Combined Paramedic and Public Health Nurse on Duty : Soviet Health Care Reaches the Isolated

Everybody in this Ukrainian farming village of 602 people knows that Natasha is keeping an eye on their health.

Yuri, the middle-aged tractor mechanic with a heart problem, is well aware that Natasha will be after him should he stop taking his high blood pressure medication. Gradually, she is convincing him that the pills will extend his life.

Only last month, Natasha discovered a lump in the breast of Anna, the wife of old Mikhail the barber. Anna had known for months that the lump was there. Natasha scolded her gently and sent her off to the cancer hospital in Kiev for further investigations.

Natasha is a feldsher, the Russian name for a health worker trained to prevent disease, treat minor medical emergencies and know when it’s time to call a doctor. The closest American counterpart would be a combined paramedic and public health nurse.

Nearly Half a Million

Although feldshers gradually are being replaced in rural areas by medical doctors, the people of Rogefka and tens of thousands of other villages across the Soviet Union make do with a feldsher as their initial point of entry to the nation’s health care system. Current statistics on the number of feldshers are not available, but a 1975 study estimated the number at 545,000.

The atmosphere of Natasha’s cleanly swept three-room post--cheery-looking even on a gray midwinter morning--is reminiscent of a rural American country doctor’s office of 60 years ago.

There is a freshly painted white medicine cabinet standing on the linoleum floor behind a desk. The cabinet contains bandages, a thermometer and a few simple instruments. A poster on the wall warns of the dangers of alcoholism.

Outside, near the front door, an old-fashioned iron-handled pump rises out of the snow, the post’s only source of running water.

But it is Natasha, wearing a white coat and a Russian medic’s high-domed cap, who dominates the scene.

Role Is Well Defined

Like the 1.3 million physicians and the more than 3 million mid-level health workers who staff the mammoth Soviet health system, Natasha’s role in her community is well defined.

“My chief task is preventive--to identify people who are at high risk of acquiring a serious disease--like heart or respiratory disease or babies who are not growing well,” she said in an interview.

Anyone injured or ill enough to require a doctor is sent to a nearby town or city, where he or she is cared for at a clinic or hospital.

Many Soviet doctors resist working in rural areas. Like colleagues in the United States, their preference often is to become specialists, which means studying and practicing in urban centers where the specialty hospitals and centers of learning are located.

In the cities both the strengths and weaknesses of the Soviet health system become apparent. If Anna, the woman with the breast lump discovered by Natasha, had lived in a city, the lump most likely would have been detected at a clinic serving residents of the neighborhood where she lives.

Still Make House Calls

The “polyclinic,” as it is known, is the basic unit of the Soviet health system. About 80% of all health care is delivered in polyclinics, which generally are located in or near apartment complexes and serve about 50,000 people each. Polyclinic doctors spend about half their time making house calls.

Children go to pediatric polyclinics. In addition to their neighborhood facility, adults also may attend one located at their place of work. Depending on the industry, the workplace clinic sometimes is better appointed and offers more elaborate services than the neighborhood one. This is because factory managers believe it worthwhile to spend the extra money in order to keep workers healthy and on the job.

In addition to going to the polyclinic, patients with chronic illnesses such as heart disease also may attend special clinics called dispensaries, which are staffed by specialists. Patients must pay for drugs that are prescribed at polyclinics, but the drugs are free when ordered for hospitalized patients or by dispensary doctors.

Places for Resting

Workers also have access to an unusual Soviet institution called a “prophylactorium,” a kind of sanitarium or rest center where for a modest cost they and their families may spend up to several weeks once a year undergoing a kind of rest cure. Residents are grouped according to chronic illness.

University students have their own polyclinics where they receive special attention directed at preventing disease and easing the stresses of studying.

No feature of the health system is regarded more highly by the Soviet people than the emergency system. It is one area where the Soviets have matched--or even outdone--the accomplishments of Western medicine.

Any citizen who feels the need can order an ambulance to his home by calling a central ambulance control center and explaining the problem to a trained person who takes the call. There is no charge to the patient.

Sent to the Home

A physician trained in cardiology, obstetrics, trauma or general medicine is dispatched together with a nurse or feldsher and a driver. The cardiologists carry with them portable electrocardiograms that can transmit heart beat patterns by telephone to a central station. Air ambulances are used in rural areas where the patient may live hundreds of miles from a hospital.

In Moscow, the central ambulance control center directs 7,000 ambulance runs every 24 hours at an annual cost of $75 million. As might be expected, a sizable proportion of the calls--about 30%--turn out to be medically unnecessary.

Nowhere is the careful planning that typifies the Soviet health system more apparent than in the way hospitals are organized. Hospital size ranges all the way from 10 or 15 beds for a basic rural hospital, where, for example, babies from surrounding villages are born, to 1,000-bed urban general hospitals where the most complex medical care and surgery take place.

Regardless of its size or function, each hospital within each of the nation’s 15 republics is a part of an integrated network under the Health Ministry. This means that, at least on paper, it is possible for each patient to flow through the system until the niche best suited for his needs is found.

Specialty Care

For example, patients with heart disease or cancer likely will be sent to one of the regional heart or cancer hospitals scattered across the country. Some of these specialty hospitals are still being built, staffed or fully equipped.

As yet, according to Dr. Yuri Balenkov, director of the All-Soviet Cardiology Research Institute, Soviet surgeons are able to perform only 10% of the 150,000 cardiac bypass operations that Balenkov estimates are needed annually.

“We have the structure in each of the 15 republics, but we need better organized cardiology care in each neighborhood,” Balenkov said. “We have only half the number of special cardiac clinics that we need, and we do not have enough cardiac care units.”

A similar shortage of resources exists on the cancer side--not enough facilities and trained personnel to do Pap smears on all women, for example.

Nevertheless, American doctors who have watched Soviet surgeons operate say the problem is not with the quality of the surgery, especially in the specialty hospitals, but with the chronic shortage of everything from cardiovascular drugs, antibiotics and monitoring equipment to oxygen and disposable needles.

Life-or-Death Matters

All these shortages, which a new government program is now trying to correct, not only add to public frustration but, along with other inadequacies, seriously affect whether patients live or die.

Partly because of the high infant mortality rate, authorities are attempting to give mothers and children a high priority in obtaining care.