As his medical van bumps down the dirt roads of the Russian countryside, Dr Yuri Sоkоlov can’t help but feel nostalgic for the days of the Soviet Union.
“I was comfortable enough with my work and I didn’t feel this humiliation of poverty,” the 77-year-old remembers of his time as the head of the village hospital in Ilinskoe, in the picturesque Kaluzhskaya region south of Moscow.
That hospital has long since shuttered, and stands boarded up on the edge of the village. Ilinskoe and the surrounding areas are now served by Dr Sokolov and a single nurse, whose respective monthly salaries are around 25,000 and 14,000 rubles (£250 and £140).
When he finally retires, there will likely be no doctor at all, only a medical assistant – known in Russia as a “feldsher,” a role that requires less training and offers less advanced care.
The trajectory of Dr Sokolov’s 50-year career is far from unique, and it reflects a crisis in Russian healthcare that is accelerating the decline of the country’s vast rural areas.
Even as the Kremlin spends millions on new facilities to deal with the coronavirus outbreak in Moscow, and scrambles to roll out the world’s first vaccine against the virus, village hospitals are being left to wither.
Half of Russia’s hospitals closed in the first 15 years of Vladimir Putin’s rule; according to a 2017 report from the Center for Economic and Political Reforms, a Moscow think tank, there will be no village hospitals left by 2023 if closures continue at their current rate.
Meanwhile, the number of doctors in some regions have more than halved year-on-year, despite government programmes to attract newly qualified medics to the provinces.
“It seems like it’s getting harder and harder,” Dr Sokolov said during his daily round.
Over the course of the day he will drive to administer flu vaccines, deliver coronavirus swabs to a laboratory, and check in on a 94-year-old woman in a nearby settlement, who is still in good health.
He will also have to pacify a villager who has refused to undergo a second coronavirus test after his wife tested positive for the virus, shouting at the doctor that he will need to come back with police if he wants to take another sample.
Doctor Sokolov understands why it is hard to bring new blood to the villages, where rates of poverty and unemployment are twice as high as they are in cities.
“There’s hardly any work here. There’s some for the young people, but you see that many people really do drink too much. They haven’t exactly been born fortunate.”
Anastasia Vasileva, an eye specialist who heads the Doctors’ Alliance trade union in Moscow, blamed a lack of funding not only for villages in decline like Ilinskoe but for hospitals elsewhere that at times resemble “something out of a horror movie”.
Dr Vasileva has been travelling the country to highlight the plight of doctors in regional areas, as her organisation fights for better conditions and pay.
The Doctor’s Alliance has made video reports of provincial hospitals in states of disrepair, which have not seen the most basic improvements in years. Some buildings shown in the reports lack running water; in others, water drips down from the ceiling and mould grows along the walls.
Even before the coronavirus hit Russia, doctors in the provinces were striking or protesting.
The plight of a tuberculosis clinic in Chernavsky, a village some 1,000 miles to the east of Moscow, hit national headlines when riot police were called in after doctors launched a campaign to save it from closure.
At the start of this year, a pediatric clinic in Moscow drew international attention when medics there started speaking out over mismanagement and corruption.
Since then, doctors on the frontline against coronavirus have complained of a lack of personal protective equipment, while some medical staff have said they have yet to receive pandemic-related bonuses promised by Mr Putin. Others have left their jobs permanently, or temporarily refused to work because of concerns about their safety.
For her efforts, Dr Vasileva was briefly arrested during a research trip this summer, and Russian state media has singled her out for attacks.
“All the problems we have with medicine start with money,” Dr Vasileva said, pointing to the fact that Russia has roughly half the healthcare spending as a percentage of GDP as many European nations. “We have very little money going into medicine, or maybe it goes into medicine and then is somehow misused or siphoned off somewhere.”
Russia has offered one-off payments of one million rubles (£10,000) to doctors who agree to work in rural areas for at least five years.
But Dr Vasileva said some medics were opting to pay the bonus back rather than stick out the full term, or leave immediately once the five years were up. She said it would be impossible to encourage doctors to live in the provinces until overall infrastructure there is improved.
“The responsibility is colossal and the work is really hard, really complicated…(doctors) might be promised accommodation, but they don’t get it. There’s no schools, you have to drive to them, but the roads are bad. There’s no public transport. And that’s only the half of it.”
In his clinic in Ilinskoe, where leaflets warning of the dangers of tuberculosis and Aids lie at reception, Dr Sokolov expressed bitterness that the Kremlin was bankrolling Moscow at the expense of the provinces.
Life was being made easier for Muscovites – who have comparatively good healthcare – to keep them happy and prevent them protesting against authorities, he said. “Moscow lives off the rest of Russia. And who is this done to protect?” He pointed to the sky, a reference to the man who has ruled over the country for the last two decades.
Ilinskoe is not the only village in the area where medical care has been scaled back. In the neighbouring village of Kudinovo, there is now a single doctor for a population of some 3,000, after a second doctor recently left for private practice and a medical assistant died.
On a weekday morning, dozens of people were waiting in a cramped reception to see the remaining Doctor Galina Ryzehnkova, some for more than two hours. Only one was wearing a mask, despite the ongoing pandemic; out-of-date posters advised patients to inform the doctor if they had been to China or in contact with Chinese citizens over the past two weeks.
“It’s like this every day,” said Dr Ryzhenkova, after appointments with around 50 children and 20 adults. Despite the added workload because of a lack of staff, she described herself as a “patriot” and said she was proud to have worked in Kudinovo for the last 30 years.
But she understood why it might be hard to find a replacement for her colleague who recently left for the private sector. “When you’re young, you want a good job, you want a good office, you have ambitions.”
Svetlana Stepanova, a Kudinovo local who had brought her granddaughter for vaccinations at the clinic, said the health system “had to find more people”.
“You can lose two and a half hours waiting here,” she said. “This is the 21st century.”
The Kremlin has declared healthcare a priority, and has said the closures of hospitals in remote regions are part of a wider plan to consolidate resources into high-tech, centralised facilities.
Experts admit the bloated system inherited from the Soviet Union needed reform, but say this is being carried out in a haphazard way that is disproportionately hurting those in the provinces.
“It’s not like [Russia] is not spending any money on healthcare,” said Dr Judyth Twigg, an expert on Russian healthcare and a senior associate at the Washington-based Center for Strategic and International Studies. “It’s national projects. They’ve built an enormous amount of high-tech hospitals and clinics, not just in Moscow, but also in Saint Petersburg and other bigger, medium-sized cities. But that’s happening simultaneously with the degradation of other areas.”
Dr Twigg said the situation in rural areas was “awful” and showed little signs of improvement.
“There’s no political incentive for investment, because rural voters tend to be Putin backers anyway. Demographically, these villages are dying off, so you probably don’t care too much about their politics.”
Dr Sokolov agrees that he and others like him have been left behind. “It’s a sad time, it’s better not to talk about it,” the grandfather of two said.
“I feel like a person from another age.”
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