COPD in Russia / ХОБЛ в России

“The draconian nature of Russian law is softened by the non-obligatory nature of its implementation”

An anonymous Russian saying

This week my blog post will consider the impact of chronic lung disease within Russia, focussing in on the role of smoking related disease, which amongst us medics is called COPD (chronic onstructive pulmonary disease).  Please see the previous post if you would like an introduction to COPD.

As is often the case, Russia has a unique situation, with its history, demographics and healthcare system all playing their part.  Intriguingly the situation of COPD in Russia has been a difficult topic to research.  Few studies seem to have been completed to define its incidence or prevalence.  With around 44 million smokers and rising, Russia has the highest smoking total and proportional prevalence in Europe.  Around 400,000 Russians are thought to die from smoking related diseases each year.    There are also significant barriers to primary care access and very limited screening.  Together this suggests significant under-diagnosis of COPD.

A primary health study conducted by Chuchalin et al within the Ryazan region of Russia (Рязань; population 1,306,600), ran from October 2004 to March 2005 (1).  Two districts were chosen, within which 16 primary health centres were chosen at random for recruitment.   Subjects received lung function tests and assessment for risk factors of chronic respiratory disease in the form of a household survey.  Results showed that whilst men are at greater risk: 60% of men smoke; 40% of men have occupational ‘dust’ exposure; prevalence of breathlessness, cardiovascular disease and chronic respiratory disease is two times higher in women than men.  Despite this 14% of men reported regular sputum production (4% women), suggesting some form of respiratory disease.  Low lung function was noted in 14% of the sample.  Overall COPD prevalence was said to be 1.6%, comparable with Russia as a whole.  It was noted that asthma treatment was also significantly underused, complicating the picture somewhat (the main drug of choice is theophylline – easily becomes toxic, many side effects, variable compliance).

What sense be made of this picture?  An extremely high level of smoking and occupational chemical exposures (especially amongst men), yet low rates of COPD.  I feel this study highlights some interesting and pertinent points within the peculiar ‘Russian paradox’

A society in smoking transition

Russia has been a society in transition.  As the soviet-era drew to a close, supplies of many goods became scarce.  Cigarettes were no exception.  This led to tobacco rationing, triggering the so called ‘tobacco riots’ where angry smokers caused chaos on the streets of Moscow and St Petersburg (2).  The Russian government responded by relaxing import laws, allowing multinational tobacco corporations to enter the Russian market.  With a population of 143 million citizens, few sales controls, low product taxation, a country previously naïve to marketing and eagerly desiring the western lifestyle, Russia was greatly attractive (3).   Today a pack of filtered cigarettes can cost less than $1 (£0.65).  As a result of the above Russia has become the third largest market for tobacco in the world.  All four major global tobacco firms now have high stakes in the Russian market, competing hard against one another in their sales drives.  The tobacco lobby is a formidable force affecting politics.  With the health impacts of smoking typically occurring in mid to late life, the long-term impacts of the smoking boom are only now being fully realised.  With smoking prevalence so high, COPD is an ever increasing burden.  Until recently little public awareness of the connection between smoking and chronic lung disease existed.  Hence smoking prevention is a relatively new concept! 

Sociodemographic changes

Russia is said to be experiencing a demographic crisis.  Deaths significantly outnumber births, meaning a comparatively higher number of the elderly.  Besides sub-Saharan Africa, the nations of the former Soviet Union (FSU) are the only world region to be experiencing a decline in life-expectancy.  Key to this is a huge gender disparity.  Men die increasingly young.  As COPD likelihood and severity increase with number of years smoked, many may never reach the point of significant impairment.  Men are also less likely to attend healthcare facilities (some truths are international!), and as such as less likely to receive a formal diagnosis for their breathing problems.

Healthcare provision

A multinational survey from the international COPD coalition noted several shortcomings in Russian COPD awareness and care provision (4).  It was found that patients viewed their symptoms as age/smoking related, rather than due to an underlying lung condition.  As a result, patients generally presented at advanced disease stages and chose to attend their GP rather than a respiratory physician.  Questions have also been raised regarding limited and outdated education of COPD treatment amongst primary care physicians.  Of those patients diagnosed with COPD, further barriers to effective care exist.  Whilst oxygen, inhalers and antibiotic therapy are available within Russia, provision varies depending on states and distance from large treatment centres.  Furthermore, treatment costs are not fully covered by the government or private insurance schemes.  As COPD is inversely associated with socio-economic status, many people simply cannot afford regular or optimal treatment.  Around 90% of formally diagnosed COPD patients within Russia are not receiving treatment recommended by national or international guidelines (5).

However it’s not all doom and gloom - changes are happening…

Smoking cessation

In 2008 Russia ratified the WHO Framework Convention on Tobacco Control, which called for a 10-15% decrease in smoking by 2015.  In summer 2010 the Russian Ministry of Health and Social development introduced warning labels on cigarette packaging for the first time.  Shortly after, President Vladimir Putin signed the national tobacco control concept paper.  Laws on public health relating to tobacco consumption began to be debated and rewritten, including discussions on smoking bans in public places, banning small tobacco retailers/kiosks, and limiting tobacco advertising including banning display case advertising in larger stores.  From June 2013 smoking will be banned in offices, school premises and around stations.  From 2014 this will extent to all public areas, including cafes, restaurants and long-distance trains.  Significant fines for breaking the rules are to be introduced (6).

Improved data collection, training and health services

Following on from the Ryazan study, COPD has now been mapped within a further 10 regions.  Over the past 3 years 35,000 primary care physicians have attended seminars on COPD, asthma, and smoking prevention.  The ‘Pulmobil’, a mobile COPD diagnosis and management centre was also unveiled in summer 2012, with the intention of enhancing service provision and coverage.  Studies are now on-going to assess the impact of these measures, including health centre utilisation by COPD patients.

Public awareness and attitudes

Media campaigns highlighting the health impact of smoking are increasingly common in newspapers, magazines and on television.  President Vladimir Putin has also publicly stated his desire for greater smoking cessation.  Surveys have shown mixed public opinion on the proposed changes; greater smoking controls for indoor public places such as offices and schools have generally been accepted; resistance has however been felt towards smoking bans covering shared stairwells, beaches and parks.  Increasing tobacco taxation also remains a politically sensitive topic, in particular amongst the industrial class, a loyal electoral base for President Vladimir Putin.  Critics of the proposed laws cite some impracticalities in the authoritarian nature of the rules and also question a lack of support for those wanting to quit smoking (7).  As is a common issue within Russia, it remains to be seen how rigidly the new rules are enforced.

Concluding remarks

COPD has long been underdiagnosed and undertreated in Russia.  Demographic changes are likely to exacerbate this situation in years to come.  The past five years have seen major changes in Russia, with increased public awareness, smoking controls and medical provision.  Whilst greater access to diagnostic facilities and provision of treatment is required, further barriers to COPD recognition can be overcome.

Thank you for reading this far - as usual, any comments greatly appreciated!

References

1) World Health Organisation (2006) Global Alliance Against Chronic Respiratory Diseases, Report of General Meeting 2005, Geneva. [online] Available at: http://www.who.int/respiratory/publications/WHO_NMH_CHP_CPM_05.4_eng.pdf [Accessed: 4 May 2013]

2) Greenstone.org (1997) Untitled. [online] Available at: http://www.greenstone.org/greenstone3/nzdl;jsessionid=E020827CE566B08981881AF4BB7ED8FE?a=d&d=HASH2255c5db003ea388a30032&c=cdl&sib=&ed=1&p.s=ClassifierBrowse&p.sa=&p.a=b&p.c=cdl [Accessed: 30 Apr 2013]

3) Holmes D. Smoking in Russia: will old habits die hard? Lancet. 2011 Sep 10;378(9795):973-4.

4) Scheld, J. (2007) ICC Country Report "Faces of COPD". The International COPD Coalition

5) World Health Organisation (2013) Global Alliance Against Chronic Respiratory Diseases, 7th General Meeting Report (2012), St Petersburg. [online] Available at: http://www.who.int/gard/publications/GARDGMReportStPetersburg2012.pdf [Accessed: 4 May 2013]

6) Rt.com (2013) Crackdown on smoking: Putin signs radical anti-tobacco bill into law — RT Russian politics. [online] Available at: http://rt.com/politics/putin-signs-radical-anti-smoking-bill-into-law-389/ [Accessed: 4 May 2013]

7) Harding, L. (2013) How will Russians cope with the smoking ban?. [online] Available at: http://www.guardian.co.uk/world/shortcuts/2013/feb/25/will-russians-cope-smoking-ban [Accessed: 1 May 2013]

Images

Image 1 – http://gdb.voanews.com/44A8821F-E0E1-4B9B-A29A-71D9255FA12C_mw1024_n_s.jpg

Image 2 – http://stoletnik.ru/articles/novosti/2013/03/01/v-rossii-zapretili-kurit-v-liftax-i-pod-ezdax/

Diabetes in Russia / Сахарный диабет в России

Welcome to my non-communicable diseases blog on Russia.

Russia is not renowned for its healthy diet... When it’s minus 30C outside your window, a deep-fried potato cake, generous dollop of sour cream and glass of sugary tea to finish, appeal infinitely more than a salad and mineral water. Oh, and that jog around the park will have to wait until May – there’s 2m of snow on the field at present…

In this first post on non-communicable disease in Russia, I’ll be considering the situation of diabetes within Russia including the opportunities and challenges facing its management.

So, what exactly is diabetes? Diabetes (also called diabetes mellitus) can be defined as an inability of the body to effectively get sugars, the body’s instant energy source, from the bloodstream into the cells. Normally, the body produces a hormone called insulin, which allows entry of sugar into the cells. The two most common types of diabetes relate to problems with insulin: diabetes type 1, where the body is unable to produce insulin; and diabetes type 2, where the cells of the body become less sensitive to the insulin that’s produced.   Without adequate treatment with either sugar controlling medications or insulin injections, diabetes will lead to major short and long-term health consequences. These include an increased risk of: heart attack, stroke, kidney disease, leg ulcers, loss of sensation, loss of vision, impotence and dementia. Unsurprisingly depression is also associated with diabetes. Whilst diabetes cannot currently be cured, it can be managed effectively, significantly reducing the likelihood of developing disease complications.

Russia has a population of around 140 million people. Around 2,8 million have an officially recorded diagnosis of diabetes [2008 estimate]. However, a health screening programme in 2006 involving 6 million Russian citizens found a diabetes prevalence of 5.5%, which if extrapolated suggests a national diabetes prevalence nearer to 8 million individuals. With an increasing in average age and level of obesity this figure is likely to rise still further. Significant under-diagnosis results in frequent late presentations – by this stage it’s often too late to reverse the disease consequences. As a result, 90% of the current health expenditure of diabetes is spent on limb amputations, heart disease, stroke complications, and kidney failure, with less than 10% being spent on insulin.

So, what are the major challenges facing diabetic care in Russia? 

1. Staffing: Until recently, little emphasis had been placed on primary care i.e. general practitioners looking out for diabetes risk factors like blood pressure, obesity, family history and raised cholesterol. The number of endocriniologists (hormone and diabetes specialists) is also low, with less than one per 50,000 population.

2. Standardisation: Until recently, there was very little in the way of official evidence based diabetes management policies, tailored towards the Russian population. Such guidelines have now been produced, however providing education for medical staff and changing deeply engrained management habits has faced some resistance. Some health facilities also possess outdated or ineffective equipment, further frustrating delivery best-practice.

3. Patient education: Many people simply aren’t aware of what diabetes is, what the risk factors and signs are, and how diabetes can be effectively managed.

4. Funding: Currently state funding only provides insulin for those registered disabled. All other diabetic medications and blood glucose monitoring equipment is provided by the regional health authorities. As the economic situation within the regions fluctuates, so too does the quality and continuity of medication and equipment supplied.

5. Geography:   Russia covers a ninth of the world landmass. Certain regions are incredibly sparsely populated and geographically isolated. Combined with extreme weather conditions, differing languages and ethnicities, and varying levels of education, providing effective on-going diabetes management is challenging to say the least.

However, things are now beginning to change. In 2002 the government of Russia embarked on ‘the federal target programme for diabetes mellitus’. The National Diabetes Institute and the Endocrinology Research Centre (ERC) were launched within the Russian Academy of Medical Sciences, Moscow. Within this, departmental subdivisions have been created focussing on each of the major complications of diabetes, with a specific department for diabetes education. Through these evidence based national guidelines and treatment algorithms have been produced and disseminated for the first time. A national register of patients with diabetes has been founded with the intention of accurately recording diabetes prevalence, incidence, disability, complications, mortality causes and rates, as well as provision of monitoring equipment.  Through the federal programme around: 150 diabetic foot units, 100 diabetic eye centres, 20 haemodialysis units and >1000 education centres have been designated as diabetes management units.  Data collected from 2003-2008 suggested an average decrease in measured HbA1c from 10.8 to 8.1 (HbA1c is a blood test measuring average blood sugar level over the past 3 months).

Steps for the future

Currently the National Diabetes Institute is pushing for greater diabetes screening and increased numbers of endocrinologists to allow more rapid referral. They are also arguing for an improved staffing ratio in rural areas to account for the distances involved.  Concerns regarding federal funding for insulin provision (independent of disability) and the continuation of the diabetes register (currently staffed by volunteers) are on-going. It is hoped that media campaigns will improve public awareness and data collected showing the cost-benefit ratio of close diabetes monitoring and so prevention of complications will build support for further improvements and thus put pressure on authorities regional and national to build upon the positive progress achieved over the past decade.

 

References

Novonordisk (2008) Diabetes in Russia: Problems and Solutions. [online] Available at: http://www.novonordisk.com/images/about_us/changing-diabetes/PDF/Leadership%20forum%20pdfs/Briefing%20Books/Russia%20II.pdf [Accessed: 22 Apr 2013].

Diabetes Voice (2013) 1 1 H e a l t h d e l i v e r y National and regional organization: the key to effective diabetes care in Moscow . [online] Available at: http://www.idf.org/sites/default/files/attachments/article_475_en.pdf [Accessed: 22 Apr 2013].

Young TK, Schraer CD, Shubnikoff EV, Szathmary EJ, Nikitin YP. Prevalence of diagnosed diabetes in circumpolar indigenous populations. Int J Epidemiol. 1992 Aug;21(4):730-6

Picture taken from: http://health.passion.ru/novosti-zdorovya/sobytiya/besplatnye-proverki-na-diabet-po-vsei-rossii.htm

Chronic Disease within Russia

How healthy is Russia?

As part of my masters coursework, I've been asked to write a weekly blog focussing on different aspects of non-communicable disease within Russia. Over the coming weeks I'll be considering diabetes, breathing disorders, heart disease, cancer, mental health and more!  Whilst it's only week two, it's been fascinating to see the different approaches, unique challenges and potential opportunites in providing heathcare to the largest country on earth.  

Any thoughts, comments and questions would be very very useful to me - either comment beneath, via facebook or email.  I'm eager to learn as much as I can from the project!

Looking backwards, looking forwards, looking east!

The year that was 2012 is slowly drawing to a close.  It's been a busy one.  I've been blessed with many opportunities to head east, visiting quite a few countries for the first time.  This has included: a parisian New Years celebration with old friends (plus oysters & cigars); navigating a crazy interrail route around Ukraine, Hungary, Poland, Austria and Germany (with a tour of Chernobyl powerplant enroute); enlightening medical teaching trips to Ukraine (twice); summer camps with teaching opportunities in Lithuania and Belarus; short stays in Latvia and Estonia; backpacking around Russia having chance to see St Petersburg, Moscow and Kursk (with fantastic guided tour); and giving a week long series of lectures as part of PRIME on 'Whole Person Medicine', 'Stigma in healthcare' and medical communication skills to medical students at the University of Cluj-Napoca, Transylvania (Romania).  I've been made incredibly welcome by those I've met and have some great new friends.  I'm always amazed at how despite different cultures, the gospel (aka good news and promises of Jesus) unites people all around the world.  I have been shown such love, kindness and patience by those I've met and often stayed with over the past year - I cannot be thankful enough!  It's also been the year where I've gone from medical newby panicking about taking bloods to scary SHO on-call, being given even scarier responsibilities.  I've had some really great wards, inspiring supervisors and a fantastically supportive and caring church family, who've helped me keep my perspectives in check.  Furthermore, by grace, Preston now has a Christian Medical Fellowship group.

2013 also looks to be another year of challenge and adventure, with potential trips to Czech rep, Austria, Ukraine and Romania on the horizon.  Latvia is another contender.  God willing, I'm hoping there may also be a trip/holiday to Russia in the pipeline (buh-dum-cha!).  This may even be the long awaited year when I embark on the Trans-Siberian railroad and finally reach Vladivostok, the 'Ruler of the East'.  If the pace of work continues, 2013 should additionally herald the completion of year one of the Global Health masters (PG cert - woop!) and also potentially the dreaded MRCP part 1 (medical speciality exam). Mega Слава Богу if I manage that one!

Most excitingly however... there is a likely change of scenery ahoy.  Whilst adminsitrative formalities are ongoing, I've accepted a clinical position in south-west Germany to start in September 2013 (black dot on map beneath).  I can envisage many opportunities and beneficial challenges in working there; I greatly look forward to embracing these!   

So, what have I learnt in 2012?

1. Trust in God; work hard; things happen.
2. Travel is easy, the mind provides barriers, flexible is key. (Haiku!)
3. Effective time management is never to be underestimated.
4. Necessity is the mother of invention.
5. I have the ability to teach.
6. Stereotypes are limitted in truth, isolation helps reenforce them.
7. Aspirations are not limitted to a particular culture.  Neither is self-interest.
8. The Russian language is an enigma slow to unravel.  The reward of doing so however is bountiful.
9. God is faithful, even when I am not.  Praise be purely to him.

Key
-  Yellow : Countries visited previously
- Orange: Countries visited this year
- . Red  .: Countries on the hit list for 2013
-  Green : Germany, planned new home
-  Black  : Location from Sept 2013

Corruption in healthcare

Corruption is a major problem in healthcare.

Corruption in healthcare is a major problem in the nations of the former soviet union.  There are many reasons for this, however none that are insurmountable.  My masters' tutorial group chose the topic of healthcare corruption for our presentation.  Your thoughts on the presentation are most welcome!

Corruption in healthcare

Corruption in Healthcare on Prezi

Why is there corruption?
No nation is immune to it, however some health systems are unfortunately afflicted by it more than others.  Ultimately it boils down to the problem of the human heart - putting perceived personal interests above those of others (and of God).  Christians we can be shining lights in this field, showing that corruption needn't be the only way.  Key in this is remembering:

•  Who we are:
• Romans 3:23 - all have sinned, all fall short of God's glory.

•  Personal accountability & integrity:
• Matthew 7:3-5 - pull the log out of our own eye before others

•  Jesus' sacrificial love:
• Matthew 22:37-39 - love the Lord your God with all your heart, soul, mind and strength, love your neighbour as yourself.

•  We are accountable:
• Luke 16:10-13 - God cares about how we live.
• “One who is faithful in a very little is also faithful in much, and one who is dishonest in a very little is also dishonest in much. If then you have not been faithful in the unrighteous wealth, who will entrust to you the true riches? And if you have not been faithful in that which is another's, who will give you that which is your own? No servant can serve two masters, for either he will hate the one and love the other, or he will be devoted to the one and despise the other. You cannot serve God and money.”