Medicine shortages, doctors’ emigration, frontline assignments: how war hit Russian medicine

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The war and the subsequent sanctions dealt a heavy blow to Russian medicine as well: clinics faced an acute shortage of many drugs, especially expensive ones and those needed to treat serious illnesses; the best doctors left the country, while others were sent to the frontline areas and occupied territories.

The war and sanctions have hit Russian medicine in different ways, since Russia does not have a unified system of medical care: the polyclinic is completely separate from the hospital and is separately financed, there is a branching network of departmental institutions, the Emergency Ministry has its own clinics, and then there are separate hospitals of the Federal Medical and Biological Agency (FMBA) – a structure which is neither military, nor civilian; it can provide paid services and at the same time dispatch doctors to the front or the occupied territories. Because of this lack of unity, it is impossible to rely on statistical figures, but a certain idea can be formed from conversations with doctors and departmental staff, suppliers of medicines and medical devices (MDs).

Disruptions in supply of life-saving medicines

Although drugs and medical devices are not directly subject to sanctions, these markets are now going through shakes like an airplane in a turbulence zone. During the first shock after the start of the war, banks, container shipping, dual-use products (many of the “heavy” medical devices - external ventilators, spare parts and expensive electronics for radiotherapy and intensive care equipment) and insurance companies were hit by sanctions; that shock was a serious one.

By the summer, the situation stabilized. New payment schemes were set up, “corridors” for deliveries were found, and managers began to build up inventories. Stability was attained with the relative stabilization of the ruble exchange rate, although prices rose by 7-8% according to some estimates. However, one segment has completely sagged, and will not recover in the foreseeable future; it concerns those diseases which require the use of expensive (and very expensive) medicines and consumables. This segment has been suffering due to funding cuts and complicated logistics (supplies have been restored, but new schemes often fail). Due to underfunding, the market is shrinking, and it is not profitable for businesses to keep a warehouse of expensive medicines, which now sell worse, inside the country, it is better to sell a thousand packs of cheap aspirin over the same period.

For some types of disease, interruptions in medical supplies are very dangerous. For example, with drug therapy for cancer (which is often combined with surgery), it is very important that the patient receive all prescribed medication on time and in the correct dosage. If this does not happen, both the therapy and the surgery are wasted. For example, in many clinics there is a shortage of Pembrolizumab, which is used to treat lung cancer and the terrible tumor melanoma. It has to be injected every three weeks, and if there is no drug, there is no treatment. Ipilimumab, which is used to treat children over 12 years old and adults with inoperable and metastatic melanoma and might be the only chance for survival, had disappeared for a while. Later, deliveries resumed, but many patients missed the deadline and died. I am told the drug is now available again in many hospitals. Nivolumab is intended for a wider range of diseases - gastric, bladder, colorectal and lung cancers. The absence of the drug means more and more patient deaths.

Numerous problems with the therapy of orphaned diseases in children can also be observed. Interruptions in supplies of hormonal drugs have also been numerous. And often there is nothing to replace the medication with. It can be said that the availability of aspirin in pharmacies does not seem to be under threat. But children's Ibuprofen has simply disappeared in many places. Simple drugs, which are used to treat 70-80% of diseases, are and will be available, albeit for a higher price. But there are problems with more “complex” diseases.

Moscow doctors also speak about disruptions in the supply of Marcaine, a drug for spinal anesthesia. Hospital pharmacies have to buy not even analogues, but Russian predecessors of the French drug, which either do not work at all or work ineffectively. The situation is the same with other drugs, but it is especially noticeable in the case of anesthesia during surgery.

Problems have arisen not only with medicines, but also with medical products, which affects, for example, endoprosthetic replacement of large joints. Most Moscow hospitals still have consumables for joint replacement, but in Siberia many are no longer able to purchase first-line products, with excellent quality and an excellent reputation. Hospitals in Siberia, Primorye, and Central Russia are losing endoprostheses from American, Swiss, British, German and Italian manufacturers (Zimmer, DuPuy, Smith & Nephew, Mathys, Lima). Instead, doctors started using second- or event third-line prostheses made in China, Turkey and India. This is due to financial problems “in locales” and the fact that, given the irregular supplies, importers primarily focus on the high-capacity markets of Moscow and St. Petersburg. Moreover, a prosthesis is a multi-component device (stem, cup, head, liner). In conditions of scarcity, doctors began to mix components from different manufacturers.

Shoulder prostheses are now almost completely unavailable in Russia. They were used infrequently, and their use is even less frequent now, so suppliers no longer sell them to clinics. Over time, a prosthesis wears out and needs to be replaced, and in such cases revision endoprostheses are needed. But in fact Russian clinics don’t have them anymore.

Starting next year, endoprosthetic replacement of knee joints will be removed from free health care plans in many regions; it accounts for almost half of all endoprosthetic replacements. Thus, state clinics will no longer be able to replace joints.

This year, all major manufacturers have already raised prices for medical devices and drugs by 10-15% once or twice (seeing as the world has not yet fully recovered from the post-covid economic depression). Starting with January 1, prices will rise by another 10-15%. So, for the end consumer in Russia, the price of imported medicines and medical devices will increase by 35-40% in 2023 compared to 2022, excluding the difference in exchange rates.

The above examples do not only apply to orthopedics but also to spine surgery, heart and vascular surgery, intensive care and so on, whenever expensive imported materials are required.

All in all, the main thing that happened with the outbreak of war was that a severe financial deficit was added to logistical problems.

Moving abroad

The other day it was announced at one of the official meetings that nearly 100,000 IT-specialists had left Russia since the beginning of the war. There is no official data on medical doctors, but the number is obviously lower, because a surgeon, in contrast to a computer technology specialist, cannot take his workplace with him; having a diploma and specialization acknowledged in most Western countries is a long and complicated procedure. It is not even one percent, but a fraction of a percent, of those who have left the country. One group consists of young specialists from big cities, who are just starting their professional careers and have time to have their diploma recognized. The second group consists of established doctors, opinion leaders. People behind whom are not only patients, but also students, forming a “school.”

Ilya Fomintsev, founder of the School of Oncology Patient Care and Oncologists’ Training, left for Israel. Sergey Morozov, radiation diagnostician, professor, former chief specialist of the Moscow Health Department, left for Europe. Norair Zakharyan, former head of the orthopedics department of Moscow City Clinical Hospital No 31, the best traumatologist and orthopedist of Moscow in 2019 according to the city Department of Health, left for Armenia. Oleg Udovichenko, a leading specialist in the treatment of “diabetic foot” patients, left for Kazakhstan. One of the most promising young traumatologists of Russia, Anton Semenisty, author of many articles published in international journals, a sought-after lecturer abroad, left for Europe.

So far, health care is being adequately provided - there are well-skilled replacements. But in the long term there will be a problem of continuity and training of young doctors. Once familiar and the most effective opportunities for postgraduate training are going away - Europe has become inaccessible. And not only Europe - any trip to an international conference requires a lot more money. And in the end, it is patients who will suffer.

Missions to the frontline zone

With the onset of the war, Russian doctors have been dispatched to the frontline zone to help the wounded, and not all such missions are voluntary, and not only doctors from military hospitals are being sent to the occupied territories. As a rule, military doctors treat at their workplaces those wounded, who have already been triaged and selected for transfer to the “center”. This explains the low lethality rate reported by military medical officials: according to witnesses, the wounded are dying in civilian hospitals near the frontline zone in the Rostov region, Krasnodar krai, Crimea and Belarus. Only those heavily wounded who have good “prospects” for survival reach military hospitals.

Usually, doctors from civilian hospitals are dispatched to the frontline on a voluntary basis. For example, Moscow’s Botkin Hospital’s head doctor sets a kind of an “assignment”: each ward has to dispatch a certain number of doctors to the frontline. In this case, it’s up to the doctors to decide who will go. A doctor earns about 200,000 rubles for a two-week stint at the front. All payments are made through the hospital’s accounting and cash departments. There is no shortage of people willing to go.

As for FMBA doctors, they are essentially required to go to the front. As already mentioned, the FMBA is a peculiar institution. The doctors there face the choice: either go on a business trip (with relatively small pay) or get fired and possibly prosecuted. Those who did not want to participate in principle, had to emigrate.

As for the mobilization, doctors have actually managed to evade it: some have moved abroad, some simply stay away from enlistment offices (and nothing happens to them), some have formally enrolled in postgraduate training courses while staying on their main job (and nothing happens to them either). There is no certainty that the authorities will continue letting doctors off the hook so easily in the future in case of new waves of mobilization. For the time being, the demand for medics is covered by those temporarily dispatched to the front and those working in civilian hospitals located within the frontline zone, in Belarus and the occupied territories.

Andrey Volna is an orthopedic traumatologist, an honorary representative of Russia at the International Traumatology Orthopedic Training Foundation, Chairman of the Board of the AO Trauma Russia 2002-2013 community.