The Pharmaceutical Journal Vol 265 No 7112 p339-340
September 2, 2000 Articles

A return ticket to Siberia

By Pamela Mason

Imagine a general medical practice moving over 12,000 miles in six weeks. Travelling just three-and-a-half thousand of those miles in a period of eight days, I am one of 175 patients in that practice as we journey by private steam-hauled train from St Petersburg, Russia, into Siberia.

Our general practitioner, employed by the travel company especially for the duration of the trip, is Dr Valentina Banfilova. Not a general medical practitioner, but a gastroenterologist, Dr Banfilova works, for most of the year, in a Moscow polyclinic. Polyclinics, rather than cosy domestic surgeries, are the places where primary care normally takes place in Russia. A bit like small district general hospitals without inpatients, polyclinics employ general medical physicians and paediatricians, who have responsibilities for adults and children in geographical sectors of the community or at places of work. But about half the doctors in polyclinics are - like Dr Banfilova - specialists, and since patients have direct access to these specialists, general physicians are often bypassed altogether. This emphasis on specialists, self referral and an absence of "first port of call" general practitioners developed as part of the Soviet health system. However, in line with several other countries, the Russian health ministry has developed a strategy of moving away from the specialist-led system, and general practitioners or "family doctors" as they are known in Russia, started to exist in 1994. But how quickly GPs will spread is anyone's guess. Unlike doctors in many countries, Dr Banfilova is not financially well off. Her salary of $30 a month is much lower than the average wage in Russia, and her one-off payment of around $200 as a doctor on the train makes quite a difference. Under communism, medicine was a poor relation of physics, engineering and other "scientific" subjects. The scientific model reigned supreme, and this was, and is, reflected in an enthusiasm for medical technology at the expense of the more psychosomatic issues. Doctors in Russia are still used to directing their patients. Now near to retirement age, Dr Banfilova has been trained in this model, and although she can see the problems with it, she is not convinced that things will change quickly. A member of the communist youth movement in her younger days, she has happy memories of summer camps and bridge building in the Ural mountains, so she is no stranger to travelling on the Trans-Siberian railway. The longest direct-service railway in the world, it crosses forest, steppe and desert, not to mention two continents and eight time zones, on its way from Moscow to the pacific coast at Vladivistok. It is a real lesson in human geography - which flying ill affords - watching landscapes, architecture and people changing slowly as we move from Europe into Asia. Even if one silver birch does look much like another!

Dr Valentina Banfilova: travelling physician

Climate

Everyone thinks Siberia is cold. My mother was no exception, as I well remember from my childhood when she used to shout at me for leaving the back door of our house open in the winter, saying "it's like Siberia out there." Yes, Siberia can be cold - very cold - but not all of the time. Indeed, with recorded temperatures as high as 150F (65C) and lows of –97.8F (–72C), Siberia has the world's largest difference between summer and winter temperatures. Travelling in an air conditioned train with outside temperatures ranging from about 20C to 39C, we are quite fortunate.
It makes one wonder how people survive such extremes, particularly in the light of the fact that some of our own elderly population suffer from hypothermia in conditions which are much more moderate. Recently, researchers from London and Moscow looked at how people's protective measures against exposure to cold change as temperatures fall in the winter months in the Yakutsk region of Siberia.¹ They wanted to find out how effectively measures adopted in the extreme cold of Siberia helped to protect people from death in winter.
Not surprisingly, they found that people in Siberia wore very warm clothing in winter - often up to four layers - with thick coats, often of fur, replacing anoraks. Even at temperatures of –20C and below many people spend a considerable amount of time outside, either walking to work or waiting for public transport. Although overall death rates from cardiovascular diseases in Russia are about two-and-a-half times ours in the UK, the researchers found that mortality from such causes did not increase in the winter as it does in the UK. Mortality from heart disease appeared to be unaffected by the fall in temperature at least down to –20C. This, they concluded, has lessons for us in that high winter mortality in the UK could be prevented by people wearing sufficient clothing and adequately heating their houses.

Health crisis

Not that health in Siberia is all good news; far from it. Indeed the health crisis facing the whole of Russia is now well known. After a period of improvement following the second world war, life expectancy began to lag behind that in Western Europe in the 1960s. An improvement in the mid-1980s coincided with a national campaign to reduce alcohol consumption, but this was reversed and life expectancy fell from 70 years in 1989 to 64 in 1995. The reasons for this are poorly understood, but poverty is often assumed to be the cause. The abrupt change in socioeconomic conditions with high rates of job turnover, increase in crime and heavy alcohol consumption all undoubtedly help to account for the reduction in life expectancy.
However, a study in 1998 showed that the regions of European Russia that seem to have suffered most in terms of reduced life expectancy are those which in 1990 had a higher than average household income.² A possible explanation given by the authors is that regions of high income are characterised by features that reduce life expectancy. In Russia, high salaries were often used to compensate for hard manual work or for harsh climatic conditions. In Siberia, where development relied on mining, heavy industry and intensive agriculture in an extreme climate, the monthly household income in 1990 was 10 per cent higher than in European Russia. Moreover, in Siberia, higher salaries were paid to encourage population resettlement to a region where few people would have chosen to go.
However, the abrupt changes of recent years have resulted in Siberia becoming relatively disadvantaged. By the mid 1990s, morbidity and mortality data for Siberia - at least for people of working age - were looking worse than the average for Russia.³

Medicines

This is not helped by shortages of medicines - at least in the public sector. In the Soviet era, all medicines used to be free, but since 1990 the range of medicines available in Russia has grown enormously, with drugs imported from the US and European countries, but of course, the state cannot afford to pay for all of these. The Ministry of Health has now developed an essential list of drugs for Russia, and all are available free of charge on prescription. However, not all prescribed drugs are available all of the time, and patients often have to buy or pay the difference for substitutes.
Moreover, one can go to a pharmacy in Russia and buy most prescription medicines with the exception of sedatives and tranquillisers, and also opiate analgesics, which are available mainly in hospitals. A new medicines act, which came into force in September 1998, should eventually help to regulate supply of medicine, but this will not be achieved in a hurry.
Russia has one pharmacy outlet for every 2,500 people (compared with one per 4,500 in the UK), but with a population density of only 22.8 per square mile, thousands of Russians, particularly in Siberia, do not have a pharmacy on the doorstep. The population in Siberia is concentrated along the trans-Siberian corridor, and most of them - at least that is how it seems - are travelling along it on the train every day.

Stations

A stop at a station is quite a social occasion, and for those spending several days on the train, an opportunity for some much needed exercise. On the platforms elderly women run private enterprises from buckets and tables, selling pirozhki (sausage rolls), blini (pancakes), buns, cakes, fried fish, roast chicken and, at least in the summer, strawberries in abundance. Then there are the newly privatised kiosks with their well stocked shelves of fruit juice, cola, chocolate, and the inevitable vodka. At £1 a bottle the latter is a bargain. Main railway stations also have a health care room, where primary care, but not emergency care, can be obtained. Financed by the ministry of railways, these facilities have long been a feature of the trans-Siberian and are intended for the use of train travellers only. The medical care is usually provided by a feldsher - a well qualified nurse - or occasionally by a doctor. Almost every station has a pharmacy, usually in the form of a kiosk, with medication on display with a price. Sometimes medicines are in boxes, sometimes they are displayed in strips. Prices seem to vary enormously, but at one station, the cost of a course of antibiotics at eight roubles is about the same as three bread rolls and a cup of tea. A 2g tube of Zovirax cream costs 90 roubles, 28 nifedipine 10mg is 16 roubles, 30 indomethacin 25mg is 90 roubles and 12 Solpadeine eight roubles.

Almost every station has a pharmacy, usually in the form of a kiosk, like this one at Tayshet

Ailments

Quite often I see Dr Banfilova replenishing her stocks of medication for the ongoing journey. On the train she keeps her medicines in a suitcase - a fairly basic range of antibiotics, antiseptic creams, antihistamine tablets and eye drops, to reflect what she was able to obtain from the polyclinic in Moscow and what from her previous experience on these trips has taught her she would need. She also has a machine to measure blood pressure, and, surprisingly, she also carries a bottle of ammonia to use in an emergency for anyone who faints. But the main ailments on a trip like this are sprained ankles from falling over the railway tracks, red eyes from leaning out of the carriage window too near to the smoke of the steam engine and insect bites. Yes, the mosquitos are there to greet you at every stop.
Dr Banfilova is particularly worried about tick borne encephalitis, of which there is an epidemic in Russia this year, due partly to a mild winter and partly to a reduction in use of agricultural chemicals. She is anxious that when we leave the train out in the countryside we should do so with our heads, arms and legs well covered. Tick borne encephalitis is caused by a virus transmitted to humans by infected ticks, and in endemic areas such as the densely forested areas of Siberia up to 5 per cent of ticks are infected. After an incubation period of seven to 14 days, symptoms of 'flu with fever, headache and vomiting develop. Then after a symptom free interval of one to three weeks, up to 10 per cent of patients develop a meningo-encephalitis. This may last a few months and patients recover spontaneously. However there is a 1-2 per cent risk of permanent neurological damage and death. A vaccine is available and is recommended for anyone spending prolonged periods in the forested areas of central Europe and Asia.
Donning a well laundered white coat every day, Dr Banfilova seems to be pretty busy with her practice of 175 patients. I suspect many people appreciated the ability to visit a doctor without an appointment, even if they did have to walk the length of 10 train carriages to see her. True, she did not have ready access to all modern medical facilities - during some of the journey she would have had to call a helicopter to get someone to the nearest emergency care and she may have trained in a medical model that is now outdated in the west - but she had a wonderful sense of humour and enormous dignity. Although self-care is now quite rightly encouraged in the west, I think many people on the train enjoyed the now rare experience of having their ankle bandaged by a doctor and a consultation which could continue as long they wanted.

Pamela Mason is a pharmacist and freelance writer from South London

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