(Moscow) – Health workers in Russia face threats and retaliation from employers and law enforcement for speaking out about unsafe working conditions during the Covid-19 pandemic, Human Rights Watch said today. Unsafe conditions include a lack of adequate personal protective equipment to safely treat suspected or confirmed patients and prevent the spread of disease.
While health workers faced the most acute shortages in protective gear in March and April, Human Rights Watch found that supplies the government promised have not fully materialized and that health workers continue to face health risks as community transmission of the virus remains high.
“Instead of listening to health workers’ legitimate concerns about safety and trying to address them, employers and officials in some cases disciplined or even prosecuted them for speaking out,” said Hugh Williamson, Europe and Central Asia director at Human Rights Watch. “Front-line medical workers should be able to report hazardous conditions without being threatened, fired, or prosecuted.”
Human Rights Watch interviewed 14 health workers from 11 regions, including Moscow and St. Petersburg, between May 15 and June 1, 2020. They worked in public ambulances and at inpatient and outpatient facilities, and included doctors, paramedics, nurse practitioners, a maternity nurse, and a nursing student. Eleven of them were women. Human Rights Watch also analyzed laws, decrees, and policy documents, and interviewed a representative of a health workers’ union and the head of a charitable organization providing personal protective equipment to hospitals.
Human Rights Watch also reviewed numerous health workers’ posts on social media and traditional media about their situation. The health workers interviewed may not be representative of the broader population, but Human Rights Watch observed patterns and similarities in their accounts of gaps in occupational safety and health protection during the pandemic, consistent with accounts cited in media reports.
Russia announced its first confirmed cases of Covid-19 on January 31 and now has over 511,000 known infections, the third-highest number in the world. On March 29, Moscow, the epicenter of the epidemic, ordered a lockdown through June 8, and most regions followed suit.
By April, health workers were taking to social media to protest what they said was inadequate personal protective equipment in facilities admitting Covid-19 patients. A website commemorating health workers who have died from Covid-19 listed 406 names as of June 12. At least 186 of these cases were corroborated by the news outlet Mediazona. On May 26, the Ministry of Health said that 101 health workers had died from coronavirus.
In a March 19 decree, the Health Ministry said that all ambulance, inpatient, and outpatient facilities interacting with suspected or confirmed Covid-19 patients should be adequately stocked with personal protective equipment, including a cap, surgical gown, gloves, and respirator, regardless of whether they perform aerosol-generating procedures, a standard higher than the World Health Organization (WHO) recommends. But in many places these supplies did not arrive for up to one month later.
An ambulance doctor from the particularly hard-hit region of Dagestan told Human Rights Watch, “When we got our first Covid-19 patients towards the end of March, we knew what was happening but all they [the hospital administration] gave us for protection were [plastic] rain slickers and surgical masks, which we washed and dried on the radiators.”
She said health workers had no respirator masks, and an inadequate supply of surgical masks, gowns, and disposable gloves. When she posted a video online pleading for equipment, the head doctor of her facility pressured her to rescind it. “He called me all distressed, saying he was getting a lot of pressure from the Ministry of Health,” she said. “They were angry over being exposed like that. He said they wanted me to record another video, to say … that we actually had everything we needed.”
She refused, and in late April her hospital received 150 respirator masks, as well as protective robes and gloves, from charity groups responding to her video, though not before she fell ill with Covid-19.
Even in late May, Human Rights Watch research suggested that while workers in ambulance brigades and hospitals working exclusively with Covid-19 patients reported increased supplies of personal protective equipment, other health professionals reported having less protection despite having regular contact with patients showing Covid-19 symptoms. Some workers described “economizing,” reusing equipment or using it selectively, while others suggested that the supplies were distributed inequitably, describing instances in which junior health personnel were left without equipment while more senior staff had priority.
Human Rights Watch interviewed three health workers who were fired or forced to resign for criticizing hospital leadership or refusing to work in unsafe conditions. One of them is also being prosecuted for “spreading false information.” In late March, Russian lawmakers amended legislation to increase the penalties for spreading false information to three years in prison, and imposed hefty fines for administrative or misdemeanor offenses.
The amendment’s sponsors contended the punishments were necessary to prevent panic in light of increasing amounts of fake news about the virus. However, Human Rights Watch found several instances in which the authorities used the law to silence health workers, as well as journalists reporting their complaints.
WHO has issued interim guidance on Covid-19 concerning the rights, roles, and responsibilities of healthcare workers. Employers and managers should provide workers with infection prevention and control and masks, gloves, goggles, gowns, hand sanitizer, soap and water, and cleaning supplies in sufficient quantity such that workers will not have to incur their own expenses. Workers have the right to remove themselves from a situation that they have reasonable justification to believe presents an imminent and serious danger to their life or health, and to be protected from any resulting retaliation.
As Russian regions begin lifting lockdown restrictions despite a continued rise in infections, it is increasingly important for the Russian government to deliver promised personal protective equipment and to take effective measures to prevent infection among health workers by protecting their right to safe working conditions.
“Russia’s health workers heroically took on a dangerous disease and dozens of them have lost their lives, including some who had to work without the most basic protection,” Williamson said. “The Russian government should act fast to bolster health workers’ occupational health and safety measures in line with WHO guidance, set up anonymous reporting channels for health workers who might fear retribution, and immediately close cases against those who spoke out.”
For more details of Human Rights Watch’s findings, please see below.
Early Stages of the Pandemic
On March 19, with almost 200 Covid-19 cases already registered in the country, Russia’s Ministry of Health published Decree 198N setting out guidance for how health facilities should organize work during the pandemic. The decree aimed at creating a two-track health system, dividing inpatient facilities into those that would specialize in treating Covid-19 and those that would accept all other patients. Ambulance services were tasked with creating “special brigades” to respond to calls from those with acute respiratory symptoms or pneumonia and to take swabs for testing where necessary.
The decree requires all ambulance facilities, inpatient facilities dealing specifically with Covid-19 patients, and outpatient facilities taking swabs for Covid-19 testing to be equipped with adequate supplies of personal protective equipment (PPE), including caps, surgical gowns, gloves, shoe-coverings, and FFP2 respirator masks or their equivalent. Medical workers in “non-Covid” facilities should also don PPE if a patient shows symptoms of Covid-19, guidance that can only be followed if they also have such supplies, and immediately request transfer of the patient to a “Covid” facility.
The decree directs medical workers to dispose of PPE after each encounter with a suspected or confirmed Covid-19 patient and place it in disinfectant solution. On April 2, the Health Ministry amended the order to also include eye protection and provided a formula for daily provision of PPE to healthcare workers, entitling them to more than two sets a day.
In late April, with infections in Moscow and St. Petersburg rising dramatically for more than a month, health workers began publicly protesting inadequate supplies of PPE. Dozens of nurses from the Kommunarka hospital in Moscow, the first major hub for treating Covid-19, resigned, complaining that junior medical personnel were given used PPE, were not provided with a place to rest despite working two- or three-day shifts, and were denied promised bonus payments. By early May, health workers from across the country were posting videos online, describing dangerous working conditions, or speaking to the press. Many said they had been working for several weeks or more with Covid-19 patients without the promised protection.
Grigory Bobinov, a 45-year-old ambulance doctor from St. Petersburg, told Human Rights Watch that within about two weeks of the WHO declaring that Covid-19 had reached the level of a global pandemic on March 11, his facility was receiving an increasing number of calls from patients with likely symptoms.
“Our (hospital) administration took the position that everything will be okay and so they didn’t take any measures,” said Bobinov, who, together with colleagues, sent a letter on April 6 demanding adequate PPE and organization of special brigades to transport and treat Covid-19 patients. “Our supervising doctor said that they would create special brigades, and those who signed the letter would be part of these brigades. It was a threat.”
On April 7, Bobinov responded to a call from a patient with symptoms of a respiratory viral infection. At that time, he said, emergency operators only flagged patients as suspected of having Covid-19 if they had been abroad or had direct contact with somebody who had tested positive. The ambulance station only had two or three protective suits and no respirators, so Bobinov wore a surgical mask and gloves. The drive with the patient, who was later confirmed positive for Covid-19, took 40 minutes. By April 10, Bobinov, as well as the paramedic and the driver on the call with him, were sick. Bobinov checked himself into a hospital on April 17 and was put on oxygen support. It took him more than a month to fully recover. The driver also spent several weeks in a hospital.
Bobinov noted that by mid-April, PPE had been supplied to the ambulance station, though the management continued practices that conflicted with WHO guidelines, such as holding general meetings for all staff in closed, unventilated spaces. He said that at least half of the 110 staff in his facility were on sick leave as of late May. As of May 26, 20 percent of the people infected in St. Petersburg were health workers and eight health workers had died.
In the Moscow region, where, according to official statistics at least nine percent of health workers have been infected and 16 have died, PPE was also late in arriving. Yevgeniya Bogatyreva, an ambulance doctor in the city of Korolev, told Human Rights Watch that adequate PPE arrived only in mid-May. “The situation in April was very bad,” she said. “There was no protection, we had only thin gowns that could tear at the touch – we called them cobwebs. We had regular masks, which don’t particularly protect from infection. Only on May 16 did I receive a respirator for the first time.” Bogatyreva, the chairperson for an independent trade union, estimated that the number of infected doctors in the region was higher than officially stated. “Many get sick,” she said. “We estimate around 50 percent in the Moscow region. We know four people in the trade union who have died.”
One of the Russian regions hardest hit by Covid-19 is Dagestan, a Muslim-majority republic in Russia’s north Caucasus. In late May, officials admitted that limited and delayed testing likely led to an underreporting of deaths in the first two months of the pandemic. On May 22, the media reported Irina Tragira, who leads the infection disease medical care group at the National Medical Research Centre of Physiology and Infectious Diseases, saying that while the region registered only 36 deaths from Covid-19, it had registered 820 pneumonia deaths in the same period, many of which were likely from the virus. Health workers from Dagestan told Human Rights Watch that they received little information from hospital leadership about the novel virus, learned what they could online, and were disastrously unprepared to treat it due to lack of medications, hospital beds, and PPE.
“As an ambulance doctor, I had to deal with pneumonia cases four times over the past 10 years, but starting in April it’s like every second patient,” said the ambulance doctor from Dagestan who posted the video on social media pleading for PPE. She believes that even in late May, most patients were not registered as dying from Covid-19, but rather from pneumonia. “The Health Ministry doesn’t want to spoil the statistics,” she said. “So when 50 people died of Covid-19 only two got registered as Covid-19 deaths.”
An ambulance paramedic in Dagestan’s Botilikh district similarly said that he treated patients wearing only surgical masks and standard robes until the end of April, when volunteers raised money to buy his facility the necessary equipment. He estimated that about half of the workers at his facility had been ill with symptoms consistent with Covid-19, and two nurses and an ambulance driver died from the disease. On May 17, Dagestan’s regional minister of health said that more than 40 health workers had died of complications from Covid-19.
Ongoing Gaps, Inequities
On June 2, the Health Ministry reported that there was no longer a deficit of PPE in the country’s healthcare facilities. However, an analysis by a group of doctors, medical experts, and charitable organizations found that there was little reliable data on PPE from health facilities. Forty-nine percent of hospitals had no adequate tools for determining how much PPE they needed, nor did the most recent Ministry of Health guidelines provide them. The group, whose findings were based in part on anonymized interviews, found that 43 percent of doctors said talking about PPE deficits was “dangerous and risky,” suggesting further potential for underreporting.
Workers in ambulance brigades or “Covid-19-designated” hospitals reported increased supplies of PPE, either from charitable organizations or other sources. But other medical professionals who nonetheless came into regular contact with suspected or confirmed Covid-19 cases said they had no protection at all.
A general practitioner in Tatarstan said that while her work for an outpatient facility included interacting with and testing patients suspected for Covid-19, she was not provided with any protective gear other than a surgical mask and reusable rubber gloves for this task. On some days she had taken samples for testing from up to 30 people. The doctor bought herself a respirator and other PPE for about 5,000 rubles (approximately US $72), but noted that nurses, whose monthly salary is only around 30,000 rubles (US $437), could not afford to buy protective gear.
The doctor also said there was recently an outbreak of Covid-19 in the inpatient branch of the hospital she is affiliated with. Health workers there had no appropriate PPE, in large part because the hospital was not designated to treat Covid-19. But in late May, she said, a woman with pneumonia was nonetheless admitted, and died two days later in the intensive care unit. She was later confirmed positive for Covid-19:
The medics in the inpatient facility spent plenty of time around her, in the admission office and in the reanimation ward, and she was lying among the other patients. In the reanimation ward one doctor and a nurse got sick ... They have not closed the ward, they say that considering everyone was working in masks they should have been protected, but that was not coronavirus protection.
The group of experts said that Covid-19 patients sometimes end up in “non-Covid” facilities where staff are more likely to lack adequate PPE. A doctor in a government hospital in Perm that was not designated to treat Covid-19 said that two wards were closed after outbreaks there.
The March Health Ministry decree says that workers in “non-Covid” facilities should don PPE as soon as they suspect a patient has the virus, creating the assumption that the facility will be stocked with such equipment.
A maternity nurse who works in Sevastopol in the Russia-occupied Crimean Peninsula expressed concerns about failures to screen, isolate, and test patients, including those manifesting Covid-19 symptoms, that she said were ignored by hospital leadership:
When we asked if a young woman [who manifested symptoms] could be tested for Covid, the supervising doctor told the practitioner not to be a smart-aleck. They hide [the cases], they don’t need extra problems, if they do a test and find Covid they will have to close the maternity hospital, and who needs the headache. They [the authorities] will give them hell, including by removing them from their positions, and nobody needs that.
Workers at facilities provided with PPE by employers or charity organizations noted that sometimes the amount supplied was clearly insufficient, forcing them to reuse equipment or limit their use of it.
An ambulance paramedic, Valentina Beletskykh, said that her three-brigade unit in a rural area of Novgorod region was sent 50 respirators and four multi-use suits after she complained about a total lack of PPE in April. However, she said, the limited supply meant the staff were extremely selective about wearing PPE on call. “We economize, some don’t wear it at all,” she said. “We made the decision ourselves that if we would use it for every call, it would evaporate.”
Others suggested that not all health workers have equitable access to PPE when it is available. Doctor Bogatyreva said that PPE finally arrived in mid-May, but that there was not enough for all staff. “On [May] 16 I received a respirator for the first time,” she said. “But my paramedic was [working] in a regular mask, I don’t know why.”
An ambulance doctor in Amur region said that while her unit was well-equipped, their PPE was reused by nurse’s aides working in the infectious disease hospital. “They take them from the container where we throw them away,” she said. “They work in the Covid center, they have to use whatever they have, but because they have nothing they wear our things.”
Retaliation against Health Workers
In dozens of reported cases across Russia, hospital administration or law enforcement targeted health workers who spoke out about unsafe working conditions. In some regions, health workers openly protesting a lack of adequate PPE appeared to have been forced to retract their statements. Others faced repeated disciplinary measures or administrative charges that carried hefty fines. In Karelia, health workers were forced to sign documents saying they would not disclose information about hospital conditions to the media after several doctors resigned in protest over PPE shortages.
Human Rights Watch interviewed three health workers who were fired or forced to resign for criticizing hospital leadership or refusing to work in unsafe conditions.
Natalia Trofimova, a general practitioner at a hospital in Priozyorsk, a town of 50,000 people in Leningrad region, learned that her hospital was being designated to treat Covid-19 patients on March 27. Trofimova, who knew the hospital did not have adequate PPE to treat such patients, posted a petition on the Change.org platform. On April 1, the Health Care Committee, a body of local government, visited the hospital and accused Trofimova of “slander and betrayal,” and the head doctor threatened to fire her.
Trofimova continued working. While respirators and gowns arrived to her hospital in early April, they were distributed only after the first patient was confirmed positive with Covid-19 on April 10. Doctors, and no other staff, were only told about the positive case on April 15 and on April 17 health workers, including Trofimova, were sent home to self-quarantine.
When Trofimova returned to work in late April, the head doctor told her she was being fired for “violating doctor-patient confidentiality,” for sharing on social media a picture of a nurse taking Covid-19 samples to show that the nurse did not have adequate PPE. A patient’s face could be seen in the background. On May 27, Trofimova was summoned to the police and accused of “spreading false information” over her Change.org petition, an administrative offense punishable by a fine of 100,000 rubles (US $1,447).
Trofimova worked in the same hospital as Alyona Zotina, a final-year nursing student employed as a nurse. Zotina was openly critical of the decision to open the Covid-19 wing without adequate PPE, and supported Trofimova after she was fired. Zotina said that her supervisors regularly pressured her to quit her activism. Even though she had previously been encouraged to apply to work at the hospital after graduation, on June 1 she was told that she should look for work elsewhere.
Human Rights Watch also interviewed a doctor who refused to work with suspected Covid-19 patients without adequate PPE and was pushed out of her job as a result. Angelina Kanovsky, a radiologist at an oncology hospital in Moscow, said that on April 14 her supervisor wanted her to perform chest X-rays on 20 patients whom she immediately suspected might have Covid-19. Many medical practitioners in Russia said they turned to CT scans of people’s chests as an alternative diagnostic tool for the disease, though its accuracy has not been established.
“We usually have 20 patients per day for two doctors, sometimes less, and only occasionally they [require] chest [X-rays],” she said, explaining why she suspected the cases were related to the Covid-19 pandemic. “We never have influxes like that.” Her supervisor said they would give her a surgical mask, but she still refused to work without a respirator and other appropriate PPE, offering to take two weeks of unpaid leave instead. Upon her return in late April, her supervisor again insisted that she conduct chest X-rays without proper PPE. “The supervising doctor said in general terms that you have no choice,” she said. “Either you work with everything we give you or you quit.” Kanovsky quit her job in May.
Yulia Volkova, a doctor in Sochi, was charged with “spreading false information” on May 7 because she posted a video about the lack of PPE. Tatyana Revva, an intensive care unit doctor in Volgograd region, was summoned for questioning by the Investigative Committee in April for speaking out on social media about a lack of PPE and other equipment to treat Covid-19. The media outlet Meduza documented two additional cases in which medical personnel were threatened with “false information” charges by their supervisors or law enforcement. While there have been no known criminal charges against doctors for false information, a criminal case was opened after Tatiana Voltskaya, a journalist, interviewed a doctor in St. Petersburg who told her that some patients in his facility had died because of severe shortages in resources and personnel.
The investigation is ongoing.
Rights to Life, Health
Russia is a party to many international human rights treaties, including the International Covenant on Civil and Political Rights (ICCPR), International Covenant on Economic, Social and Cultural Rights (ICESCR) and the European Convention on Human Rights (ECHR), all of which guarantee fundamental rights for health workers; many of these rights are also incorporated into Russian domestic law.
Among the most fundamental rights guaranteed by international human rights law are the rights to life and to the highest attainable standard of health. Respect for the right to health requires governments to take steps to prevent threats to public health and to provide medical care to those who need it. As part of the right to health, the ICESCR provides that governments should create conditions that “would assure to all medical service and medical attention in the event of sickness.”
Governments have an obligation to minimize the risk of occupational accidents and diseases including by ensuring workers have health information and adequate protective clothing and equipment. This means providing health workers and others involved in the Covid-19 response with appropriate training in infection control and with appropriate protective gear.
Governments should ensure that health workers have access to appropriate protective equipment and that social protection programs are in place for the families of workers who die or become ill as a result of their work, and ensure that such programs include informal workers, who represent a large share of the caregiving sector.
The United Nations Committee on Economic, Social and Cultural Rights has underscored that governments have an obligation to use the maximum available resources for the realization of the right to health as with other social and economic rights, and governments that are unwilling to do so violate their obligations. In light of the Covid-19 pandemic, the Committee has said that “All health-care providers must be provided with proper protective clothing and equipment against contagion.” In the context of the right to life where a lack of adequate PPE creates a foreseeable life-threatening situation, failure to provide adequate PPE to health workers exposed to Covid-19 may violate states’ obligations to protect life.
Additionally, states have positive obligations to protect the right to life when the country undertakes, organizes or authorizes dangerous activities, and fails to ensure a system of rules and sufficient control to reduce the risk to a reasonable minimum. In addition to its March guidance, the WHO provided further guidance in April and June – the latter says that medical masks should be worn by all healthcare workers interacting with Covid-19 patients and that respirator masks should be worn by those conducting aerosol-generating procedures. The Centers for Disease Control and Prevention states that face masks do “not provide the wearer with a reliable level of protection from inhaling smaller airborne particles and [are] not considered respiratory protection,” and recommends that health workers wear respirators where possible.
Retaliation against medical workers for speaking out about lack of PPE and other violations of their rights is a clear violation of the right to freedom of expression and such acts of retaliation, in particular against whistleblowers, should be prohibited by law.