Admiral's suicide shakes Russia’s healthcare system

Admiral's suicide shakes Russia’s healthcare system
by Natalia Antonova, Anna Arutunyan
17 February 2014

Vyacheslav Apanasenko

The shocking suicide of a Navy admiral has prompted official investigations into the bureaucratic hurdles Russian cancer patients face when trying to obtain pain medication.

According to the experts, administrative problems, a lingering Soviet mentality and a misguided drug policy are to blame for continued lack of access to decent palliative care in Russia.

Rear Admiral Vyacheslav Apanasenko shot himself on February 6 in Moscow. He died on February 10, after spending several days in a coma. According to the Facebook page of Yekaterina Lokshina, Apanasenko’s daughter, the admiral was terminally ill with pancreatic cancer and had trouble gaining access to pain medication.

“My mother was trying to get him morphine vials (which his condition required),” Lokshina wrote. “To get a five days’ supply of vials, one has to spend many hours dashing between many doctors’ offices in the clinic, [even] spend a few days. By the day’s end, one signature was still required – and the clinic closed. My father was outraged. It was the last straw.”

Lokshina also provided the text of Apanasenko’s suicide note. “I ask that no one be held responsible, save from the Health Ministry and the government,” he wrote. “I am prepared to suffer, but watching the suffering of my loved ones is intolerable.”

New decree not being implemented?

Deputy Prime Minister Olga Golodets demanded last week that the Health Ministry launch an official investigation into how Apanasenko’s care was handled. Golodets also demanded that it analyze how a December 2012 ministry decree, which allows an individual district oncologist to prescribe pain medication to cancer patients without requiring any additional signatures or permissions, was being implemented throughout Russia.

Prior to the decree, aside from a prescription, a patient also needed multiple signatures, usually including that of the head doctor. The number of signatures varied depending on regional directives. But according to the experts, the December 2012 decree is not, in fact, being carried out due to general administrative chaos – which means that for terminally ill patients like Apanasenko, not much had changed after the decree was initially passed.

“Head doctors at hospitals and officials don’t transmit new regulations to their subordinates in a comprehensible way,” Yan Vlasov, chairman of the Public Council for the Protection of Patients’ Rights at the Federal Service for the Oversight of Healthcare, told The Moscow News. “This fluctuation of regulation, this lack of transparency about what you can and can’t do, it’s all created a situation where [doctors] are completely disoriented.”

Apanasenko’s suicide forced the government to admit that new rules on pain medication were not being adequately implemented, but officials are pointing fingers at each other when it comes to finding a systematic solution.

The war on drugs

A large part of the red tape is blamed on the Federal Drug Control Service.

“The Federal Drug Control Service (FSKN) is the ideologist behind this red tape. It’s supposed to fight drugs,” Alexei Starchenko, doctor and member of the board of directors at the League for the Protection of Patients, told The Moscow News. “But where is it easier to fight drugs? In the streets? Or in the clinics? Obviously it’s easier to intimidate people in clinics than in the streets.”

Health officials acknowledge the pressures coming from the FSKN. Anatoly Makhson, head oncologist at the Moscow Health Department, told government daily Rossiiskaya Gazeta that the war on drugs had really turned into a war on narcotic analgesics. Makhson also harshly criticized the restrictions placed on certain kinds of narcotic analgesics – such as transdermal analgesic patches – in Russia. “A drug addict needs a large dose in a short period of time to get high, while [the medicine] in the patches is absorbed over a period of three days,” he said. “But some wise guy decided that addicts can somehow find a way to get fentanyl [a narcotic] out of the patch.”

The FSKN, meanwhile, blames regional health officials for failing to ease access to pain medication. According to an official statement released by the FSKN in response to Apanasenko’s death, “[even though] there was a principal decision on the federal level [to simplify the process of obtaining pain medication], the relevant agencies on the regional level have still not reorganized the system to increase the availability of narcotic analgesics for the treatment of various kinds of pain.”

Bureaucracy, corruption blamed

According to Vasily, a Moscow oncologist who asked that his last name not be used for privacy reasons, Russian doctors deal with so much bureaucracy that providing adequate care is a challenge. “This will sound rude, but when it comes to [prescribing] pain medication, most doctors are forced to think more about covering their asses than they are about what is going on with the patient,” Vasily told The Moscow News. “They keep passing these decrees at the federal level, while at the local level, doctors still fear for their jobs.”

Russian doctors do have reason to fear for their jobs – and worse – when it comes to prescribing pain medication. In May 2013, Alevtina Khorinyak, a doctor in Krasnoyarsk, was found guilty of drug trafficking and forging paperwork for writing out a prescription to a cancer patient who was not officially in her care. The patient in question was in severe pain, but was denied medication at his own clinic allegedly because the clinic ran out of quotas for free prescriptions. Khorinyak said in court that she could not stand by and do nothing after being contacted for help by the suffering patient’s family. In September 2013, Khorinyak’s conviction was thrown out and her case returned for review. A new verdict is pending.

While Golodets has also called for the gathering of educational councils for oncologists so that they may better understand the new rules, it remains to be seen whether or not Apanasenko’s suicide will change the overall system. “It might get easier in the urban centers,” Vasily theorized. “In the country, where local healthcare is desperately trying to survive, less paperwork means less chances for a doctor to receive ‘gifts,’ if you know what I mean. Think about it, is there real incentive [to follow the new rules] for these doctors?”

Vasily’s views were echoed by Alexei Levinson, head of the department of socio-cultural research at the Levada Center. According to Levinson, Russian doctors have become “harsher and more self-interested” in recent years. Levinson believes that even though Russian healthcare is ostensibly free, that’s not the way things actually work on the ground. “Even if it’s officially free, in reality you have to pay for everything,” he said.

Lack of accountability a problem

A system of top-down management also contributes to a lack of accountability as far as patients in Russia are concerned.

According to Lidia Moniava, the manager of the children’s program at the Vera Fund, which specializes in supporting Russian hospices, lopsided notions of legal accountability are a particular problem in palliative care. “In Russia, doctors can be punished for a mistake on a prescription for pain meds,” Moniava said. “But they will not likely be punished if they don’t provide adequate pain medication to a dying patient.”

Soviet legacy and social inequality

Moniava also believes that Russian palliative care remains underdeveloped due to a Soviet medical legacy that made suffering and death taboo subjects both for the medical establishment and society at large. “For decades, people who were in pain, people who were listed as incurable, people with disabilities, they were basically hidden from view,” she said. “This is why society doesn’t emphasize with these people’s suffering – they simply don’t see it.”

In the Soviet Union, palliative medicine was not a priority, which is part of the reason why there is so little understanding of how it is supposed to work today, Moniava believes. “The truth is, the pain that cancer patients endure is unbearable – it strips them of their humanity,” she said. “But we are not open about this pain as a society; we’re simply not used to it.”

Different standards of care for privileged officials and the rest of society contribute to a climate in which the majority of Russia’s terminally ill patients must endure needless suffering, other experts believe. Specialized clinics and hospitals that cater to officials in particular may shield these officials from understanding what challenges ordinary patients face.

“We have two medical systems, the aristocratic one – for the Health Ministry, for prosecutors and judges – and the one for serfs, but [both] subsist on our [tax] money,” said Starchenko, of the League for the Protection of Patients. “Until a health official starts getting treated in the same hospital as an average person, nothing is going to change, even if you write a million decrees,” he added.

Grim statistics

For now, terminally ill patients continue to face an uphill battle in trying to receive adequate palliative care.

According to a recent editorial in Rossiiskaya Gazeta, “No other developed nation has such a profound problem with pain relief for the terminally and chronically ill as [Russia] does.” The editorial cites 2010 statistics by the International Committee on Drug Control, which place Russia in 38th place out of 42 in terms of the availability of narcotic analgesics in Europe. Only Albania, Moldova, Ukraine and Macedonia have lower availability rates than Russia.

Source: The Moscow News.