Winter 1995 (3.4)
Health and Medical Care
by Betty Blair
Health care used to be fairly adequate in Azerbaijan under the Soviet regime. So much so that it's hard to believe the catastrophic collapse that has occurred these last few years since independence. Along with education and housing, health care used to receive the Soviet's highest priority. Everyone had access to it. And it was free. The government was the grand daddy of all insurance companies, picking up the tab for everybody.
Despite its serious flaws, mostly associated with centralized planning and control, the Soviet Health System must be given credit for its achievements. There were many fairly advanced medical facilities throughout Azerbaijan. Even villagers in remote mountain passes in the Caucausus had access to medically trained personnel. Medical education was given high priority and many professionals received training-proportionately more than in the West. Many specialized centers were built in Baku, alone-Oncology, Urology, Rheumatology, Resortology, Hematology, Ophthalmology, Diagnostic, and numerous others. Scattered across the countryside were "Therapeutic Centers," built against scenic backdrops of mountains or sea and located next to hot or sulfur springs, or unique natural resources such as the healing oil of Naftalan.
In the Soviet health system, considerable emphasis was placed on preventive medicine or what they called "prophylactic medicine". One of their greatest achievements was in eradicating infectious and contagious diseases-the same dragons that are starting to rear their ugly heads these days-tuberculosis, diphtheria, hepatitis, malaria, polio, anthrax, cholera, typhoid, tetanus and others.
Left: Newborn in Sumgayit Maternity Hospital. Summer 1995
Interdependence of the Soviet System
The medical system worked because the Central Government had deliberately established a network of relationships for pharmaceuticals, medical equipment and supplies that was totally interdependent. It stretched across that vast Soviet Empire, extending to the so-called Soviet satellites in Eastern Europe, especially Czechoslovakia, East Germany and Hungary.
No Republic was an entity to itself. None were self-sufficient. The same strategic policy was carried out in industry. A nut was manufactured in one Republic, a bolt in another. Cotton was produced in one region, but processed in another, often hundreds or even thousands of miles away. In other words, the entire system was based on interdependency and functioned as a whole. Health and medical care were no exceptions.
But with the collapse of the Soviet Union, these relationships and links, for the most part, were broken. And the Republics, which were left financially bankrupt, had no choice but to try to gather their wits about them and start to rebuild an infrastructure on their own. In Azerbaijan, two other factors clouded the horizon: the Armenian aggression in Karabakh that has been going on now for eight years (though a cease-fire seems to be holding). This conflict has left more than a million people homeless as refugees from Armenia and displaced persons within Azerbaijan try to find a new life for themselves. Resources, both human and financial have had to be diverted to deal with these problems.
Why Feature Health?
Our intention in this issue is to present some of the major concerns related to health in Azerbaijan these days. Virtually nothing is available in the West in English about this topic. We'd like to raise some questions, and hopefully generate some interest that will result in finding solutions to these critical, life-threatening problems.
Front cover of Molla Nasraddin, satiric magazine of the early 1900s deriding treatments that physicians give which are often worse than the origianl ailments.
In most parts of the world today, especially in developing countries, you'll find long lines of people waiting in front of hospitals and clinics. But in Azerbaijan, there are no long lines and if you step inside the hospitals and clinics, things are relatively quiet. There are few exceptions.
It's not that people aren't sick these days. In fact, the general condition of health has deteriorated considerably since independence. People have to deal with more stress with less money. One of the first casualties is a less nutritious diet.
But avoiding hospitals, in turn, further impacts health negatively in two major ways. With infectious diseases, the patient remains unknown and anonymous creating the possibility for the disease to spread further, and leaving medical officials totally helpless in understanding the prevalence of the disease in the community.
With chronic diseases, the patient's health is likely to deteriorate to such an extent that it may be too late to save him. If he does survive, it's likely to take longer to recover, and more medicine, which is not readily available, will be required which, in turn, further drains financial resources.
Ask anyone in Azerbaijan what they would do if they got sick. Their first reaction is an abrupt warning, "Don't!" But if they really did become ill, their first tendency would be to call a friend who was a medical professional. Hospitals are considered as the last resort. When Azerbaijanis go there, they don't expect to find medicine, and they don't expect to receive services unless they pay bribes to the medical staff. It's illegal but that's what is happening these days especially since doctors, themselves, can't live off the $10-$15 salaries that they receive each month.
One Azerbaijani observed, "We simply aren't protected anymore. Darwin was right, It's sheer survival of the fittest. We can die from a scratch if infection sets in." His comments seem exaggerated. They may not be.
Lack of Reliable Statistics
Typically, in introductory health-related articles, statistics are presented to give the reader a quantitative sense of the extent of the problem. We've deliberately avoided statistics here just as we did in our Environment issue (see August 94; 2:3). We're concerned about their reliability and fear many of them may be misleading. To maintain accurate statistics requires financial resources and there are no computers or copy machines to facilitate the task as medical records are usually written by hand.
As Dr. Jamil Aliyev, Director of Azerbaijan's Oncology Center, pointed out, "Don't look at our hospital admissions to understand the prevalence of cancer in our country (72). Hospital admissions are down. But cancer incidence has probably increased. Admissions are low simply because people can't afford to pay for the treatment."
Another cultural factor skews statistics related to hospitals. When someone is terminally or critically ill, it's not unusual for relatives to approach a doctor and ask to take their loved ones home to die. Their real concern is that no autopsy be carried out. It's unbearable for most Azerbaijanis to think of their loved ones being cut or mutilated in any way. The medical staff usually complies. Hospital statistics don't look as bad that way.
In Azerbaijan's health plan for the future, what is clearly missing is a workable strategy. Health officials talk about constructing a top rate hospital with top facilities and professionals which would be a "pay-for-service" center. Some of the extra money that would be earned from this facility would then filter to other hospitals-so they say.
It's interesting to see the oil industry at work these days tirelessly exploring every possibility for a feasible pipeline route to transport Azerbaijan's oil to the international market. The oil industry has a strategy. It's clear where they intend to go and how they plan to get there. But when it comes to medicine, no one seems to have a serious plan or strategy, especially in relationship to a comprehensive National Health Care Program.
Excuses are repeated over and over again like broken records-the war, the economy, the refugees. But those are all the more reasons why Azerbaijan has to have a plan. Without a vision, the medical care will continue to develop haphazardly, and not just a few people, but the majority of them will "fall through the cracks".
While Parliament debates whether or not to privatize the medical system, privatization has already "kicked in" at hospitals-unofficially, of course. Generally speaking, those who can pay, receive services. Those who can't, are out of luck.
Health is more than a personal question that can be solved on a personal level. The body of knowledge necessary for treatment is too vast; the preparation of pharmaceuticals and medical equipment and supplies, too complex. The question of trying to maintain good health and treating diseases extends across international borders. That means that politicians and government officials must get involved to solve the problem.
At the present, nearly all medicine, vaccines, and supplies that are being used in the Republic are donated via humanitarian relief. But international aid, no matter how generous it may be, or even could be, can never by viewed as anything other than auxiliary to a nation's medical system. Aid should never be perceived as a solution to the national health problem because it will never be sufficient. Even with these agencies' assistance, Baku is still not able to take care of its everyday problems, much less emergencies (see "The Crisis of Beta Thalassemia").
Just as the oil industry is working nonstop, in the same way, political officials must work for health just as tirelessly. It's equally as critical to the welfare of the nation.
One of the strengths of the cohesion of the Soviet system was that decisions were made in Moscow. Local entities in the Republics, for the most part, simply carried out orders. That's part of the dreadful legacy for the new Republics. Too many people are inexperienced in knowing how to plan and strategize. Too few have been trained to make and take responsibility for major decisions. The situation is further complicated when there is no money in hand. But there is no choice except for Azerbaijanis to take accountability aggressively for resolving their health problems. The Ministry of Health must initiate carefully thought-out plans. Ideas are what exhilarate and inspire people to act. The head must lead, not the extended palm.
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