Although Russia still has a relatively low number of confirmed corona cases, medics are bracing themselves for the worst, facing serious shortages of personal protective equipment and pressure on medical staff. Online newspaper Meduza asked medics in the whole country about their experiences. If the pandemic escalates, all the existing systemic problems in the Russian medical system will explode, conclude Pavel Merzlikin and Alexey Yablokov.
President Putin during his visit to Covid-19 hospital in Kommunarka near Moscow on March 24. Photo: Kremlin.ru
On March 25, Russian President Vladimir Putin gave a televised nationwide address on the coronavirus pandemic (since March 31th Moscow and many regions have been going into full lockdown which the president called just a 'non-working week', ed.). He explicitly recognized the contributions of Russian doctors, saying, 'you are now on the front lines of defense for our country. My heartfelt thanks to all of you for your self-sacrificing work.'
A week beforehand, Russia’s Health Ministry issued Order No. 198, titled 'On a temporary workflow for medical organizations to fulfill prevention and risk reduction measures against the spread of the new coronavirus infection COVID-19.' The order listed specific steps that both clinic directors and health directors at regional governments are expected to take as the pandemic escalates across Russia. Among other things, the Health Ministry expects medical facilities to be prepared for an influx of patients with acute respiratory symptoms and ready to test them immediately for the new coronavirus, all while protecting workers using personal protective equipment (PPE) and disposable laboratory equipment. The order suspends routine health examinations and tells clinical staff to look into the possibility of rescheduling pre-planned treatment, including inpatient treatment.
The day after the Health Ministry released its order, we asked medical professionals to contact us and describe what they actually see on the ground in Russia’s hospitals, from caseloads to supply levels. By March 31, we had received more than 500 responses from medical workers around the country, from Moscow and St. Petersburg to Udmurtia and Khabarovsk.
We then reached out to more than 30 of those sources using the contact information they provided. That group included doctors, among them infectious disease specialists, as well as other medical personnel such as nurses and technicians. The majority of these sources spoke to severe obstacles already facing the Russian healthcare system but requested anonymity out of concerns that they might be fired. Their names and titles are in Meduza’s possession, as are additional documents confirming their roles in the healthcare system. For example, most of the individuals quoted below provided copies of their professional identification records.
President Putin adresses the nation on the coronavirus for the first time on March 25. Photo: Kremlin.ru
'We are no China'
The most frequent complaint we received from medical staff was that their facilities were either running low on personal protective equipment or had run out of protective supplies altogether. Russia’s hospitals don’t have enough masks, gloves, or antiseptics to keep employees from getting infected and, in turn, infecting more patients. Kristina, a nurse from Yekaterinburg who asked for her name to be changed, told Meduza that her hospital’s leadership had ordered all employees to sew their own masks out of gauze or risk being fired. 'We’re no China. We don’t have anything here. That’s what my bosses are telling me,' Kristina added.
Most sources requested anonymity out of concern that they might be fired
Medical workers from Moscow, St. Petersburg, the Leningrad region, and other areas described similar shortages. Nurses and even doctors reported having to purchase masks out of pocket or sew them at home. 'We haven’t been given respirators. It was lucky that shortly before the pandemic, we had bought respirators on our own dime to protect ourselves from tuberculosis,' said Ivan, who works in a hospital in the Stavropol territory.
Special protective suits for doctors working with potential COVID-19 patients are also in short supply. Most of our sources said their hospitals simply don’t have any. 'We have the usual sterile coats and everyday masks. We only see the rest on TV. We don’t have anything that we should. On the local level, in individual hospitals, what happens is that the doctors just put on what they have,' explained Tatiana, a medical worker from the Tyumen region.
Some professionals working in hospitals that have confirmed COVID-19 cases said they do have protective suits and masks, but employees are still at risk because the equipment is low-quality. 'The masks aren’t flush to the face, and they don’t provide complete cover,' wrote Artyom, who works at a hospital in the Tula region.
Doctors also said their hospitals have been unable to buy new equipment due to tight budgets and a spike in prices for the scarce supplies they need. Lead doctors at hospitals have resorted to asking their staff to save masks by changing them less often than the typically prescribed two-hour cycle. Doctors usually have to disinfect their own masks as well. Some have had to wear each mask they can get for several days in a row.
Shortage of tests outside Moscow and St. Petersburg
Most doctors who contacted us from hospitals where COVID-19 cases have been confirmed said they and their staff take no additional protective measures unless a given patient has already tested positive. Staff examine patients who display fevers and other common symptoms of the new coronavirus wearing ordinary gauze masks, which have been shown to prevent viral infections at far lower rates than disposable masks.
The assumption that patients do not have COVID-19 unless their cases are confirmed is also putting other patients at risk. 'Only confirmed coronavirus cases are being treated in the infectious disease building. Patients who have viral pneumonia, atypical pneumonia, or acute respiratory viral infections but do not have any foreign travel in their medical histories typically stay in the therapeutic building [with non-COVID-19 patients] until a coronavirus infection is confirmed,' said Artyom from the Tula region.
Despite the risk of the doctor-patient and patient-patient contacts involved in that setup, it is rare for either the doctors or the patients involved to be isolated. 'Doctors and personnel aren’t tested unless there are symptoms,' said Dmitry, who works in a Moscow hospital (the chief doctor of Moscows main Covid-19 hospital tested positive on March 31th - ed.). However, many hospitals have begun measuring their workers’ temperatures as they enter and banning all visits from relatives, even to newborn babies.
Hospital employees say their workplaces have not taken extra precautions in part because they are already short-staffed and in part due to a shortage in express tests, which are not available at all in most hospitals outside Moscow and St. Petersburg. Tatiana from the Tyumen region said that doctors in her hospital can take swabs, but they have to send them into the regional capital, Tyumen, to be analyzed. 'They aren’t sent into the city right away, and when they are driven over, we don’t know how many days later they analyze the samples. We have to let our patients out of quarantine without any test results after the 14 days are up,' she explained.
President Putin with chief doctor of Moscows main Covid-19 hospital one week before the doctor tested positive on corona. Photo: Kremlin.ru.
Some medical workers who work directly with coronavirus tests have been able to test themselves. However, even they have had to grapple with supply shortages. Ivan (name changed), a biologist working in a Moscow laboratory, said he and his coworkers were notified last week that they would be processing coronavirus tests.
‘At first, as far as PPE goes, there were standard disposable surgical sets (cloth shoe covers, suits, hats, masks) and gloves. Those sets are entirely adequate if you’re looking for protection against typical biological materials. But they do not protect the neck, the eyes, or the lower legs. On short notice, our bosses got ahold of disposable overalls with hoods, glasses, and plastic face protection shields. So far, it’s been enough, but the organization itself is buying everything. Those expenses were not planned in our budget, and before long, we might be seeing a deficit in [financial] resources for purchasing equipment, disposable supplies, and so on,' Ivan said.
On top of the threat of supply shortages, about a third of the staff at Ivan’s workplace have taken leave without pay to avoid coming into contact with the potentially infectious samples coming into the lab, he said. Another third have agreed to work with the samples, and the other third has to handle all of the laboratory’s routine work. The biologists are now working at least 13 hours a day, including on weekends.
Routine care presents a challenge amid the pandemic, too. Many hospitals haven’t cut off non-coronavirus-related doctors’ visits, according to several doctors in a range of different regions. With medical workers trying to do their normal jobs while caring for COVID-19 patients, their overall workload has severely increased. One employee at a private dental clinic that is not in Moscow or St. Petersburg said his employer hasn’t just kept routine visits going; his team has started describing every case as ‘sharp pain' to keep patients in the clinic’s cycle. Another medical worker said his institution has only stopped physicals and other exams on paper, while in reality, there are 'lines of 80 – 90 people' outside the doctors’ offices.
In yet another side of the healthcare pipeline, several ambulance staffers told Meduza that calls have spiked in recent days. That influx has included a large number of calls triggered by the psychological effects of the COVID-19 epidemic: some callers have respiratory symptoms that do not require emergency care, while others have psychologically-induced coughs or psychic breakdowns. Patients who might previously have called a doctor or an urgent care facility are now immediately calling ambulances and asking for an express coronavirus test to be conducted on the spot at home. Trauma bay employees, meanwhile, have reported a drop in their workload as more and more people stay home, making them less susceptible to injury.
Some medics noted that their hospitals have not seen a serious uptick in traffic and have been doing fine as a result. Most believed this was the case because no part of Russia has yet reached the peak of its local coronavirus epidemic. One neurologist from Novokuznetsk, Dmitry (name changed), said that even though his hospital has cancelled all routine visits, its workload never decreased: 'There are a whole lot of calls, people panicking, and our ambulances are very, very busy,' he said.
Hospitals are seriously understaffed
Medical workers told Meduza that many nurses and hospital aides are now working 1.5 times or double their usual full-time hours. Doctors are being called back from vacation time or prohibited from taking days off. On top of those extra hours, many hospital staffers are seeing their facilities open new wings or buildings for future coronavirus patients without making any new hires to match. They expect even more pressure on their time and labor in the coming weeks.
Dmitry, the neurologist working in Novokuznetsk, emphasized in an interview that even before the COVID-19 pandemic, doctors were facing heavy workloads due to a shortage of mid-rank and junior staff. He said the May Decrees, a series of national policy goals issued by Vladimir Putin in 2018, are in part responsible for that shortage: the decrees protected salaries for hospital aides but not janitors, leading many facilities to lay off all of their aides only to rehire them as janitors. 'They do a large cluster of the work here. They won’t go into the hotbed [of the pandemic] and keep working, and they’ll be right not to. Our department is a unified mechanism. A doctor can do their nurse’s work, and the nurse can do their aide’s work. And that’s exactly what we’re going to do, but will that produce what we want to see — a smoothly operating mechanism that can cover our society like an umbrella? I doubt it. There’s a little aphorism going around nowadays: "What’s the difference between a war hero and a veteran? The veteran spends his time reminiscing sadly about the war hero and making toasts for him to rest in peace."’
'There’s a shortage of absolutely everything, from medications to equipment and all the way to personnel'
In most of the regions we surveyed, medical workers told us that hospitals are currently working to establish a reserve of doctors from various departments who can help infectious disease specialists, primary care doctors, and pulmonologists at the peak of the epidemic. Meanwhile, post-doctoral residents completing their training in Moscow’s hospitals wrote that they’ve been offered full-time jobs in their infectious disease departments as ICU anesthesiologists, pulmonologists, primary care doctors, and infectious disease specialists. Similar practices have been reported among medical students in New York. 'We had a meeting, and they said they’d be sending us off to work. They also hinted that if we say no, it’ll happen anyway, just without pay — as practice,' one Moscow medical resident said.
A number of medical staff emphasized to us that in some hospitals, the situation is so bad that when the COVID-19 pandemic reaches its peak, it will make 'no real difference' for seriously ill patients whether they seek hospitalization or stay home.
Overall, most doctors said that as the coronavirus pandemic escalates, all the existing fault lines in the Russian medical system will expand. 'We have to remember what’s happened to the medical system within the last few years (critics say reforms have made the Russian public healthcare system less accessible, especially for people in the regions - ed.). First of all, there’s been a drop in motivation, both materially and socially — people don’t like doctors, see. The feeling is that we’re responsible for anything and everything that goes wrong. Second of all, there’s a lack of trust in administrators. We’ve gotten used to solving every problem ourselves in most cases. We’ve gotten used to lies about our raises and our equipment purchases. Plus, there’s a shortage of absolutely everything, from medications to equipment and all the way to personnel,' concluded the neurologist, Dmitry, in an interview for Meduza.