|In June 1992, a medical team consisting of Thomas Johnson, M.D.,
Thomas Pezzella, M.D., of the University of Massachusetts Medical Center and Julia Logan,
a medical student, spent several days in Pushkin assessing medical needs and becoming
better acquainted with Pushkin's health care personnel and facilities. This was done
in cooperation with the Worcester Pushkin Sister City Program.
This program is involved with exchanges of health care teams, as well as providing desperately needed medical equipment and supplies to support a fractured health care system, and a recovering economy.
Future programs involve collaboration with affiliate groups of the World Heart Foundation to allow greater and easier access to equipment and supplies for Russian Cardiac surgery programs.
In August, September, 2003, Doctor Pezzella made a tour of the major cardiac surgery centers in St Petersburg, Moscow, and Tomsk, Siberia. The Russian Cardiac Surgeons are proud, well trained and capable. They are committed to further development and excellence. With increased funding and political support the Russian Cardiac Surgery Programs will continue to grow and develop. They have an enviable history in the seminal discoveries and advances in cardiac surgery.
On Location – Russia
Russia is the largest country in the world (17,075,400 sq km) with a population of 142.4 million that has decreased in recent years (1) (Figure 1). It has a storied history, with a proud culture and an educated population (Figure 2). Over the past 100 years, Russia has experienced three major forms of government--- monarchy, communism, and now democracy. The transition periods have been at times turbulent and violent. The population has suffered through two major wars of the 20th century with a massive loss of people (20-30 million combined military and civilian). Yet its contributions in the arts, sciences, technology, and engineering have been and remain numerous and noteworthy. The political and economic progress of Russia has increased in recent years, as evidenced by an average 7% yearly increase in GDP, mainly related to oil and gas revenues (2).
As with the majority of present day countries, health, social services, and education receive less attention and financial support from the central or federal government. Yet the Health Development Index (HDI) is 74.1 (1). The health care spending in Russia is 5.6% of GDP, compared to the world average of 10.2%. However, healthcare spending has increased over the past few years as part of a national priorities project (3).The demographics continue to change, especially the decreasing life span of males( 58.7 years), and an increasing elderly population ( 12.5% over 65 years of age) (Figure 3).
The incidence of chronic illness is rising in Russia, especially cardiovascular and cancer diseases. The double burden of communicable diseases, especially tuberculosis, diphtheria, syphilis, brucellosis, and HIV/AIDS, has made the access and availability of both preventive and curative strategies a challenge (4). The transition over the past 16 years from a totally socialized system to a hybrid of government funding, insurance, and self-pay continues to be a challenge and source of frustration, and oftentimes despair. The rise in violence, alcohol consumption (160-180 half liters vodka/ year for adult males), smoking (70% of men; 30% of females), unemployment (despite a decreasing workforce), and drug addiction have accelerated the increase in the incidence and prevalence of chronic disease, trauma (both violent and accidental), mental illness, and suicide. Denisov (5) has outlined three themes that characterize the healthcare transition since the collapse of the USSR (CCCP) since 1991: collapse of geographic and administrative relationships; changing demographics and migration; and internal political conflicts, along with imbalance in economic growth.
Despite these somewhat pessimistic facts, the healthcare structure or system continues to evolve in a progressive manner. Initially, the fully funded socialized system was designed to preserve a healthy workforce as part of national economic policy (4). With the democratic transition, the centrally controlled system gave way to fragmented initiatives in the 89 federal republics or regions (“oblasts”) (6). This resulted in decreased funding, bureaucratic allocation of resources and money, and resultant increased “out of pocket” financial burden to cover pharmaceuticals and supplies, not to mention under the table compensation. In May 2000, President Putin combined the 89 regions into seven federal regions to allow for more inter-regional coordination and implementation of policy (7). A new Ministry of Health and Social Development was established. This ministry will also assume responsibility to oversea medical education.
The medical education system has not changed appreciably (8). The system of “free standing” medical institutes (about 54) still prevails. They are separate from the academic universities. This system advocated early specialization and empirical clinical training. Following primary and secondary school, the medical institute duration is six years. At 23-24 years of age, specialized training includes a mandatory one-year internship (internatura). Another year or two (ordinatura) is followed by a three residency in the specialized area (residentura). Of the 86 academic centers in Russia, about five offer specialized training in cardiovascular surgery. The premier academic center for cardiovascular (CV) training is the Bakoulev Scientific Institute in Moscow (Figure 4). The majority of CV surgeons in Russia have received part or all of their training at the Bakoulev institute. The pathway to achieve Academician is a much longer and arduous process.
There are 75 centers in Russia with cardiac care services (9). Seventy-three centers perform open-heart surgery. Thoracic surgery is a separate specialty. It is estimated that there are about 1,000 cardiac surgeons practicing in Russia. There is no national registry to document the exact number, or board to refer to. The training system remains the traditional German pyramid system with many residents progressing to junior attending level and remaining in that position for varying lengths of time. It is clearly the professor/ apprentice model. Hard working, dedicated, technically talented surgeons progress at an accelerated rate in this hierarchal system. It is reminiscent of the original Halstead system at Johns Hopkins, prior to the evolution of the “rectangular” system in the USA following World War II, as championed by ED Churchill at Massachusetts General Hospital (10).
The burden of cardiovascular disease in Russia is high. The Soviet Union did not report vital statistics to the World Health Organization (11). Yusuf et al. (12) has illustrated the stages of epidemiological transition for cardiovascular diseases (CVD) (Figure 5). Russia is in stage 5, with >35% annual mortality secondary to CVD. Unger (13) has presented a survey of worldwide annual cardiac surgery procedures (Figure 6). Russia is estimated at 37 million population. This has changed in recent years. In 2005, 23,257 open-heart procedures were performed in Russia at 73 centers (9). The average yearly increase from 2002 is 2,000 per year. The incidence and prevalence (backlog) of cases is difficult to determine, but clearly, there is a need to increase the annual caseloads. The limiting factors include well-trained surgeons, access geographically (especially east of the Urals in Siberia), and funded centers with capable teams/systems/equipment/ supplies. Congenital heart surgery remains the major operation with valve surgery second, and coronary bypass surgery rising. It is doubtful that Russia will develop a standardized, time fixed cardiovascular residency program. As in Western programs, the market forces will dictate transition
It is difficult to assess the contributions of Russia in CV surgery since most of the work was recorded in Russian and largely unavailable during the Soviet era. This has changed dramatically in recent years, as more abstracts and manuscripts are being presented and published in English. As an example, 50 abstracts from the Bakoulev Institute were presented at the May 2007 meeting of the European Society for Cardiovascular Surgery. Historically, many original contributions in CV surgery came from Russia (14).
Professor Nikolai Petrovich Sinitsin from Nizhny Medical Institute conducted early experimental heart transplants in the early 1940’s (15). Professor Vladimir Demikhov also contributed to early cardiac transplantation in the 1940’s, as well as experimental internal mammary artery bypass anastamosis in the early 1950’s (13, 14). Professor V I Kolessov is credited with the first mammary artery – coronary bypass in 1967 (16); ( J. Thorac Cardiovasc Surg 1967; 54: 535-544). The largest series of contemporary surface cooling operations for congenital heart problems was pioneered in Novosibirsk (17). This operation is still being performed in Mongolia. The first successful caval-pulmonary operation (popularized by Glenn) was performed by Professor E N Meshalkin in April 1956 (15). It has historically been referred to as “the Russian Operation”. Presently, more Russian scientific contributions are being published in Western journals (18-20).
In recent years, centers in Western Europe have reached out to their colleagues in Eastern Europe and Russia. Hans Borst has reported on the initiatives of the European Association for Cardiothoracic Surgery to help support programs and offer further observational and fellowship training in selected Western European centers (21, 22). In 1998, Professor Borst visited 11 centers in Russia. He commented that the economic/political constraints were momentary and that the enthusiasm, optimism, ability, and hard work of the Russian cardiac surgeons would prevail. He did, however, highlight that the opportunities for the younger surgeons needed to improve.
Following a trip to Pushkin City in 1992, with a group from the Worcester MA/ Pushkin, Russia Sister city program, to evaluate healthcare at the community hospital level, a second trip was taken by this author to Russia in August 2003. This included a train trip from Helsinki, Finland to Shanghai, China over a 2-month period. Six Russian CV centers were visited in St Petersburg, Moscow, and Tomsk, Siberia. A recent one-month trip to Russia in August/September, 2007 was made to the Bakoulev institute in Moscow. This afforded the author the opportunity to get an insight into the status of CV surgery in Russia, as well as to interact with the local doctors and staff.
The Bakoulev Scientific Center for Cardiovascular Surgery—Russian Academy of Medical Sciences is one of the 86 academic centers in Russia. It is the major center for CV care and surgery in Russia. Headed by Professor Leo A Bockeria (Figure 7), the center performed 4,158 open-heart operations in 2005, with over 3,000 for congenital heart disease. The institute is divided into departments, each with a chief and team. These departments include congenital neonatal (< one year); congenital (one to three years); congenital (> three years); and adult acquired disease (Figure 8). The organization and flow of care is highly efficient (Figure 9). The operative aspects are standardized and kept simple, with cost efficiency a primary goal (Figure 10). Advanced technology was evident. One example includes an operative sterilizer that utilizes ozone technology (Figure 11). (www.orion-si.ru, in Russian). Western cardiac valves were used, as well as the lower cost Russian tilting disc MIKS valve. The Bakoulev also produces a mechanical heart valve, as well as its own homograft and heterograft material. The team approach to perioperative care combines Anesthesia, Surgery, Perfusion, Cardiology, and Intensivists. A weekly Tuesday afternoon conference reviews the previous week cases, as well as morbidity/mortality discussions (Figure 12). Detailed and accurate statistics for all the Russian programs are maintained (8).
In summary, the Russian CV surgery programs are progressing at a pace only limited by economic/political constraints. The future challenges include increased awareness of the CV disease burden, access to care, a planned strategy to educate and train future CV surgeons, well-equipped/ staffed centers, and financial support. The openness and bluntness of our Russian colleagues is balanced by their congeniality and willingness to learn, as well as share there proud legacy in CV surgery.
There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new order of things.