Setting the Stage

Plodding along with packing up my life in Baltimore. Packing and throwing things away, hauling your belonging to the curb in hopes someone will walk off with it so that you don't have to jam it into your car and take it to the dump....scheduling contractors, their schedules running over...we've all been there before. Drudgery, but it must be done. Otherwise, how would we get from here to there?

I did make it to the Embassy of Kazakhstan twice last week to drop off my visa paperwork and then pick up my visa. Too bad the consular section is this small basement area with its own separate entrance. I would have loved to see the embassy proper, it was quite gorgeous (if somewhat imposing) from the outside.

What is really on my mind is a background paper I read about the state of the health care infrastructure in the former Soviet countries. This paper was done in 1999 at the advent of the ZdravPlus project to set the stage for the reforms needed and the potential strategies that could be used. While I had had some idea of the system from my travels, studies, and discussions with those who had used the health care system, this paper discussed everything: how doctors become doctors, pharmacology, epidemiology, research, levels of care, etc.

The two things that really leapt out at me were the structure of the system and the lack of formal epidemiological training as we know it. [Oh, and there was a third: There was no private sector for pharmaceuticals. Try to wrap your brain around that last one, if you can. I kept thinking about the Big Pharma industry here, the billions spent on R&D and now advertising, and then tried to imagine a world where it was all state sponsored. Go ahead. Try it. My brain almost exploded trying to wrap itself around this idea of a world with no Big Pharma.]

Back to the system. In urban areas, it's not unusual for there to be 30 hospitals in one city. This wasn't done so that there would be ready access to everyone who needed care. It's because there was a tremendous focus on specialization under Soviet times. So you have one structure that's oncology only. Another that's cardiology only. Then a maternal center for ob/gyn. And another for peds. And yet another for "dermavenerology", where skin and STIs are treated. Then there are testing centers with lab and x-ray and other diagnostic equipment.

I don't think it takes an economist to see that there are massive costs associated with building separate facilities for everything. Your initial costs are tremendous. And the costs to the public, having to go to separate centers for all of their care, are enormous. Go to one place to have your hypertension treated, go to another for your foot fungus. Primary health care? Considered a "flunky" specialty. Historically, the poorest student went into PHC. And given the existing structure of the system, all they do is refer.

In rural areas they did weave in many types of care into one or two facilities. The problem in rural areas is that there are few people manning those posts, with insufficient training to treat many common problems. So they would get referrals to the cities.

I'll get to the state of epidemiological research in that region another time. This is the thing that really interests me, so I'll devote a whole post to it.