Socialized Health-Care Nightmare; Y. Maltsev and L. Omdahl

The ' 'official" vision of socialists was clean, clear, and simple: all needed care would be provided on an equal basis to the entire population by the state-owned and state-managed health industry. The entire cost of medical services was socialized through the central budget. The advantages Dr. Maltsev gained his insight as an adviser to the last Soviet government on issues of social policy, including health care, and as a patient in the system. He teaches at Carthage College in Kenosha, Wisconsin. Louise Omdahl, a nursing educator and manager, is actively involved in humanitarian assistance through nursing con tacts in Russia and has visited numerous Russian health-care facilities. of this system were proclaimed to be that a fully socialized health-care system elimi nates "waste" that stems to "unnecessary duplication and parallelism" (Le., competi tion) while providing full coverage of all health-care problems from birth until death.

But as we have learned from our own separate experiences, the Russian health care system is neither modern nor efficient. In contrast to the impression created by the liberal American media, health-care in stitutions in Russia were at least fifty years behind the average U.S. level. Moreover, the filth, odors, cats roaming the halls, and absence of soap and cleaning supplies added to an overall impression of hopelessness and frustration which paralyzed the system. The part of Russia's GNP destined for medical needs is negligiblel and, according to our estimates, is less than 2.5 percent (compared to 14 percent in the United States, 11 percent in Canada, 8 percent in the U.K., etc.). Polyclinics and hospitals in big cities have extremely large numbers of beds allotted for patients reflecting typical megalomania of bureaucratic planning. The number of beds in big cities would usually range from 800 to 5,000beds. Despite the difference in average length of stay, less than one-half were uti lized. In the United States hospital stays for surgery are three to seven days; in Russia stays average three weeks. American moth ers typically leave the hospital a day or two after giving birth. New mothers in Russia 590 remain for at least a week. It was explained that the length of stay was necessary due to unavailability of follow-up care after hospi talization. A physician was reluctant to discharge a patient before the majority of healing had occurred. In addition, there was no financial incentive for early discharge, as reimbursement was directly related to num ber of "patient-days," not the necessity for those days.

Scarce Supplies, Inadequate Personnel Supplies are painstakingly scarce-sur geries at a major trauma-emergency center in Moscow that we observed had no oxygen supply for an entire floor of operating rooms. Monitoring equipment consisted of a manual blood pressure cuff, no airway, and no central monitoring of the heart rate. Intravenous tubing was in such poor condi tion that it had clearly been reused many times. The surgeon's gloves were also re used and were so stretched that they slid partially off during the surgery. Needles for suturing were so dull that it was difficultto penetrate the skin. All of this took place in 95 degree F temperature with unscreened windows open; though the hospital was built less than twenty years ago, there was no air conditioning. Utilization of medical/nursing personnel was very different from our model. The ratio of nurses to patients in the ordinary hospi tals was 1 to 30, compared to 1 to 5 in the United States. Duties of the nurse ranged from housekeeping to following medical orders. When asked for her "best nurse," a head nurse in Moscow helped a young woman up from scrubbing the floor. Five minutes later she was practicing intravenous insertions with equipment donated by us.

Both of these functions were in her "job description," however unofficial that may be. Nurses are unlicensed and are not con sidered an independent profession in Rus sia. As a result, all their duties are delegated, with assessment and most documenta tion completed by physicians. The educa tion of nurses occurs at an age comparable 591 to the last two to three years of American high school.2 Nurses are educated by phy sicians, not other nurses. A separate body of scientific knowledge in nursing does not exist. The role of a patient advocate, heavily assumed by nurses in the United States was distinctly lacking in Russia. Nurses were subjugated to medical bureaucracy. Pa tients' rights and patients' privacy were all but ignored. There is no legal mechanism to protect patients from malpractice. To our amazement we were asked to photograph freely in patient-care settings without seek ing patient consent. Patient education and informed consent were dismissed by the socialized system as an unnecessary in crease in time and the cost of care. If the society does not respect individual rights in general, it would not do it in hospitals. The Russian medical oath protects the "good of the people," not necessarily the "good of the person.,,3 Apathy and Irresponsibility Widespread apathy and low quality of work paralyzed the health-care system in the same way as all other sectors of Russian economy. Irresponsibility, expressed by a popular Russian saying (' 'They pretend they are paying us and we pretend we are work ing.") resulted in the appalling quality of the "free" services, widespread corruption, and loss of life. According to officialRussian estimates, 78 percent of all AIDS victims in Russia contracted the virus through dirty needles or HIV-tainted blood in the state run hospitals. To receive minimal attention by doctors and nursing personnel the patient was supposed to pay bribes. Dr. Maltsev witnessed a case when a "non-paying"

patient died trying to reach a lavatory at the end of the long corridor after brain surgery. Anesthesia usually would "not be avail able" for abortions or minor ear, nose, throat, and skin surgeries, and was used as a means of extortion by unscrupulous med ical bureaucrats. Being a People's Deputy in the Moscow region in 1987-89, Dr. Maltsev received many complaints about criminal 592 THE FREEMAN • NOVEMBER 1994 negligence, bribes taken by medical appa ratchiks, drunken ambulance crews, and food poisoning in hospitals and child-care facilities. Not surprisingly, government bureau crats and Communist party officialsas early as 1921 (two years after Lenin's socializa tion of medicine) realized that the egalitarian system of health care is good only for their personal interest as providers, managers, and rationers, but not as private users of the system. So, in all countries with socialized medicine we observe a two-tier system one for the "gray masses," and the other, with a completely different level of service for the bureaucrats and their intellectual servants. In the USSR it was often the case that while workers and peasants would be dying in the state hospitals, the medicines and equipment which could save their lives were sitting unused in the nomenklatura system. 4 A "Privileged Class"?

Western admirers of socialism would praise Russia for its concern with the planned "scientific" approach to childbear ing and care of children. "There is only one privileged class in Russia-children," pro claimed Clementine Churchill on her visit to a showcase Stalinist kindergarten in Mos cow in 1947. The real "privileged class" Stalin's nomenklatura-were so pleased with the wife of the ' 'chief imperialist" Winston Churchill that they awarded her with an "Order of the Red Banner." Facts, however, testify to the opposite of Mrs. Churchill's opinion. The officialinfant mor tality rate in Russia is more than 2.5 times as large as in the United States and more than five times that of Japan. The rate of 24.5 deaths per 1,000 live births was questioned recently by several deputies to the Russian Parliament who claim that it is seven times higher than in the United States. This would make the Russian death rate 55 compared to the U.S. rate of 8.1 percent per 1,000 live births. In the rural regions of Sakha, Kalmykia, and Ingushetia, the infant mor tality rate is close to 100 per 1,000 births, putting these regions in the same category as Angola, Chad, and Bangladesh. Tens of thousands of infants fall victim to influenza every year, and the proportion of children dying from pneumonia is on the increase.

Rickets, caused by a lack of vitamin D and unknown in the rest of the modern world, is killingmany young people. 5 Uterine damage is widespread, thanks to the 7.3 abortions the average Russian woman undergoes dur ing childbearing years. Mter seventy years of socialist economiz ing, 57 percent of all Russian hospitals do not have running hot water, while 36percent of hospitals located in rural areas of Russia do not have water or sewage. Isn't it amaz ing that socialist governments, while devel oping sophisticated systems of weapons and space exploration would completely ignore basic human needs of their citizens? "It was no secret that on many occasions in the past 70 years, workers' health had been sacri ficedto the needs of the economy-although the cost of treating the resulting diseases had eventually outweighed the supposed gains,"6 stated Russian State Public Health Inspector E. Belyaev.

Man-made ecological disasters like catas trophes at nuclear power stations near Chelyabinsk and then Chernobyl, the literal liquidation of the Aral Sea, serious contam ination of the Volga River, Azov Sea and great Siberian rivers, have made unbearable the quality of life both in the major cities and the countryside. According to Alexei Yab lokov, the Minister for Health and Environ ment of the Russian Federation, 20 percent of the people live in "ecological disaster zones," and an additional 35-40 percent in "ecologically unfavorable conditions.,,7 As a sad legacy of the socialist experiment, we observe a marked decline in the population of Russia and experts predict a continuation of this trend through the end of the century. From Russian State Statistical Officedata, it appears that in 1993 there were 1.4 million births and 2.2 million deaths. Because of inward migration of Russians from the "near abroad" -former "republics" of the Soviet empire, the net fall in population was limited to 500,000. The dramatic rise in SOCIALIZED HEALTH CARE NIGHTMARE 593 mortality and significant decline in fertility is attributed primarily to the appalling quality of health services, and the deteriorating environment. The head of the Department of Human Resources reckons that the fer tility index will remain at around 1.5until the end of the century, whereas an index of 2.11 would be necessary to maintain the present population. 8 But, "the only lesson of history is that it does not teach us anything" says a popular Russian aphorism. Despite the ob vious collapse of socialist medicine in Rus sia, and its bankruptcy everywhere else, it is still alive and growing in the United States.

It possesses a mortal danger to freedom, health, and the quality of life for us and generations to come. Incentives Matter The chief reason for the dire state of the Russian health-care system is the incentive structure based on the absence of property rights. The current lack of goods and edu cation within health care has caused Rus sians to look to the United States for assis tance and guidance. In 1991 Yeltsin signed into law a Proposal for Insurance Medicine. 9 The intent is to privatize the health-care system in the long run and decentralize medical control. "The private ownership of hospitals and other units is seen as a critical determining factor of the new system of 'insurance' medicine. ,,10 It is moving to the direction the United States is leaving-less government control over health care. While national licensing and accreditation within health-care professions and institutions are still lacking in Russia, they are needed for self-governance as opposed to central gov ernment control.

Decay and the appalling quality of ser vices is characteristic of not only "barba rous" Russia and other Eastern European nations, it is a direct result of the govern ment monopoly on health care. In "civi lized" England, for example, the waiting list for surgery is nearly 800,000 out of a pop. ulation of 55 million. State of the art equip ment is nonexistent in most British hos pitals. In England only 1°percent of the health-care spending is derived from private sources. Britain pioneered in developing kidney dialysis technology, and yet the country has one of the lowest dialysis rates in the world. The Brookings Institution (hardly a supporter of free markets) found 7,000 Britons in need of hip replacement, between 4,000 and 20,000 in need of coro nary bypass surgery, and some 10,000 to 15,000 in need of cancer chemotherapy are denied medical attention in Britain each year. 11 Age discrimination is particularly apparent in all government-run or heavily regulated systems of health care. In Russia patients over 60 years are considered worth less parasites and those over 70 years are often denied even elementary forms of the health care. In the U.K., in the treatment of chronic kidney failure, those who were 55 years old were refused treatment at 35 percent of dialysis centers. At age 65, 45 percent at the centers were denied treat ment' while patients 75 or older rarely received any medical attention at these centers. In Canada, the population is di vided into three age groups-below 45; 45-65; and over 65, in terms of their access to health care. Needless to say, the first group, who could be called the "active taxpayers," enjoy priority treatment.

Socialized medicine creates massive gov ernment bureaucracies, imposes costly job destroying mandates on employers to pro vide the coverage, imposes price-controls which will inevitably lead to shortages and poor quality of service. It could lead to non-price rationing (Le., based on political considerations, corruption, and nepotism) of health care by government bureaucrats. Socialized medical systems have not served to raise general health or living standards anywhere. There is no analytical reason or empirical evidence that would lead us to expect it to do so. And in fact both analytical reasoning and empirical evidence point to the opposite conclusion. But the failure of socialized medicine to raise health and longevity has not affected its appeal for politicians, administrators, and intellectu als, that is, for actual or potential seekers of ~w~. D 594 THE FREEMAN • NOVEMBER 1994 1. Pavel D. Tichtchenko and Boris G. Yudin, "Toward a Bioethics in Post-Communist Russia," Cambridge Quarterly of Healthcare Ethics, No.4, 1992, p. 296.