Understanding health care in the south Caucasus: examples from Armenia
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《英国医生杂志》
1 Médecins Sans Frontières, Manushyan St 48, 375012 Yerevan, Armenia
Correspondence to: T von Schoen-Angerer, Médecins Sans Frontières, Am K?llnischen Park 1, 10179 Berlin, Germany tavschoen@yahoo.com
Along with sociopolitical and economic problems, the medical poverty trap in the south Caucasus region exacerbates its health problems
Introduction
Clinicians in the former Soviet Union have developed distinct treatment approaches and do not share the Western paradigm of evidence based medicine.16 Diagnostic criteria are often different, and many drug treatments and physical therapies (x rays, electric fields, etc) are unheard of in the West.17 Generally, treatment methods from Soviet times tend to involve many—often obsolete—drugs, long treatments, some of the highest use of injections in the world, and lower thresholds for admission to hospital and surgery.18 19
Fig 1 The south Caucasus region
Doubtless there is reason to acknowledge an important medical tradition and its many accomplishments. However, overdiagnosis, avoidable operations, and overprescription of drugs are not only harmful, putting patients at risk of adverse reactions and leading to drug resistance,16 but they also make health care even less affordable and contribute to the medical poverty trap. The objective is not to make medicine everywhere the same or to insist on international norms but to make medicine more patient friendly and accessible.
Beginning with the suspension of the Hippocratic oath at the beginning of the Russian revolution in 1917, the Soviet state interfered and "deprofessionalised" medicine, emphasising the doctor's duty to defend the interest of the state rather than of the individual.20 When the Soviet empire collapsed, some doctors welcomed the opportunity for change,21 but many others, especially those with sanitary-epidemiological training (the Soviet equivalent to public health), have remained nostalgic about the old methods, which assured efficient disease control but neglected human rights.
Today, disease control and the public health functions of the state are ambiguous and highly problematic: while the preference for a controlling and penalising public health approach is ever present, there is a lack of means and too much corruption to enforce it. All too often, control mechanisms have become perverse instruments to extort bribes, rather than delivering a public good.
Sexually transmitted infections
A distinction should be made between a controlling public health approach and blatant abuses of human rights. During Soviet times psychiatry was used to punish dissidents.26 Emphasis was on large mental institutions—as was also the case in Europe and North America until only a few decades ago. Mental health services were affected disproportionately to other health services when the Soviet Union collapsed, and hospital conditions deteriorated further. In 1995, in the psychiatric hospital of Vardenis, Armenia, on winter mornings after there had been electricity cuts (resulting in no heating) at night, dead bodies were carried outside, thrown over the hill, and left for the animals. Nurses handed out the same drugs to all patients indiscriminately, and patients were beaten when they became agitated.
Since then, many improvements have occurred in the region, thanks to the initiatives of different organisations (such as the Geneva Initiative on Psychiatry) and greater awareness by local health authorities, but the situation is still dire for many patients. In a context where most people live with their extended family, stay in hospital becomes indefinite when families refuse to have the patient return home. We found that people with mental problems living outside institutions in Armenia are often more vulnerable than those living inside (box 2).27 Entire families are isolated from the community because of stigma; patients are hidden away, their health care reduced to renewal of drug prescriptions—if there is money to pay for them. Mental diagnoses often continue for life without review, and lack of confidentiality further contributes to the extreme stigma that people with mental illness experience in this context.28 Clinical psychology and social work in the Western sense were non-existent during Soviet times, and there is still little experience and hardly any resources.
Box 2: Stories obtained from mental patients in Armenia, December 2003
A 26 year old woman lives with her mother in a 10 m2 room in a refugee hostel in Tchambarak, a little town in the mountains. Winters are long, with temperatures below - 30°C. The only things they have are two old beds with one blanket each, a little table, an old television, and a bookshelf. They receive a monthly pension of $8 and once a day a meal, provided by a charity soup kitchen. Although she is psychotic, the daughter had never visited a psychiatrist, nor had her mother, who is also suffering from mental problems. During working days, the daughter now visits the MSF day centre in Tchambarak, where she knits and draws, and where she can feel at home.
A 15 year old girl has learning difficulties and has signs of autism. Her parents are not really poor but have decided that they do not want to spend any money to buy medication or to let her visit a psychiatrist. For them, she is a punishment from God and the less she is at home the better.
A 56 year old woman was diagnosed with schizophrenia in Russia, where she last had a consultation with a psychiatrist 15 years ago. Her son lost his eyesight at the age of 13 when a shell hit their house during a bombardment. Since then he has been "nervous" and sometimes behaves aggressively. He has not left his bed for more than 10 years. The mother takes medication and gives the same to her son as she does not see how else she can help him.
The Armenian ministry of health has recently recognised the importance of deinstitutionalisation. Médecins Sans Frontières started a joint pilot project with the ministry offering free psychiatric care through a multidisciplinary team approach (including psychiatrists, psychologists, and social workers) in a newly created mental health centre in Sevan and ergotherapeutic activities in day centres. This approach is more patient centred and more holistic and many patients show considerable improvement. Attendance by patients with schizophrenia is good, but few people with depression, anxiety, or personality disorders attend, probably because of fear of stigma. Many obstacles to deinstitutionalisation still exist: psychiatrists have a very low threshold for hospital admission as they are held legally responsible for any misdoing by their patients. The lack of alternative housing such as supervised apartments prevents discharge of patients when families refuse the patient or have—illegally—sold the patient's apartment. Still, improving outpatient mental health care is a precondition for reducing institutionalisation.
Conclusions
McKee M, Shkolnikov V. Understanding the toll of premature death among men in eastern Europe. BMJ 2001;323: 1051-5.
World Health Organization. World health report 2003: shaping the future. Geneva: WHO, 2003. www.who.int/whr/en/ (accessed 15 Jun 2004).
Badurashvili I, McKee M, Tsuladze G, Mesle F, Vallin J, Shkolnikov V. Where there are no data: what has happened to life expectancy in Georgia since 1990? Public Health 2001;115: 394-400.
Staines V. A health sector strategy for the Europe and Central Asia region. Washington DC: World Bank, 1999: 46-7. (Health, nutrition, and population series.)
Toon P. Reforming the Russian health service: otherwise it might be convenient. BMJ 1998;317: 741-2.
Collins T. The aftermath of health sector reform in the Republic of Georgia: effects on people's health. J Community Health 2003;28: 99-113.
Whitehead M, Dahlgren G, Evans T. Equity and health sector reforms: can low-income countries escape the medical poverty trap? Lancet 2001;358: 833-6.
Lewis M. Informal health payments in central and eastern Europe and the former Soviet Union: issues, trends and policy implications. In: Mossialos E, Dixon A, Figueras J, Kutzin J, eds. Funding health care: options for Europe. Buckingham: Open University Press, 2002: 184-225.
Hovhannissyan S, Tragakes E, Lessof S, Aslanian H, Mkrtchyan A. Health care systems in transition: Armenia. European Observatory on Health Care Systems, 2001:31. http://www.who.dk/document/e73698.pdf (accessed 15 Jun 2004).
Theocharopoulos Y, Malakyan K. Access to health care in Tchambarak and Vardenis regions, Gegharkunik Marz, Armenia. Brussels: Médecins Sans Frontières, 2003.
Skarbinski J, Walker HK, Baker LC, Kobaladze A, Kirtava Z, Raffin TA. The burden of out-of-pocket payments for health care in Tbilisi, Republic of Georgia. JAMA 2002;287: 1043-9.
Qulieyeva DP, Huseynov SA. Primary health care revitalization in Azerbaijan. Croat Med J 1999;40: 210-5.
Balabanova D, McKee M, Pomerleau J, Rose R, Haerpfer C. Health service utilisation in the former Soviet Union: evidence from eight countries. Health Services Research (in press)
Slogett A. Evaluation report on the revolving fund schemes originated by Oxfam UK in Armenia, Azerbaijan and Georgia. London: London School of Hygiene and Tropical Medicine, 2002.
World Bank. Poverty reduction strategies and PRSPs. www.worldbank.org/poverty/strategies (accessed 15 June 2004).
Mawer C, Ignatenko N, Wares D, Strelis A, Golubchikova V, Yanova G, et al. Comparison of the effectiveness of WHO short-course chemotherapy and standard Russian antituberculous regimens in Tomsk, western Siberia. Lancet 2001;358: 445-9.
Grabbe L. Understanding patients from the former Soviet Union. Family Med 2000;32: 201-6.
Pavin M, Nurgozhin T, Hafner G, Yusufy F, Laing R. Prescribing practices of rural primary health care physicians in Uzbekistan. Trop Med Int Health 2003;8: 182-90.
Hutin Y, Hauri A, Armstrong G. Use of injections in healthcare settings worldwide, 2000: literature review and regional estimates. BMJ 2003;327: 1075-80.
Pellegrino ED. Guarding the integrity of medical ethics: some lessons from Soviet Russia. JAMA 1995;273: 1622-3.
Cassileth BR, Vlassov VV, Chapman CC. Health care, medical practice, and medical ethics in Russia today. JAMA 1995;273: 1569-73.
Platt L, McKee M. Observations of the management of sexually transmitted diseases in the Russian Federation: a challenge of confidentiality. Int J STD AIDS 2000;11: 563-7.
Hope & Help NGO, UNFPA. Report on some aspects of commercial sex work. Yerevan: Tigran Mets, 2001
Khachikyan K, Babayan K, Danelyan H. Treatment and prevention of uro-sexual chlamdyosis, ureaplasmosis and mycoplasmosis . Methodological guidelines. Yerevan: Ministry of Health, 2001.
Clayes P, Ismailov R, Rathe S, Jabbarova A, Clayes G, Fonck K, et al. Sexually transmitted infections and reproductive health in Azerbaijan. Sex Transm Dis 2001;28: 372-8.
Poloshij B, Saposhnikova I. Psychiatric reform in Russia. Acta Psychiatr Scand 2001;104(suppl 410): 56-62.
Anakhassian K, Muselle S. Assessment of the situation of people with mental problems living outside institutions in Gegharkunik and Syunik Marz, Armenia. Brussels: Médecins Sans Frontieres, 2001.
Van Baelen L, Avetisyan T. Knowledge, attitudes and behaviour towards mental health problems in Tchambarak and Gavar (November 2003-January 2004). Yerevan: Médecins Sans Frontières, 2004.(Tido von Schoen-Angerer, )
Correspondence to: T von Schoen-Angerer, Médecins Sans Frontières, Am K?llnischen Park 1, 10179 Berlin, Germany tavschoen@yahoo.com
Along with sociopolitical and economic problems, the medical poverty trap in the south Caucasus region exacerbates its health problems
Introduction
Clinicians in the former Soviet Union have developed distinct treatment approaches and do not share the Western paradigm of evidence based medicine.16 Diagnostic criteria are often different, and many drug treatments and physical therapies (x rays, electric fields, etc) are unheard of in the West.17 Generally, treatment methods from Soviet times tend to involve many—often obsolete—drugs, long treatments, some of the highest use of injections in the world, and lower thresholds for admission to hospital and surgery.18 19
Fig 1 The south Caucasus region
Doubtless there is reason to acknowledge an important medical tradition and its many accomplishments. However, overdiagnosis, avoidable operations, and overprescription of drugs are not only harmful, putting patients at risk of adverse reactions and leading to drug resistance,16 but they also make health care even less affordable and contribute to the medical poverty trap. The objective is not to make medicine everywhere the same or to insist on international norms but to make medicine more patient friendly and accessible.
Beginning with the suspension of the Hippocratic oath at the beginning of the Russian revolution in 1917, the Soviet state interfered and "deprofessionalised" medicine, emphasising the doctor's duty to defend the interest of the state rather than of the individual.20 When the Soviet empire collapsed, some doctors welcomed the opportunity for change,21 but many others, especially those with sanitary-epidemiological training (the Soviet equivalent to public health), have remained nostalgic about the old methods, which assured efficient disease control but neglected human rights.
Today, disease control and the public health functions of the state are ambiguous and highly problematic: while the preference for a controlling and penalising public health approach is ever present, there is a lack of means and too much corruption to enforce it. All too often, control mechanisms have become perverse instruments to extort bribes, rather than delivering a public good.
Sexually transmitted infections
A distinction should be made between a controlling public health approach and blatant abuses of human rights. During Soviet times psychiatry was used to punish dissidents.26 Emphasis was on large mental institutions—as was also the case in Europe and North America until only a few decades ago. Mental health services were affected disproportionately to other health services when the Soviet Union collapsed, and hospital conditions deteriorated further. In 1995, in the psychiatric hospital of Vardenis, Armenia, on winter mornings after there had been electricity cuts (resulting in no heating) at night, dead bodies were carried outside, thrown over the hill, and left for the animals. Nurses handed out the same drugs to all patients indiscriminately, and patients were beaten when they became agitated.
Since then, many improvements have occurred in the region, thanks to the initiatives of different organisations (such as the Geneva Initiative on Psychiatry) and greater awareness by local health authorities, but the situation is still dire for many patients. In a context where most people live with their extended family, stay in hospital becomes indefinite when families refuse to have the patient return home. We found that people with mental problems living outside institutions in Armenia are often more vulnerable than those living inside (box 2).27 Entire families are isolated from the community because of stigma; patients are hidden away, their health care reduced to renewal of drug prescriptions—if there is money to pay for them. Mental diagnoses often continue for life without review, and lack of confidentiality further contributes to the extreme stigma that people with mental illness experience in this context.28 Clinical psychology and social work in the Western sense were non-existent during Soviet times, and there is still little experience and hardly any resources.
Box 2: Stories obtained from mental patients in Armenia, December 2003
A 26 year old woman lives with her mother in a 10 m2 room in a refugee hostel in Tchambarak, a little town in the mountains. Winters are long, with temperatures below - 30°C. The only things they have are two old beds with one blanket each, a little table, an old television, and a bookshelf. They receive a monthly pension of $8 and once a day a meal, provided by a charity soup kitchen. Although she is psychotic, the daughter had never visited a psychiatrist, nor had her mother, who is also suffering from mental problems. During working days, the daughter now visits the MSF day centre in Tchambarak, where she knits and draws, and where she can feel at home.
A 15 year old girl has learning difficulties and has signs of autism. Her parents are not really poor but have decided that they do not want to spend any money to buy medication or to let her visit a psychiatrist. For them, she is a punishment from God and the less she is at home the better.
A 56 year old woman was diagnosed with schizophrenia in Russia, where she last had a consultation with a psychiatrist 15 years ago. Her son lost his eyesight at the age of 13 when a shell hit their house during a bombardment. Since then he has been "nervous" and sometimes behaves aggressively. He has not left his bed for more than 10 years. The mother takes medication and gives the same to her son as she does not see how else she can help him.
The Armenian ministry of health has recently recognised the importance of deinstitutionalisation. Médecins Sans Frontières started a joint pilot project with the ministry offering free psychiatric care through a multidisciplinary team approach (including psychiatrists, psychologists, and social workers) in a newly created mental health centre in Sevan and ergotherapeutic activities in day centres. This approach is more patient centred and more holistic and many patients show considerable improvement. Attendance by patients with schizophrenia is good, but few people with depression, anxiety, or personality disorders attend, probably because of fear of stigma. Many obstacles to deinstitutionalisation still exist: psychiatrists have a very low threshold for hospital admission as they are held legally responsible for any misdoing by their patients. The lack of alternative housing such as supervised apartments prevents discharge of patients when families refuse the patient or have—illegally—sold the patient's apartment. Still, improving outpatient mental health care is a precondition for reducing institutionalisation.
Conclusions
McKee M, Shkolnikov V. Understanding the toll of premature death among men in eastern Europe. BMJ 2001;323: 1051-5.
World Health Organization. World health report 2003: shaping the future. Geneva: WHO, 2003. www.who.int/whr/en/ (accessed 15 Jun 2004).
Badurashvili I, McKee M, Tsuladze G, Mesle F, Vallin J, Shkolnikov V. Where there are no data: what has happened to life expectancy in Georgia since 1990? Public Health 2001;115: 394-400.
Staines V. A health sector strategy for the Europe and Central Asia region. Washington DC: World Bank, 1999: 46-7. (Health, nutrition, and population series.)
Toon P. Reforming the Russian health service: otherwise it might be convenient. BMJ 1998;317: 741-2.
Collins T. The aftermath of health sector reform in the Republic of Georgia: effects on people's health. J Community Health 2003;28: 99-113.
Whitehead M, Dahlgren G, Evans T. Equity and health sector reforms: can low-income countries escape the medical poverty trap? Lancet 2001;358: 833-6.
Lewis M. Informal health payments in central and eastern Europe and the former Soviet Union: issues, trends and policy implications. In: Mossialos E, Dixon A, Figueras J, Kutzin J, eds. Funding health care: options for Europe. Buckingham: Open University Press, 2002: 184-225.
Hovhannissyan S, Tragakes E, Lessof S, Aslanian H, Mkrtchyan A. Health care systems in transition: Armenia. European Observatory on Health Care Systems, 2001:31. http://www.who.dk/document/e73698.pdf (accessed 15 Jun 2004).
Theocharopoulos Y, Malakyan K. Access to health care in Tchambarak and Vardenis regions, Gegharkunik Marz, Armenia. Brussels: Médecins Sans Frontières, 2003.
Skarbinski J, Walker HK, Baker LC, Kobaladze A, Kirtava Z, Raffin TA. The burden of out-of-pocket payments for health care in Tbilisi, Republic of Georgia. JAMA 2002;287: 1043-9.
Qulieyeva DP, Huseynov SA. Primary health care revitalization in Azerbaijan. Croat Med J 1999;40: 210-5.
Balabanova D, McKee M, Pomerleau J, Rose R, Haerpfer C. Health service utilisation in the former Soviet Union: evidence from eight countries. Health Services Research (in press)
Slogett A. Evaluation report on the revolving fund schemes originated by Oxfam UK in Armenia, Azerbaijan and Georgia. London: London School of Hygiene and Tropical Medicine, 2002.
World Bank. Poverty reduction strategies and PRSPs. www.worldbank.org/poverty/strategies (accessed 15 June 2004).
Mawer C, Ignatenko N, Wares D, Strelis A, Golubchikova V, Yanova G, et al. Comparison of the effectiveness of WHO short-course chemotherapy and standard Russian antituberculous regimens in Tomsk, western Siberia. Lancet 2001;358: 445-9.
Grabbe L. Understanding patients from the former Soviet Union. Family Med 2000;32: 201-6.
Pavin M, Nurgozhin T, Hafner G, Yusufy F, Laing R. Prescribing practices of rural primary health care physicians in Uzbekistan. Trop Med Int Health 2003;8: 182-90.
Hutin Y, Hauri A, Armstrong G. Use of injections in healthcare settings worldwide, 2000: literature review and regional estimates. BMJ 2003;327: 1075-80.
Pellegrino ED. Guarding the integrity of medical ethics: some lessons from Soviet Russia. JAMA 1995;273: 1622-3.
Cassileth BR, Vlassov VV, Chapman CC. Health care, medical practice, and medical ethics in Russia today. JAMA 1995;273: 1569-73.
Platt L, McKee M. Observations of the management of sexually transmitted diseases in the Russian Federation: a challenge of confidentiality. Int J STD AIDS 2000;11: 563-7.
Hope & Help NGO, UNFPA. Report on some aspects of commercial sex work. Yerevan: Tigran Mets, 2001
Khachikyan K, Babayan K, Danelyan H. Treatment and prevention of uro-sexual chlamdyosis, ureaplasmosis and mycoplasmosis . Methodological guidelines. Yerevan: Ministry of Health, 2001.
Clayes P, Ismailov R, Rathe S, Jabbarova A, Clayes G, Fonck K, et al. Sexually transmitted infections and reproductive health in Azerbaijan. Sex Transm Dis 2001;28: 372-8.
Poloshij B, Saposhnikova I. Psychiatric reform in Russia. Acta Psychiatr Scand 2001;104(suppl 410): 56-62.
Anakhassian K, Muselle S. Assessment of the situation of people with mental problems living outside institutions in Gegharkunik and Syunik Marz, Armenia. Brussels: Médecins Sans Frontieres, 2001.
Van Baelen L, Avetisyan T. Knowledge, attitudes and behaviour towards mental health problems in Tchambarak and Gavar (November 2003-January 2004). Yerevan: Médecins Sans Frontières, 2004.(Tido von Schoen-Angerer, )