Thursday, December 29, 2005

The State of Healthcare in the Soviet Union: The Lack of Medical Lasers

This article was published in both Medical Laser Industry Report, October 1990 and Laser Report, December 15, 1990.

Irving J. Arons
Arthur D. Little

During late July 1990, I was priviledged to join a delegation of medical laser specialists and other health care professionals, under the auspices of the People to People Ambassador Program, invited to tour the medical community in the Soviet Union. Our group, organized by the American Society for Lasers in Medicine and Surgery, was composed of specialists in gynecology, plastic surgery, thoracic surgery, urology, general medicine, and myself, representing the field of ophthalmology. In addition to the ASLMS group, a veterinarian working with lasers, a health care safety specialist, and two medical technical/clinical lab specialists were included in our delegation.

We were able to visit a medical laser research institute in Moscow, and four hospitals, one each in Moscow (Soviet Russia), Tbilisi (Soviet Georgia), Kharkov (Soviet Ukraine), and Leningrad/St. Petersburg (Soviet Russia, again).

Our overall impression was that the facilities and equipment in use were woefully decrepit and/or non-existent or years behind Western standards. However, the medical personnel we met were dedicated professionals.

Of particular note, we found that the hospitals -- even one claimed to be only three years old -- were ill kept and falling apart. The facades were cracked and broken, the hallways and stairwells unswept, and the grounds surrounding the buildings not cared for at all. In counterpoint, we found the patient rooms were clean and staffed with dedicated nurses and doctors doing their best with what they had. This was particularly evident at the Karzigan Childrens Hospital in Moscow. The wards were filled with children with trauma of all kinds, but they were all smiling and very well cared for by an attentive staff of nurses and aides. It was here that we learned that a typical doctor with less than 10 years service earns between 240-260 rubles a month (the equivalent to about $40 at the official exchange rate of 6 rubles to the dollar, and only $20-30 at the black market exchange rate of 10-15 rubles to the dollar), a beginning research worker earns 140-150 rubles per month, and a surgical nurse get about 110 rubles for regular shifts. (In contrast, the bus drivers providing our transportation were paid 400 rubles/month and we were told that street sweepers earned as much as 700 rubles/month!)

The hospital equipment, especially for diagnosis and surgery, was particularly non-existent, and, according to our laboratory clinicians, the clinical laboratory equipment was barely adequate to care for the patients in the wards. But we must emphasize, both the hospital administration and medical staff were dedicated to providing the best care possible to their patients. What they lacked in equipment they more than made up with in numbers and dedication.

As for medical lasers, and new medical treatments using lasers, except for the laser institute in Moscow, the only lasers that the hospitals seemed to have were low powered therapeutic types, basically HeNes and GaAs infrared lasers. The hospital in Leningrad had several CO2 lasers, and claimed to have other surgical equipment, but we only saw therapeutic lasers in operation. We were told that only about 100 of approximately 15,000 hospital-based physicians in Kharkov have access to or use surgical lasers. We would guess that the percentages are not much different in the other 14 Soviet Republics. At the hospitals we visited, the majority of the half dozen lasers they claimed to have -- if they had any -- were either HeNe or GaAs therapy lasers, used to treat open sores, pain, and in one hospital in Tbilisi (Soviet Institute of Clinical & Therapeutical Research), for treating myocardial infarctions by clearing viruses in the blood through intravenous use of a HeNe laser connected to a fiber inserted through an arm vein. The same hospital also used a scanning HeNe laser to alleviate angina chest pain by scanning the laser beam across the patient's chest.

At a trauma hospital in Leningrad (the Ambulatory Institute Hospital), we saw a 40-50 watt CO2 laser in the corner of an operating room, and another upstairs in a storeroom along with the usual HeNe lasers. We saw no evidence of a YAG laser although the laser specialist at this hospital claimed to have just received one, but which he had not yet unpacked. In the same storeroom with the spare CO2 laser, we were told that a small laser sitting on top of packing crates was a new UV laser, apparently solid-state since there was no evidence of any gas bottles or connections for one. (An interesting side note, we observed a burn therapy ward at this hospital, and it was disconcerting to see flypaper strips hanging from the ceiling.)

At the hospital in Kharkov (The Central Regional Hospital), we were told that they had an Ar laser used in ophthalmic treatments (but we did not see it).

The National Research Institute of Laser Surgery in Moscow claimed to be doing considerable research with medical lasers, performing 47,000 laser procedures annually. It is supposedly, one of 52 laser centers in the Soviet Union. We were given a presentation about the clinical research they were doing with five types of high power lasers, mostly CO2 and YAG -- and two prototype free electron lasers, used for PDT studies. The FELs, according to the slides shown us, may be revolutionary, in that they appeared to be about the size of a large sized desk, much smaller than any other FEL I have seen -- and I have seen the Stanford FEL and pictures of others. Attempts to find out more about this laser development were fruitless, however I plan to get back in touch with my contact at the Institute to see if I can possibly learn more about this exciting laser development. (Several weeks after my return to the States, I received a call telling me that a defector from the Moscow Laser Institute wanted me to know that he had built the laser in question and it was not an FEL, but rather an electron beam generator pumping a chemical laser use in their PDT work.) When we asked to see their lasers, we were politely told that they were in another building and couldn't be shown to us. Apparently, the person holding the key to the lab was not available!

According to a profile of the Soviet healthcare community recently published by Medistat, a UK healthcare publication, what we saw in the Soviet Union this summer is typical and not out of line with what others have reported. The Medistat profile stated that the Soviet Union has some 23,000 hospitals with 3.6 million beds, and in addition, some 38,000 polyclinics and other outpatient centers. Capital investment in recent years has concentrated on the construction of new facilities to boost the number of beds, but many of the new facilities have been built at unsuitable sites, and the majority of Soviet hospitals having little in modern equipment with some lacking the basic necessities of adequate sanitary facilities or even heating.

The polyclinic is the main unit in the primary healthcare network, and the first point of contact for most Soviet patients. They serve districts of 50,000 to 60,000 inhabitants and are staffed by doctors responsible for around 2000 patients. In addition to general doctors, each polyclinic has specialists in area such as cardiovascular disease, oncology and renal medicine.

The Soviet Union has the highest number of doctors per capita, with a total of 1.3 million doctors serving a population of 275 million. In addition, there are 3.3 million medical assistants. Women doctors are well represented, accounting for about 70% of all doctors. (We were told the percentage was closer to 50%, at least at the facilities we visited.)

As you know, until recently, all planning was done centrally, and for five years in advance -- the so called Five Year Plan. The most recent healthcare plan was put together in August 1987. That five-year plan attempted to address the chronic underfunding of the healthcare system, calling for new hospitals while neglecting older ones which will now need to undergo drastic major refurbishment. Expenditures for medical equipment had also been limited in the past, with the majority of funds allocated for new buildings. But the new policy included allocation of more resources for the purchase of modern equipment, in particular the polyclinic facilities were to be upgraded with proper diagnostic and treatment services to enable the patients to be treated at the clinic rather than to be referred to local hospitals. According to Medistat, 5.4 million rubles had been allocated for the purchase of new equipment over the two year period 1988-1989.

Discussing the state of the Soviet medical equipment market, Medistat states that the USSR suffers from a chronic shortage of equipment, particularly in the high tech areas such as computerized scanning, ultra-sound, renal equipment, and as we found out, laser treatment devices. Even basic equipment such as electrocardiographs and routine surgical instruments and disposable syringes are in short supply, with the problem being further aggravated by the fact that much of the Soviet produced equipment is sub-standard.

The current five-year plan envisages accelerating development in the medical industry and raising the technological level both within its industry and in its healthcare facilities. We hope that this can be accomplished. It is sorely needed.

A similar report, written by Dr. Bryan Shumaker, the tour director, appeared in the official journal of the ASLMS, Lasers in Medicine and Surgery, 10:597-600 (1990). In his writeup, Dr. Shumaker used portions of my writeup taken from this source, thus the similarities. Here is a link to Dr. Shumaker’s writeup.


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