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Is Russian healthcare ready for the fight against coronavirus?
Material posted: Publication date: 11-04-2020
Cases of coronavirus in Russia, according to official figures, while a few thousand, but the health system is already a serious problem. In the future, we could face a shortage of literally everything: medical, remedies, beds in hospitals, medical ventilators, test, medication. What's happening on the front lines of the fight against COVID-19 and what is the tensile strength of a health system, to understand "Vedomosti".

Optimism less

"We get out [of this situation] right, and I hope, maybe even earlier than [2-3 months]", – said recently the President of Russia Vladimir Putin. On 24 March he visited the hospital in Kommunarka, where they treat patients with coronavirus and suspected him. The President's hand shook with the head physician Denis Protsenko. Both of them were without masks.

The head physician of the hospital in Kommunarka Denis Protsenko accompanies President Vladimir Putin on March 24. After a week Protsenko detect coronavirus, and Putin will work remotely. /Press service of the President of Russia

– How do you like the hospital? – said Putin.

– Space! answered Protsenko.

A week later it turned out that Protsenko picked up the coronavirus. The tone of the authorities changed. On 2 April, Putin announced that the situation in the country is complicated, to extend the weekend until the end of April and allowed the government to impose a state of emergency. The President went on to work in the remote mode, reported Putin's press Secretary Dmitry Peskov.

Optimism diminished and the Russians: 48 per cent believe that Russia is not to avoid epidemics, and the same number believe that the health system is not ready, showed a poll of "Levada-center". Only 9% of citizens assess the situation in health care as good, while 52% are dissatisfied with it. The main problems are the high cost and lack of access to quality treatment for the citizens, as well as lack of qualified doctors and modern equipment, say polls by IPSOS and pollsand.

The first cases of coronavirus in Russia appeared officially on 1 March, on April 9, 10 already infected 131 people died – 76.

What brought health care reform

Starting an epidemic of coronavirus has exposed the weaknesses of health care reform, noted on March 28, the chief economist of VNESHECONOMBANK.Of the Russian Federation Andrey Klepach on the forum "Next 20 years". Reduced the number of beds in hospitals and infectious disease physicians. The authorities have not learned the lesson of the swine flu pandemic, which showed how easily infection can spread around the world.

Protest in Moscow against the reduction of health workers in 2014 /Denis Abramov / Vedomosti

The health Ministry is supposed to cut middle and Junior medical staff, believes Klepach. Do it for the execution of the may decrees of Putin's 2018 about raising the average wage in health care. According to the data of Rosstat, since the beginning of 2013 and the end of 2019 the number of Junior medical staff was reduced to 265 000 people (2.6 times), the average staff – to 1,314 million (9.3%), doctors – up to 704 000 people (2%), infectious diseases by 10% compared to 2011, or until 6884 specialists.

Almost 2.4 times and decreased the number of beds infectious profile from 140 000 in 1990 to 59 000, according to Rosstat. In Moscow in 2011, and is eliminated almost 2200 from 4823 beds. 3rd infectious diseases hospital in printers for 570 seats in 2015, the authorities decided to rebuild in industrial warehouse complex. "It can be used under such an emergency. In the end, now build a new one [in Moscow]," says head of the Union of paramedics Dmitry Belyakov.

Hurt became not much less. According to Rosstat, got severe infection (excluding tuberculosis and sexually transmitted diseases) in 1990 was 4.4 million people, and in 2018 and 3.5 million In total load profile of the doctor has more than doubled, and this has affected mortality from infections. If in 1990, died of 0.35% of infectious patients, in 2018, to 0.82%. As a result, according to who statistics, Russia's mortality rate from infections occupies 87 th place in the world.

How physicians work

In connection with the shortage of staff Putin called on if necessary to involve even interns, professors, teachers and students. Previously the capital of the infected or suspected coronavirus were hospitalized to the infectious hospital of № 1 and № 2, and also in the new complex in Kommunarka. Now they were taken in the Center of them. N. I. Pirogov Institute of emergency care named. N. V. Sklifosovsky clinical hospital № 15 named. O. M. Filatov and others In all branches of adapting premises and train staff indicates the representative of the Moscow health Department. Since April, the government gradually pureprofile 31 Federal institution with more than 10,000 beds.

The conditions in which today are the doctors? "Die or die – so you can describe our shifts now – wrote in his Instagram nurse recently redeveloped hospital of Moscow. We are all in the "dirty zone" work in the following outfit: surgical pyjamas, on top of a protective suit, goggles, a respirator, two pairs of gloves, rubber boots, overshoes. In the "dirty area" not to take anything <...> and that means you cannot: drink, eat, go to toilet, and at some point it becomes almost impossible to breathe <...> in the Morning after a day of hard work in a respirator I was crying from powerlessness," she writes.

Nurse of the therapeutic Department of the Moscow hospital, recently reformed in infectious infected with coronavirus /instagram.com/wall_e.e

"We have a huge burden already. And even now, these patients were added [diagnosed with coronavirus], very hard, – told "Vedomosti" paramedic of the St. Petersburg ambulance Maria. – The average working day – more than 12 hours. No compensation is not. Paramedics no category, the average salary rate of 1.5 will be about 60 000 RUB. For the plowing now what we get is just peanuts".

To encourage physicians, the government has allocated the Ministry of 10.2 billion roubles on surcharges for work with infected with a coronavirus or people at risk. But they are unequal: the doctors will be able to count on 80 000 roubles, nurses – 50,000, paramedics – by 25 000, the President said. And hardly it is possible to pay back the state debt to the doctors, said co-chair of the interregional Union of health workers "Action" Andrey Konoval. Work with harm to health or overtime in the day or night should be paid much higher for all workers, since in normal times they are very not receive.

Than to defend

To communicate with patients in Kommunarka Vladimir Putin dressed in a yellow hazmat suit TyChem 2000C American company DuPont and pornalicious mask UNIX 6100 Russian company "Sorbent" (enters into holding "Zelinsky groups"). The price of the protective equipment of the President – more than 10 000 RUB.: mask cost 6620 RUB, filters to it – 1512 RUB, protective overalls – 2581 RUB But to find them in retail correspondent of "Vedomosti" failed. In "Zelinsky groups", "Vedomosti" said that respirators and masks in the next month does not appear, although the plant operates around the clock, "Will in the best case at the end of April. We have the volume huge, but it was dismantled on demand".

Vladimir Putin dressed in a protective suit of American manufacturing to communicate with patients with coronavirus during a visit to the hospital in Kommunarka March 24 /Press service of the President of Russia

A difficult situation from other manufacturers of masks – the Russian representation of American company ZM. One of the competitors says that part of their components imported, and since the borders are closed, then the production began. The representative of ZM is said that the main imported component (filters) the restrictions do not apply and the company, on the contrary, increases the issue: "the Capacity of our plant is 50-60 million of respirators per year, in may we plan to increase production by 20%," – said the General Director of the GP in Russia and the CIS, mats Friberg. To purchase masks, the firm was advised to go to the major distributors – "tekhnoavia", "Vostok-service", "TD Trakt", but none of them the presence of masks or respirators could not confirm. "We are working 24/7. Even with the production increase we and other market participants are unable to meet the growing demand", – explained in the 3rd.

Same problem with the hazmat suits from DuPont – none of them are to find them failed.

Is there any protection for physicians

Footage bypass the new President of the Moscow clinics is in stark contrast with the situation in many other hospitals. The doctors today an acute shortage of personal protective equipment (PPE).

The guidelines of the CPS said: "the Medical staff assisting the patients with coronavirus infection-2019-nCoV and when suspected, should be provided with personal protective equipment: caps, antiplague (surgical) gowns, respirators". "In Ryazan was the case when instead of one issued as a reusable gauze bandages and said, wash and iron them yourself, not enough money," says butcher.

Problems with remedies even doctors from the capital. Sew the mask yourself ordered medical staff of the main body of the 9th medical diagnostic center of defense Ministry, wrote RBC, not setting aside even the material and extra time. On such cases reported and the Fund "Pravmir", declared the collection of funds on PPE: the daily requirement in just one hospital amounted to 200 sets of anti-plague suits, respirators, glasses, etc., but doctors sometimes do not have the basic disposable PPE. "Per employee leaves about 15 masks per day. The reserves are coming to an end", – quotes the words of one Fund of the Moscow physicians.

Farrier recalls the conflict in Vladimir, when the doctors were indignant that they are given disposable surgical gowns, even without a respirator, although it should be anti-plague. But doctors said: "it is Written [in the statement of Rospotrebnadzor] "surgical" in parentheses, then this is exactly what it should be."

"What you see on us, is not a means of protection against viral infection", the doctors recently redeveloped Pokrovskaya hospital in St. Petersburg also complained about the lack of PPE /Fontanka.ru

"Complaints of such problems we receive from all over Russia. Not even enough disposable funds, what can we say about full protection, – complains the head of the Union "Alliance of doctors" Anastasia Vasilyeva. – We are sounding the alarm for several months, it was clear what was coming, but the authorities have not launched the production of masks, there was enough for everyone – they still can't buy it". According to Vasilyeva, for drawing attention to this problem it has summoned to the Investigative Committee and questioned about the "fake about coronavirus". This happened after opposition leader Alexei Navalny has published an anonymous letter in the "Alliance of doctors" signed by a doctor Filatov hospital. It said that the Department is not prepared to receive patients with coronavirus: not enough medical staff and PPE. The chief physician of hospital Valery Vechorko on the page in Facebook has denied it.

However, close to Union sources indicate that the lack of protection remains. So, the costume should change, if you once took, for example, went to the toilet. So the doctors go in diapers and rarely try to drink water, says the employee of one of the charities.

The interlocutors of "Vedomosti", the head of one of the health funds offers immediately to take control of the sale of strategically important products – respirators and PPE, and quickly adjust their production. He also believes that it should be allowed to use funds that are not registered with Roszdravnadzor.

Risking everything

Without PPE, the doctors can do to catch the virus. "If there is no personal protective equipment, we have the right to refuse an emergency call. But I can't because we are afraid of reports and dismissal," says Maria of "er" of St. Petersburg. She seriously fears that physicians in such circumstances, may unwittingly become carriers of the infection: "there have Been several cases where a doctor was caught on coronavirus patient was without protection. In the end, he sits in quarantine for two weeks. A work-then who will? If at such a pace farther this case goes, the doctors in the ambulance and the ambulance will remain." About such cases, says the head of the Union of paramedics Dmitry Belyakov: "While it was out of my hands. Confirmed infection or not, no one will know, because his "emergency" was not used to wash dirty linen in public". Quarantined already 2874 paramedic, reported the Ministry of health on 3 April.

In a conventional disposable gloves and masks, came several times to take tests and infected with coronavirus Muscovite Alexey Antipov. About this he told in his video and showed all relevant documents. When the virus from Antipova was confirmed, came into contact with him doctors were sent to the quarantine.

The paramedic from Bugulma Anna Sidorova attends the citizens isolated themselves. "Come into the house, put on disposable caps, gowns, masks and gloves," reports her words, the administration of the Tatarstan Bugulma district /community Bugulma district

Risk and doctors in regular clinics. "We have every day in our district provide reports that so-and-so returned from there, our go – 17-20 addresses every day more and more. You have to walk, wearing masks and hats, that's all, – said the employee of the Moscow polyclinic Olga. – When you need to take samples – have to do it in the morning to 12 noon – come in, take off our clothes, throw her outside the door, on the floor, put on the usual robes, not Russia, not the same as for infectiologists, just glasses, hat and mask, and go to take strokes".

Although some patients can be treated at home, it did not lessen the burden, says Olga: "if People became less, quite a bit. Come all". According to her, devices for remote temperature measurement can not cope with such flow of people. Should be a break between the measurements, but it is not: "If you start every second to measure, the device is simply not working."

"Since medicine at the time was transferred to the category of services which serve it yourself, the doctors are staff. We are expendable, state do not care about us," complains the head of the Union of paramedics Dmitry Belyakov. From dissatisfied, in his opinion, is very easy to get rid reproach to violations or prohibited to work for half rate: "Fast" Moscow on 90% consists of foreigners and people who only became Muscovites taking mortgages, loans, there are slaves that are being demolished".

Another problem faced by the population: due to the conversion of hospitals under the communicable canceled the hospitalization and elective surgery in other patients. This, in particular, said Minister of health Michael Murashko. For example, in the Saratov region the main part of the ventilator used for planned treatment patients from which will be abandoned in favor of patients with coronavirus, reported IA "Version-Saratov" in the regional Ministry. Thousands of people will not be able to do the operation, says one of the Moscow doctors. According to close to the city hall of source, will be conducted only emergency procedures. Cancer care, chemotherapy, radiation therapy, hemodialysis and a number of other types of medical care provided in the normal regime, says the representative of the Moscow health Department.

Than to treat

As with remedies, medicines from a coronavirus similar problem. In the market shortage, as its own full-fledged production has not been established, and the world they are required.

The methodical recommendations for the prevention and treatment of coronavirus, the Ministry of health as drugs indicates ribavirin, lopinavir + ritonavir and interferon beta-1b. These same antiviral agent used against hepatitis and HIV.

As Russia imports and exports medicines

In 2018, Russia imported drugs and medical equipment by $11.5 billion, while exports were only $700 million – 16 times less, follows from the data of Rosstat. "Many drugs are made in Russia using Chinese and Indian components. There is no domestic anti-virus preparations of new generation for the protection of immunity. Now, when the ruble fell sharply, imported medicines will be inaccessible to many," says the chief economist of VNESHECONOMBANK.Of the Russian Federation Andrey Klepach. The share of import on Russian market of medicines is about 80%, the economist added. According to some medical devices of its own production in recent years even declined: for example, antimicrobials in 2017 produced 56 million vials, and a year – 40 million, follows from the data of Rosstat.

In February – March, the Ministry of health bought the drug Kaletra (active ingredients – lopinavir and ritonavir) for 3 billion rubles from the company "R-Pharm" Russian billionaire and member of the Public chamber Alexei Repik. The actual producer of the drugs is the German AbbVie. The cost of each package is 4500 RUB.

Also, the Ministry of health for 5.5 billion rubles. bought a interferon. The main supplier – the Russian pharmdistributor LLC "Biotec", controlled by Eugene Spiegel, the wife of the former Senator Boris Spiegel.

"I was prescribed these drugs, on prescription. But here such situation. To get something I can't buy. Send to friends a piece of paper with his own virus, I also have no right to. And Yes, one such drug costs 7500 rubles. the question Arises: how do I buy it?" – surprised in his video cases COVID-19 Muscovite Alexey Antipov

The vaccine for coronavirus yet. Novosibirsk center "Vector" is going to begin testing on humans in June, said Director of the center for Rinat Maksyutov in the air "Russia 1". According to the who representative Melita Vujnović, now in the world there are 20 candidate vaccines, but they are all flawed. When they do, how much it will cost, you will have time by this time the virus to mutate – these questions remain unanswered.

How to save

The major complication from the coronavirus that causes pneumonia and pulmonary fibrosis. For the salvation of seriously ill patients requires not just doctors, but also specially equipped hospital place – first with the ventilator and extracorporeal membrane oxygenation (ecmo).

In Russia, more than 47 106 medical ventilators, of which 33 974 – in intensive care units, from the data of the Ministry of health at the end of 2018, What is their average age, the report is not specified. Overall, however, the share of equipment over six years in medical institutions of the country were more than 46%.

Experts Headway Company counted 42 952 of the ventilator in Russia. Of them in Moscow – 6414, in Saint-Petersburg – 2348, in the suburbs – 2270. In some regions, they are at times less than normal, noticed mediastina "Project".

Main question: how are they working, how many of them are free and not required for service patients with other diseases.

"If suddenly there was a flash, then begin a natural selection, because 2.5 of the ventilator – two are occupied by patients, and one broken compressor", – stated in the video the medic hospital in Kalach-on-don Tatiana Revva. After that she started having problems: the user wrote a statement to the police, and was called in for questioning. "It got to the ridiculous. Management has considered all the Ambu bags (manual device to perform a temporary artificial lung ventilation. – "Vedomosti") for the ventilator, like, hands can download – so also the lung. Still got the old ventilator, disabled, – say, fix. In the end, they counted 13 pieces. Worst of all, the hospital was found fit for coronavirus of patients," – says the story Anastasia Vasilyeva from the "Alliance of doctors." The chief physician of hospital Alexander Kumeyko in the second video saidthat the institution is provided with all necessary and "the situation is completely under control".

"The Department of resuscitation and intensive therapy TSRB Balakhna not ready to provide skilled care for patients with respiratory disorders. No one working ventilator, no nebulizers, no sufficient number of dispensers, staff are not provided with PPE. If they do people with severe pneumonia, we won't get anything – nothing, and do perezarazhenie", – wrote in Instagram anesthesiologist Pavel Morozov. It heard the ventilator was urgently sent to repair, said the doctor later.

In the Nizhny Novgorod region 1100 of the ventilator 300 is broken, said Deputy Governor David Melik-Guseinov. But ventilation is not so bad, says the Director of one of the health funds. The doctors do not have enough oxygen mixtures for power devices. "If thousands will begin to enter the hospital, to save them nothing," – said the source "Vedomosti". The problem was recognized and the President – he ordered his representatives in the regions to make an inventory of the devices, to count how many patients will be able to make medical facilities, and required to increase capacity.

Where to get the equipment

To make up for the deficit, the ventilator you have to order from abroad c margin. So, the Moscow Department of healthcare without competition agreed with "Comete", which controls the head of the "national team" of one of the districts of Perm Pavel Shmakov, on delivery of 170 vehicles MythoVent German MS Westfalia for a total amount of 501 mln. Each unit will cost about 3 million rubles. "Manufacturers have raised prices, every vehicle is fully loaded will cost 28 000-30 000 euros, but they will not until may," said one of the suppliers. In the representation Westfalia "Vedomosti" said that the nearest possible supply – September, and the price of 41 000 euros.

A similar situation exists with the supply of IVL Moscow region Department of health through Irwin, which is holding Pharmeco Vladimir Babiy and ex-Minister of energy Sergey Shmatko. The company became a supplier 38 of the ventilator Medtronic us on 132 million roubles In retail devices can be found in 1,5–2 times cheaper, but the situation has changed: demand increased, and the ruble fell. The purchase was carried out is also without competition. This made the mode of increased readiness: as the spreading of the virus has extraordinary character and is a force majeure event, the law "On public procurement" allow customers to buy goods and services from a single supplier without competition, says CEO is a member of the Pharmeco company "Irvin 2" Mikhail Stepanov.

Delivery from abroad, this deficit does not compensate for, is skeptical head of the medical Fund. According to him, to take out the ventilator from Europe problematic. Restrictions or a ban on the export of medical products have entered more than 24 countries, including Germany, France, China, follows from the research of Global Trade Alert. There is no unity within Europe: export restrictions between countries within the EU undermining the single market, said the head of the European Commission, Ursula von der Leyen.

In Russia responsible for the delivery of the ventilator and ecmo, the government appointed rostec. 5700 vehicles over 7.5 billion rubles. have to produce the Ural instrument-making plant. It is a concern "radio-Electronic technology" "Rostec". Another 5 billion roubles will be spent on thermal imagers, non-contact thermometers, units for disinfection of air and so on. Ural instrument engineering plant is ramping up production from 10 to 100 units a day, a part of components imported, but while supply problems are not, assured the representative of the company.

When light does not cope with the saturation of blood oxygen, required ecmo. Them in Russia, only 124 and plans to buy another 17, said Deputy Prime Minister for social Affairs Tatyana Golikova. Almost all the imported devices, says Secretary of the Russian society of ecmo and chief anesthesiologist-resuscitator of the Ministry of emergency situations of Russia Daniel Shelukhin. They will have to buy in the USA or Germany, the price is more than 7-10 million rubles, according to recent public procurement. The treatment procedure is also expensive – about 1.5–3 million rubles, said Shelukhin. But most importantly requires trained personnel, which are lacking and fast to train.

What is the margin of safety

In the event of an influenza pandemic, the CPS expected standards of drug supplies, PPE, beds and medical equipment. The coronaviruses methodical recommendations yet. But the norms are comparable: the PPE is almost one to one, the medication is also the same, says a former chief sanitary doctor of Russia Gennady Onishchenko. Standards for influenza pandemic came from the fact that you can recover 10% of the population, of which 10% will require hospitalization, including 1.2% – ventilators (or 200 units per 1 million population). In total, according to the standards of Rospotrebnadzor, in Russia of pandemic influenza would be required over 29 000 free of the ventilator and 184 000 additional berths.

However, the coronavirus is more dangerous than the flu, indicates who. According to the data of the organization is required to hospitalize 20% of cases – in particular, in 5% the disease is severe and requires intensive care unit (Picu), of which about 12% – AV. Similar evaluation gives the Center for control and prevention of diseases of the United States. Infected when this maybe 30-40% of the population, believes Professor James Lawler.

What relation in our country? In the suburbs of the 550 infected hospitalized 170 (31%) and 10 (2%) were on a ventilator, reported April 8 by the Governor Andrei Vorobyov. Of the 696 patients with COVID-19 in Kommunarka and "Filativka" 137 was in the NICU, and 64 – on a ventilator (9%), cited data Protsenko in Facebook.

However, only in Russia for patients with coronavirus prepared 94,000 beds, said Deputy Prime Minister for social Affairs Tatyana Golikova. How medical ventilators work and free, power not reported, but the total number does not exceed 47 100, follows from the data of the Ministry of health.

While the growth rate of the number of patients Russia comes in the Wake of many European countries – as well as at first, and they have, doubling the number infected in our country occurs approximately every 3-5 days, follows from data of the European centre for prevention and control of diseases. In Europe the number of cases increased from 5000 to 500 000 in March, in Russia during the same time – from 1 to 2337 people.

MSU associate Professor Michael Tamm based on the University of Basel models predicted scenarios of development of the epidemic in Moscow (the full study is published "Medusa"). If successful outcome, when the city is maximally close to the end of June, the number of people infected can reach up to 37 000, and the dead – more than 250, the scientist said in an interview with "Vedomosti". The epidemic in this embodiment will subside by may, but the earliest the lockdown could be a double wave in the future. If we continue the current trends, then Russia, the number of infected will reach 1 million people by the end of may, however, not the fact that they are all registered, some testing, someone will not be symptoms, suggested Tamm. In any case, it will be really a tough challenge for the system.

 
Photo – hospital in Novocherkassk. In November last year, it stopped accepting patients: two senior doctors have resigned, one went to the hospital and also wrote a statement of resignation. 10% of the buildings of medical institutions of Russia are in need of reconstruction or overhaul, one third had no toilet, 40% – cold water, and in half – hot /nduma.ru

A virologist from the Institute of gene biology of RAS Anatoly Altstein more optimistic: "Usually diseases of the upper respiratory tract have a seasonal character and by summer fall". He hoped that COVID-19 adapts to the person and its pathogenicity will decrease: "When the virus is transmitted from animal to human, it begins to behave as a robber. But only to kill the media to his advantage, because the offspring will die. It is advantageous to multiply and move from one to the other. I do not exclude that two months may be enough. Sooner or later he will adapt". C agree the Deputy Director of the research Institute. Mechnikov and former chief sanitary doctor of Moscow Nikolai Filatov: "When there is more light and warmth, for the virus it would be a bad seasonal period. Will be the natural immunization of the population, and it's all over," he was quoted by the edition "Business online". Tamm disagree. The seasonality of the virus has not yet been confirmed, but if quickly gets infected and has been ill all, there will be many casualties. "This way was UK and while there is Sweden. God forbid that happened, but until we see that they have a mortality rate", concludes the expert.

Representatives of the Ministry of health and Rospotrebnadzor on the queries of "sheets" have not responded.

In preparing the material participated Bela Lyauv



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