The war and sanctions hit Russian medicine unevenly, since there is no unified system of medical care in Russia: the polyclinic is completely separated from the hospital, funding is provided separately, in parallel there is an extensive network of departmental institutions, the Ministry of Emergency Situations has its own clinics, and the hospitals of the Federal Medical -biological agency (FMBA) – not yet a military, but not a civilian structure, either providing paid services, or sending doctors by order to the frontline zone and the occupied territories, treating the wounded. Because of this heterogeneity, it is impossible to rely on statistics, but some idea can be formed on the basis of conversations with doctors, and staff of departments, suppliers of medicines and medical devices (MD).
Interruptions in essential medicines
Although the sanctions do not directly apply to medicines and medical devices, these markets are now shaking like an airplane in a turbulence zone. During the first shock after the start of the war, banks, container transportation, dual-use items (many "heavy" medical devices – external respirators, spare parts and expensive electronics for equipment for radiation diagnostics and resuscitation), insurance companies – that's when it shook very Seriously.
By summer, the situation had stabilized. New payment schemes were established, "corridors" for deliveries were found, managers began to form stocks. Stability was consolidated with the relative stabilization of the ruble exchange rate, although prices, according to various estimates, increased by 7-8% materials. This segment suffers from cuts in funding and complication of logistics (logistics (supplies have been restored, but new schemes often fail). Due to underfunding, the market is shrinking, it is unprofitable for businesses to keep an expensive warehouse in the country, which is now being bought up worse, it is better to turn a thousand packages of cheap aspirin.
For some types of diseases, interruptions in medicines are very dangerous. So, for example, in drug therapy for oncological diseases (which is often combined with surgery), it is very important that the patient receives all prescribed drugs on time and in a certain dosage. If this does not happen, then both therapy and surgery go down the drain. For example, in many clinics there is a shortage of Pembrolizumab , which is used to treat lung cancer and such a terrible tumor as melanoma. It must be administered every three weeks, and no drug – no treatment. Ipilimumab , which is used to treat children over 12 years of age and adults with inoperable and metastatic melanoma, has been missing for a while, and this may be the only chance for life. Later deliveries resumed, but many patients missed deadlines and died. I am informed that the drug is again out of stock in many hospitals. Nivolumab is intended for a wider range of diseases, including stomach cancer, bladder cancer, colorectal cancers, and lung cancer. The absence of the drug means more and more deaths of patients.
Supplies resumed, but some patients missed deadlines and died
Numerous problems with the treatment of orphan diseases in children are also in sight. Interruptions with hormonal drugs are also numerous. And often there is nothing to replace the medicine. Relatively speaking, the presence of aspirin in pharmacies does not seem to threaten anything. But children's Ibuprofen has simply disappeared in many places. There are and will be simple drugs that treat 70-80% of diseases, although they will be more expensive. But with more "complex" diseases problems.
Moscow doctors are also talking about interruptions in the supply of Marcain , a drug for spinal anesthesia. Hospital pharmacies have to buy not even analogues, but Russian predecessors of the French drug, which either do not work at all or work inefficiently. This happens with other drugs, but on pain relief during surgery, this is especially noticeable.
Problems arose not only with medicines, but also with medical devices, which affects, for example, endoprosthesis replacement of large joints. Most Moscow hospitals still have consumables for joint replacement, and in Siberia, many can no longer purchase "first line" products with excellent quality and excellent reputation. Endoprostheses of American, Swiss, British, German, Italian manufacturers (Zimmer, DuPuy, Smith & Nephew, Mathys, Lima) are disappearing in hospitals in Siberia, Primorye, and Central Russia. Instead, doctors began to install prostheses of the "second" or even "third" line – made in China, Turkey, India. This is connected both with financial problems “on the ground” and with the fact that in the conditions of irregular deliveries, importers first of all try to saturate the capacious Moscow and St. Petersburg markets. Moreover, the prosthesis is a multi-component device (leg, bowl, head, insert). In conditions of shortage, doctors began to mix components from different manufacturers.
Shoulder joint prostheses are now almost completely inaccessible in Russia. They were used infrequently, and now even less often – so suppliers removed them from sales for clinics. Over time, the prosthesis wears out, it needs to be changed, for which there are revision endoprostheses. But in Russian clinics they are practically non-existent.
In many regions, knee arthroplasty will be removed from free care programs next year, which is almost half of all arthroplasty operations. Thus, state clinics will no longer replace joints.
Public clinics will no longer replace joints
This year, all major manufacturers have already raised prices for medical devices and medicines by 10-15% once or twice (recall that the world has not yet fully recovered from the post-COVID economic depression). Since the new year, prices will rise by another 10-15%. So for the end consumer in Russia, the price of imported medicines and medical devices in 2023 will increase by 35-40% compared to 2022, excluding the difference in exchange rates.
The above examples apply not only to orthopedics – the same applies to spinal surgeons, heart and vascular surgery, resuscitation, and so on wherever expensive imported materials are required.
In general, the main thing that happened with the start of the war was that a severe financial deficit was added to the logistical problems.
Departure abroad
The other day, at one of the official meetings, a figure was named – about 100,000 IT specialists left Russia with the outbreak of the war. There is no official data on doctors, but this number is clearly lower, because a surgeon, unlike a computer technology specialist, cannot take his workplace with him, and confirming a diploma and specialization in most Western countries is a long and complicated procedure. Although the number of those who left is not even percentages, but fractions of a percent, this has a strong effect. Young specialists leave, especially not burdened with children, from large cities, whose professional life is just beginning and there is time to confirm their diploma. The second group is accomplished doctors, opinion leaders. People behind whom are not only patients, but also their students, are a kind of “school”.
Although the number of those who left is not even percentages, but fractions of a percent, this has a strong effect
Ilya Fomintsev, the founder of the school for helping oncological patients and training oncologists, left for Israel. Sergey Morozov, a radiation diagnostician, professor, former chief specialist of the Moscow Health Department, left for Europe. Norayr Zakharyan, the former head of the orthopedics department of Moscow City Clinical Hospital N 31, the best traumatologist-orthopedist of Moscow in 2019 according to the city Health Department, left for Armenia. Oleg Udovichenko, a leading specialist in the treatment of patients with a profile of "diabetic foot", left for Kazakhstan. One of the most promising young traumatologists in Russia, Anton Semenisty, the author of many articles in international journals, a lecturer in demand abroad, left for Europe.
This does not yet affect the level of direct assistance – there is a qualified replacement. But in the long term, there will be a problem of succession and education of young people. The once familiar and most effective postgraduate training opportunities are closed – Europe has become inaccessible. And not only Europe, any trip to an international conference is completely different money. And it will ultimately affect the patients.
Missions to the frontline zone
With the onset of the war, Russian doctors began to be sent to the frontline zone to help the wounded, and not all business trips are voluntary, and not only doctors from military hospitals are sent to the occupied territories. Military doctors, as a rule, treat at their workplaces those who have already been sorted and selected for transfer "to the center" of the wounded. Hence the reports of the military medical authorities on low mortality: as eyewitness colleagues say, the wounded die in front-line civilian hospitals in the Rostov Region, Krasnodar Territory, Crimea and Belarus. Quite severe, but "promising" wounded get to military hospitals.
The wounded are dying in front-line civilian hospitals in the Rostov Region, Krasnodar Territory, Crimea and Belarus
Normally, the travel of doctors from civilian hospitals is relatively voluntary. For example, in the Moscow hospital. Botkin receives a kind of “order” from the head physician: to allocate so many doctors for business trips to this department, so many to this department. And then the doctors themselves decide who will go. For two weeks business trips pay about 200 thousand rubles. Payments are made through the accounting and cash department of the hospital. There is no shortage of applicants.
Essentially, business trips of FMBA doctors are compulsory. As already mentioned, this is a peculiar structure. There, doctors are given a condition – either a business trip (with a relatively small pay), or dismissal with possible subsequent prosecution. Those who fundamentally did not want to participate in this had to emigrate.
As for mobilization, de facto doctors manage to evade it: someone goes abroad, someone simply does not come to the military enlistment office (and nothing happens), someone formally enrolled in postgraduate training courses, continuing to go to the main work (and nothing happened either). There is no certainty whether a loyal attitude towards doctors will continue in the future in the event of new waves of mobilization. So far, the need is covered by seconded and civilian hospitals in the frontline zone, Belarus and the occupied territories.
Andrey Volna – traumatologist-orthopedist, honorary representative of Russia in the International Foundation for the Training of Traumatologists-Orthopedists, chairman of the board of the JSC Trauma Russia community 2002 – 2013.