in hard-hit South Korea (2.34). The lead in hospital beds is even clearer: 8.05 beds / 1,000 inhabitants, almost three times as many as in the USA (2.77) or Italy (3.17). The vertical command structures allow a relatively quick diversion and mobilization of new resources. Examples are the hastily built new hospital for Covid-19 patients on the outskirts of Moscow and the conversion of other medical facilities and authorities in the country.

Russia has long and considerable experience in dealing with infectious diseases. Recent experience with tuberculosis, another respiratory infection that requires sophisticated diagnostics and high standards of disease control, could serve well. Russia has not managed to bring drug-resistant tuberculosis under control, but the number of cases of TB has declined by 5-6 percent annually since 2010, which is an impressive success story. Ideally, the skills and experience from the world of tuberculosis can be turned into a head start in fighting Covid-19.

On a broader perspective, however, it can be seen that the Russian health system is poorly equipped to cope with a large flow of Covid-19 patients. Despite considerable investments in the last decade, access to medical care has declined since the Soviet era and qualitative improvements are far from being universal. Corruption and a confused structure of incentives lead to distorted decisions about the use of resources. Much of the hospital equipment is old and of poor quality. The medical staff is not well trained. For example, a license for medical practice in Russia is not automatically converted into a corresponding license in Europe or the USA. So there could be a shortage of the right staff (anesthesiologists, respiratory nurses, laboratory technicians, intensive care workers) needed to handle moderate to severe Covid-19 cases. The Russian government has reiterated that it has more ventilators available than necessary (40,000 total), as well as large supplies of protective clothing for medical personnel. However, some Russian doctors are concerned that many of these ventilators are old and inoperable, and that neither the physical resources nor the staff to operate them may be sufficient for future challenges. There are also reports of wealthy Russians buying ventilators, which are now in short supply, and hoarding them for private use.

Russia does not rely on large hospitals with many specialist departments, as is common in much of the western world. Most inpatient facilities are highly specialized: there are infectious disease hospitals, maternity hospitals, cardiovascular disease centers, etc. And rightly most of the massive investments of the past decade have been in those areas that most address the country's greatest demographic challenges the most important are: obstetrics and neonatal medicine (to increase the birth rate) and non-communicable diseases (heart disease, strokes, cancer) to address the burden of premature death in men of working age. So a key question here is: is the Russian healthcare system capable of arming itself against the coronavirus in terms of personnel, infrastructure and equipment? The important thing is: will it be able to break down the considerable boundaries between the administrative and bureaucratic apparatuses of these institutions and sub-sectors - between which there has traditionally been a lack of communication and cooperation and, rather, a tendency towards competition and turf wars?

Risks and Deficits

These questions are also reflected in the survey data, which reveal the deep distrust of Russian society towards the health system. A survey of 6,500 respondents across Europe found that only 13 percent of Russians have confidence that their health system will provide them with the best possible treatment available. This is a striking contrast to the 64 percent in Spain and the 63 percent in the United Kingdom. Similar surveys within Russia found that access to medical care was persistently one of the population's greatest concerns (surpassed only by fears of inflation, poverty, unemployment and corruption). Access to medical care is one of the main general advantages for Russia: in principle, a resident with a registered residence only needs a compulsory insurance card that offers comprehensive protection. However, most Russians question the quality of the services that fall under this protection.

There are many factors that will have an impact on the extent to which the healthcare system will be challenged by Covid-19. The Centers for Disease Control and Prevention in the USA last week published data that make it clear that people with pre-existing conditions (heart disease, diabetes, chronic obstructive pulmonary disease) are much more likely to need intensive care if they are infected with the coronavirus. Russia has managed to reduce the prevalence of these ailments over the past 15 years, but they are still a problem, especially among middle-aged men. In Russia there is also a relatively high number of people with other diseases whose immune system is impaired as a result (HIV, tuberculosis, hepatitis C) and who are therefore more likely to be infected with the coronavirus.

In Russia there are also a large number of disadvantaged, marginalized people whose situation in connection with the coronavirus is currently unclear. Prisons are breeding grounds for the coronavirus (e.g. hundreds of inmates and servants of the infamous New York prison on Riker’s Island are infected). However, no data on infections or preventive measures in Russia's prisons and detention centers have yet been published. The millions of migrant workers in Russia also often live in very cramped, unsanitary conditions in dormitories or apartments where the virus can easily be transmitted; these people have no papers and therefore no access to medical care. They are therefore unlikely to be tested if they become ill.

All in all, the Russian government is still taking too many risks. Hundreds of Central Asian migrant workers were crammed into a Moscow airport for days as they waited for their flight home. The events for the 75th anniversary of the end of the war and in honor of the elderly World War II veterans - one of the risk groups - are still taking place. The Department of Defense continues with its plans to conduct the next round of conscripts nationwide in spring 2020. Given the magnitude of the danger, a faster and more robust package of measures for contact blocking would clearly be advisable. If this fails or fails, the fragility and inconsistency of the Russian health system could mean that its brave workers will face the consequences.

Translation from English: Hartmut Schröder
The Russia analyzes are jointly published by the Research Center for Eastern Europe at the University of Bremen, the German Society for Eastern European Studies, the German Poland Institute, the Leibniz Institute for Agricultural Development in Transition Economies, the Leibniz Institute for East and Southeast European Research and the Center for Eastern European and International Studies (ZOiS) gGmbH. The bpb publishes them as a licensed edition.