The discourse about exodus is prominent on Russian social media these days. Well-to-do urban professionals in their thirties and forties are heatedly discussing the need to “get the hell out.” Don’t get me wrong – most aren’t literally packing up their belongings and contacting migration agencies. But they are seriously contemplating immigration – if not for themselves then at least for their children.
What makes them want to leave? After all, they make enough money to provide for their families and go out with friends. Some ski in Europe, sunbathe in Goa and hop around the theater, music, and art exhibits that are abundant in many of Russia’s big cities. So, why are they discussing exit options?
Their answer is they do not believe they enjoy protection. If you get in trouble with the law you’ll be thrown in jail – and there’s no independent court to protect you. If you are apprehended by police, you risk a beating and abuse. You never know when a disagreement with the authorities can lead to threats to your family. These things do happen. But the sense of despair can come from events less dramatic, more mundane: if you simply get sick with something more serious than a common cold, the health care system is such a disaster that you’re likely, at best, to get sicker before you get any help.
As a Russia researcher for Human Rights Watch, I have plenty to say about police abuse and the lack of an independent judiciary here– but it is the issue of health care that has literally been jamming the blogs in recent days. This burst of outrage was triggered by a personal horror story of a young Muscovite who lost his toe – and nearly lost his whole foot – because he couldn’t get admitted to a hospital, based on a new order from the city health authorities.
In August, Dmitry suddenly developed osteomyelitis – a bone infection and inflammation– and despite a high fever and increasing pain, could neither get effective out-patient treatment nor get admitted to a hospital for over two weeks. When he was finally hospitalized, he was taken into surgery immediately. The surgeon emphasized that Dmitry nearly lost his foot because of the delay.
The new order from the Moscow health department’s chief of ambulance service instructed ambulance workers not to take patients to hospitals for a whole range of ailments (asthma, angina, measles, viral hepatitis, acute tissue inflammation, to name a few) and instead to refer them to outpatient facilities for treatment. The order, dated August 7, aims to “optimize and balance the distribution of patients between in-patient and out-patient clinics” in Moscow. But in practice, Dmitry became a victim of its aggressive implementation.
Now, there is certainly nothing wrong with trying to cut down on the hospitalization rate in Moscow – or in Russia as a whole for that matter. As part of the Soviet heritage, and with health care in theory free (but in practice plagued with quotas, waiting lists, staggering corruption and the like), Russian doctors call for hospitalization in many case when outpatient treatment could probably suffice. Patients are routinely kept in hospitals for 10 days after minor surgery or for “blood pressure prophylaxis.”
Shifting the balance toward out-patient treatment makes perfect sense, so long as outpatient facilities can provide adequate treatment. However, for Dmitry, this was not the case.
In the course of his 16-day ordeal, Dmitry saw doctors at the out-patient clinic several times. They told him they couldn’t treat his ailment, but they would not give him a hospital referral, citing the August 7 order. With the inflammation getting worse and the pain getting so intense he could no longer walk, Dmitry called an ambulance several times. The ambulance team would examine him, sigh, rant about the new order and leave sheepishly, promising that a doctor from the out-patient clinic would visit as soon as possible.
The doctor would visit – and then leave, admitting his or her helplessness in the face of such a serious condition. Finally, a particularly conscientious doctor called the ambulance herself, waited for the ambulance team to arrive, and haggled with them for about an hour and a half, literally blocking the doorway until they grudgingly put the patient on a stretcher and carried him out.
The state is not obligated to provide hospitalization for all patients without reasonable medical grounds. But it is obligated to provide the highest possible quality of medical care, whether on an in-patient or an out-patient basis. Freeing up hospital beds by referring patients for outpatient treatment is reasonable only if outpatient facilities can provide effective treatment. This is what the Moscow health authorities should have ensured before issuing an order banning patients with a series of conditions from hospitalization.
In the face of throngs of outraged people accusing them of “inhumanity” and worse, they are now saying they will pull the order but are blaming doctors for “misinterpreting” the order. They also are claiming that the issue has been blown out of proportion by journalists and Muscovites had nothing to worry about. However, the damage has been done and the lack of trust in the health care system has become even more pronounced.
“This was the last straw,” another friend of mine said, “I’m getting my family out of here.” With Kremlin officials expressing concern about the brain-drain these days, they should do something about the “lack of protection” that’s largely causing it.
Tanya Lokshina is Russia program director at Human Rights Watch.