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WHO World Health Organization |
The
UN in Russia is publishing selected excerpts from an interview given by Dr.
Mikko VIENONEN, Special Representative of the Director General, World Health
Organization (WHO) for the Russian Federation, to The Business Izvestia:
What is the mission of WHO in Russia?
Our mission is to implement public health programs developed by the WHO Regional Office for Europe in Copenhagen and WHO Headquarters in Geneva, in close collaboration with the Russian Ministry of Health and regional partners. In 2001 Russia received about $ 5 million for health development through the WHO. In 2002 it was over $ 9 million. Most of these funds were used for TB control and humanitarian aid programs conducted in the northern Caucasus region (Ingushetia and Chechnya). But I must remind that WHO is not a donor agency. Our main task is to be a knowledge organization and to transfer the latest know-how to Russian health care system and professionals. Like many other UN agencies, we also participate in HIV/AIDS control and healthy life style promotion. Unhealthy diet is one of the major causes of disease in Russia. The role of the government in this area cannot be overestimated. For instance, universal salt iodination was practically under control in the former Soviet Union. Today it has become a serious problem because salt without iodine can be freely sold and it is cheaper. If infants are seriously deficient in iodine they develop mental retardation. For adults iodine deficiency causes goiter. In Russia together with UNICEF we make efforts to lobby legislation requiring all salt sold for human dietary use to be iodinated. At the same time we must remember that salt is not a "health product", because too much salt causes also health problems. But a small amount when added with iodine is already enough.
What is particularly harmful for the health of Russian people according to WHO?
Smoking is enemy number one. In Russia 60% of men and 20 % of women are smokers. Why is it so difficult to understand that they cause serious harm to themselves and to those who are passively exposed to their smoke? The answer is, because nicotine is a strongly addictive substance, and they cannot quit even if many of them wanted to. That is why it is very important to protect young people from beginning, when they do it because of pressure from their group of friends. Very few adult people start smoking. We can estimate that about 700 Russians prematurely die every day because of tobacco related diseases such as cardiovascular diseases and lung cancer. Many of them are relatively young, in their 40s and 50s.
According to the Federal Parliament, nearly 100,000 die of alcohol every year. What do you think about it?
This number is scary! Yet it is probably an underestimate. Alcohol is the killer number two. But it must be pointed out that there is no direct association between alcohol deaths and the quality of vodka, if we do not mean poisoning by methanol. The best quality Stolichnaya or Absolut vodka is just as dangerous as "samogon" if taken too often and too much. Many people drink one bottle or more of vodka every day, which with time inevitably will cause them damage to heart, liver, brain and hormonal system. People do not seem to know that alcohol is a solvent and it gradually solves away brain tissue.
But I would not advocate full prohibition or the introduction of "the Dry Law". It has not worked anywhere. WHO advises control of advertisement, prohibition of sale to minors under 18, pricing and taxation policies which keep alcoholic beverages including beer reasonably expensive, extensive health education about safe use of alcohol, and easy access to services to rehabilitate those who have become addicted to alcohol.
What about other health risks in Russia today?
Another major cause of mortality is "the disease of poverty" a nickname of tuberculosis. Every year it kills over 30,000 people in Russia. Today nobody should die in this disease because effective and relatively inexpensive medicines have long been available. Four years ago, when I first came to Russia, the medicines needed for a 68 month course to cure one patient of TB would cost about $80. Could you guess what might it cost today? Only $20! WHO TB projects refused to pay more than the world market price, and as a consequence the expenses went down. This is functioning market economy.
HIV/AIDS has become another major health concern in Russia. According to official data, in the beginning of 2003 over 200,000 people have been tested as HIV positive. Yet, the real number of HIV-infected persons in the country is estimated to be 45 times higher. All these people affected with HIV, most of whom are young, are likely to die in AIDS within the next 10 years, especially if medication is not made available to them. Drug addiction and sharing of needles among injecting drug users is the main source of HIV-infection and the cause of "the plague of our century", affecting more and more of unfortunate drug addicts. But HIV is also more and more transmitted through heterosexual contacts, which can cause a second wave of the epidemic very soon.
HIV differs from TB in that one may be infected with tuberculosis in a metro by a fellow passenger by mere chance. With only a few exceptions (mother to child transmission and blood transfusion) HIV can be prevented by the behavior of the person him/herself by using a condom ALWAYS with casual sex contacts and ALWAYS using a clean needle if injecting a drug. Unfortunately young people think that making love and using a condom deprives them of the real feeling of love (as they would say, "it is as if trying to smell a flower through a gas mask"). Yet, it is a real "Russian roulette". Once they have got HIV there is no way we can free them from the virus. However, it should be said that with modern medicines already a lot can be done to prolong their life and improve their wellbeing. The annual cost of anti-retroviral medicines (HIV-drugs) cost for one patient per year in rich countries about $ 10,000. In Russia very few people could afford such treatment. The government does not have enough money, either. But even here with joint effort between the government, WHO, the World Bank, UNAIDS and other organizations many countries have been able to negotiate and bring the prices down to as low as $ 2,000 per patient per year, allowing much more people to benefit from it.
How is the situation in the Russian health care sector? In other words, how do the health care services compare with other countries in the world?
Such "ranking" of health systems was made for the first time in 2000 and was published in the WHO World Health Report. 191 Member States of WHO were included and Russian Federation was on the 130th place, in the same category with Brazil, Bolivia, Guyana and Peru. Compared to your country, the situation was worse in Honduras, Sudan, Burkina Faso, Kirgizstan, Turkmenistan, and Tajikistan. The top three countries were France, Italy and San Marino. The reason why Russia ranks so badly depends on the fact that life expectancy in Russia is so low and that access to health care services is not fair to poor people.
What kind of structural problems do you see in the Russian health care system?
I would not take the role of a judge, nor to speak on behalf of the WHO. An ideal health care system does not exist, but one can identify important principles that a public health care system should fulfill. I can share with you some of my personal views about it.
For historical reasons Russia continues to have several health care systems, rather than just one. I call them "parallel systems". There are hospitals and policlinics for the political elite, governmental officials, Ministry of Transportation employees, Academy of Science workers, etc. Such parallel systems paid by public money you cannot find to such extent beyond the former Soviet Union countries. They should all be integrated and made more efficient serving the whole population. Countries which rely on a private health care system have competing hospitals and clinics, but in those cases the market competition limits the excess capacity. There are even countries in Europe where the army relies on public health services instead of building their own. It becomes cheaper for them and the tax-payers.
Another problem is that health promotion and disease prevention are not well developed in Russia. Here it is believed that health check-ups ("dispanserization") and rehabilitation ("treatment in sanatoria") is enough. The rest of Europe has long ago realized that such measures only have a very limited impact. For instance, the follow-up of normal growth of children and supporting parents to promote their healthy growth is very important, but screening of diseases in general should only be done if you have a clear policy what to do when you find an abnormality. Presently Russia is undergoing an extensive dispanserization of all under 18 year old citizens, but it is not clear to me how the results will improve the health of these children. There is a risk that the encounter with the doctor remains just a ritual.
As everywhere, the medical establishment in Russia tends to be rather conservative. New treatment guidelines for tuberculosis, cancer, cardiovascular disease treatment, etc. developed by the best experts in the world are often met with suspicion and opposition. The attitude has been that the rest of the world is not in the position to provide useful advice to treatment methods developed here. But it should work both ways. If Russia has a more efficient and a better method to treat a disease, other countries should adopt that method. The core issue is, however, that whatever methodology is used, it must be scientifically tested vis-ΰ-vis other methods and be evidence based. Such "evidence based medicine" is not a very old concept and it is only starting to penetrate the thinking of Russian medical science. WHO promotes evidence based treatment protocols, because we can no longer afford to improvise care, if we know better. But our guidelines are recommendations, they are not binding documents.
What kind of relationships you have with the Russian Ministry of Health?
Our relationships are warm and close. We are colleagues and our contacts are not only "daily", I would say "hourly". I think that Minister Yuri Shevchenko and his staff understand well that WHO can provide a valuable partnership. After all, since 1948 Russian Federation is one of the first members of our organization, taking part in our decision making and telling us what we should be doing.
Let us talk about private clinics and how they prescribe medicines. For example, physicians of a private clinic diagnosed Chlamydia infection in an elderly woman and prescribed her several medicines for treatment. They also provided her with the address of a pharmacy where she should buy these medicines. However, when the patient came to a public clinic it was found that she did not have this disease at all!
It is not possible to take a stand on a single case where all details are not known to me. For instance, if the patient had already taken one tablet of the antibiotic probably prescribed to her, the public clinic could no longer find Chlamydia in the new test. On the other hand, elderly women seldom would have Chlamydia, which is a common sexually transmitted infection among young people. But generally speaking you have pointed out a universal problem everywhere. In general, the more freedom and private services are allowed, the more control you must have in place in order to protect the patients. After all, private sector is there to make profit, and in the health services people seldom know what they buy. They are vulnerable to exploitation. We all know that in Russia the supervision and control of private clinics and pharmacies is not well established. The symbiosis between doctors and pharmacies, to which you refer and which should never be allowed to exist, creates a tendency to "poly-pharmacy" (= prescribing too many, too expensive and unnecessary medicines). This is how doctors and pharmacies can increase their profit. The use of too many medicines becomes expensive to the patient and can often be harmful, because all drugs have side-effects. I know this from my own experience. I often ask people to show me their prescriptions after they visited a Russian clinic. Many of the medicines they have received are according to scientific documents without pharmaceutical value. I advise them not to take such medicines.
WHO has been working for a long time with the concept of "essential medicines". WHOs essential medicines list consists of about 350 generic names. That is all! Using a set of essential medicines, patients can receive high quality treatment, provided of course that doctors can first make the right diagnosis. All of these medicines obviously are not cheap, but many of them are. Using essential generic medicines governments could save huge amounts of money without loosing anything in quality.
Would you be able to guess, how many medicines have been registered in Russia today? Over 10,000 brand names! This situation does not symbolize high level of development, but rather it calls for concern! Pharmaceutical companies have been allowed to make profit by selling medicines with no proven pharmacological beneficial effect. The sale of counterfeit and falsified medicines is another sign of failed control and consumer protection.
Just to compare: in Norway, one of the most prosperous countries of the world with high quality health care, the list of pharmaceutical products on sale consists of about 1000 brand names. In Finland there are a little more about 2000. Yet, in the WHO ranking of health systems Norway was on the 11th place and Finland 31st (allow me to remind you here that Russias ranking was 130th). So the number of available brand names of medicines did not help Russia to get a better quality health care system, probably on the contrary. Just imagine how many of these drugs may be useless and probably harmful. I would recommend that the Russian doctors, who are good and honest and I am sure the majority of them are would look more often into the WHOs list of 350 essential medicines.
Dr Vienonen, what is your personal opinion about living in Russia?
This is my fourth winter as the Head of WHO Office in Moscow. I must admit that I have truly enjoyed living and working in Russia, and have come to love this country and its rich culture. I have a feeling that I have learned to know and understand the people. I am also honored to work here. I will always think of Russia as my second home, where I want to visit often also after my work assignment here is over. Fortunately, my permanent home is in Finland so Russia is always just around the corner.