Larissa Fedorova walked up to a counter at Moscow Drugstore No. 139 and handed two prescriptions to the pharmacist, who just shook her head, " Nyet. "
"These prescriptions are for my mother who is very ill with cancer, and she needs one of these pain relievers," Fedorova said, her voice taking on an edge of anger and frustration. "I've been searching for a month. I can't count the number of pharmacies I've visited, and I've spent hours on the telephone calling other pharmacies. . . . My 80-year-old mother is in terrible pain."
Fedorova's complaint echoes across the Soviet Union as the country's economic crisis leaves the nation's pharmaceutical industry in disarray. Soviet patients are suffering more, healing more slowly and dying because they can't get the medicines they need.
Medicines for some serious illnesses--heart problems, cancer and psychological disorders--have long been in scarce supply; now they often cannot be found at all. Even the most basic drugs--simple pain relievers, laxatives, antiseptics and the like--have disappeared from most drugstores.
Surgeons have declined to operate because they run out of solutions for post-operative intravenous feeding. Diabetics go into shock because they cannot get their insulin prescriptions filled.
The old Soviet boast that the socialized medical system here meets at least the basic needs of all the people has been abandoned, even by top officials.
"As early as next February, the country may run out of drugs altogether, since the pharmaceutical industry is crumbling even more rapidly than the rest of the economy," Igor N. Denisov, the Soviet health minister, said recently.
Only 30% of the demand for drugs will be met next year, Denisov said, unless there are drastic changes in the production of pharmaceuticals. Already this year, supply is likely to meet only 75% of demand, compared to 80% to 90% in recent years.
Analgesics, hormonal drugs, cardiovascular medicines, decongestants, allergy medicines and antibiotics are now critically scarce, according to doctors.
An informal survey of six Moscow drugstores on the availability of 10 most-frequently used medicines--ranging from analgin, the favorite pain reliever here, to a popular digestive--turns up six medicines that can't be found in any of the stores. Three medicines--an anti-hypertension drug, nitroglycerin and a sulfa-based antibacterial--were found in half the stores, and one common antibiotic with ampicillin was found in two stores.
Even traditional Russian folk medicines such as the mustard plaster, which is used by almost everyone here to ward off coughs and colds, are increasingly unavailable.
The drug shortage is a virtual case study on the disintegration of the Soviet economy and why it is failing to meet the basic needs of consumers.
The old system under which the state planned, produced and distributed medicines--and virtually everything else--is collapsing through its own inefficiency and the economic reforms of President Mikhail S. Gorbachev. But the market forces of supply and demand that reformers hope will bring an economic revival have not yet begun to work.
Most of the equipment in pharmaceutical plants here has been allowed to wear out. Inadequate investment has left managers unable to repair old machinery, let alone modernize.
Now the disintegration has been magnified by an unintended effect of Gorbachev's glasnost : Grass-roots groups, which once would not have been tolerated, are protesting pollution--including the air and water contamination of chemical plants that supply the pharmaceutical industry.
In many cases, the chemical plants were located near urban centers, close to employees and the government units that owned and operated them. Amid protests from nearby residents, a number of chemical factories have been closed, unable to pay the cost of relocation or the purchase of pollution control equipment.
"Four or five Soviet chemical factories have been closed down in reaction to the demands of local people," said Vyacheslav M. Voronin, deputy chief of the Union of Pharmacies, the official organization that controls the purchase and distribution of drugs to the Soviet Union's pharmacies. "Since they were the main suppliers of raw materials for the pharmaceutical industry, closing them affected supplies and, probably, will keep affecting them in the future."
A factory in Yerevan, Armenia, that was the main producer of synthetic resins and a factory in Kirovograd, Ukraine, that was the sole producer of hydrochloric acid for pharmaceutical use are among those that have been closed. Environmentalist groups have prevented or postponed the opening of 37 other chemical factories, Voronin said.
This failure of the pharmaceutical industry to meet the country's needs led to a dramatic increase in drug imports in 1989 and this year--but the shortages keep growing. Until 1989, imports, mostly from Eastern Europe, made up about 25% of the drugs distributed in the Soviet Union. This year, imports make up close to half of the drugs on the market, with Eastern European countries accounting for a bit more than 40%.
But here again, Gorbachev's reforms have had an indirect impact. The new economic independence from Moscow enjoyed by its former East European satellite nations and the breakup of the Council for Mutual Economic Assistance, the Communist trading bloc known as Comecon, have left delivery commitments unfulfilled.
Many contracts between countries in Comecon fell apart when members decided earlier this year to make transactions payable in freely convertible currencies and to use the world market as a basis for setting prices. Traditionally, trade between Comecon countries was conducted in transferable rubles, an artificial currency, with prices for commodities rigidly controlled. Comecon producers, including those in the Soviet Union, are now shipping goods to buyers who can pay in foreign currency.
Analgin, for example, is now scarce because Bulgaria refused to send the amount it promised, Voronin said.
As part of its greater reliance on imports, the Soviet Union is turning more to Western sources; imports from the West now run close to 10% of drugs dispensed. But drugs imported from the West must be bought with scarce convertible currency.
As drugs disappear, people go to great lengths to get medicines. "A black market for medicines always existed, but now it has become huge," said Lena M. Vrono, a psychiatrist. "The frightening thing is they sell these drugs by the pill, so there is no way to guarantee their safety, especially if there is no name on the tablet."
Izvestia, the government newspaper, reported Wednesday that two young employees of Moscow's pharmacy association were caught outside a train station trying to sell 1,530 capsules of an Austrian drug at 45 times the state price. Had they not been detained by police, they could have earned the equivalent of more than $9,000 at official exchange rates.
More than $2 million worth of medicines were lost in 1988 and 1989 alone as a result of thefts by medical personnel, Izvestia said. Thefts by pharmacy workers, doctors and employees at medicine warehouses are common, the newspaper added.
Vrono, who treats suicidal teen-agers, complains that tranquilizers and antidepressants are unavailable and even the organic mood-altering drugs she prescribed in the past are nearly impossible to find.
"I'm supposed to treat depression, but we don't have any drugs to treat it any more," Vrono said in frustration. "I cannot point to a statistical increase of suicides as a result of the shortages, because no studies have been done, but I wouldn't doubt that there has been one."
Although the shortage of drugs is especially acute in pharmacies, hospitals are also suffering.
"Our drug supply was always poor in comparison with Europe or America, but at least we had something," said Pyotr V. Konchalovsky, a surgeon in a hospital on the outskirts of Moscow. "Now we have nothing. Patients refuse to leave the hospitals because they do not believe they will be able to buy what they need in the drugstores."
Konchalovsky said his work is most hampered by the lack of antibiotics.
"People take a long time to recover, and they recover poorly," he said. "Sometimes I can hardly bear to go to work because I know that I will have to tell the patients that I cannot give them what they need to get better."
Diabetics, patients with heart disease and others who must take medicine daily suffer the most because their prescriptions disappear from the drugstores and sometimes reappear only when it is too late.
"Diabetics are often brought into my ward in shock because there is no insulin in the drugstores--this is horrible," Konchalovsky said. "People die because of it."
Even the most capable surgeons are unable to do their jobs well because of the shortages. "There is such an acute shortage of solutions for intravenous feeding that surgeons sometimes refuse to do operations because they cannot feed the patient after the surgery," he added.
Konchalovsky's hospital does have an adequate supply of glucose for intravenous feeding, but only because it makes its own; however, glucose alone is not nutritious enough, and the drugs and other nutrients that should be used with it are not always available.
In emergency situations, doctors feed patients certain baby foods through a tube inserted through their mouths and into their stomachs.
The shortages are anguishing for medical professionals. "Today, the pharmacist's job is difficult psychologically," Tatyana A. Nivokova, director of Moscow Drugstore No. 166, said. "Turning away someone who is sick--saying, 'No, no, no' when we don't have the medicines they need--leaves us all with headaches at the end of the day."
Doctors say the shortages prove false the old claim that the Soviet Union's system of socialized medicine meets the people's needs.
"Maybe 30 or 40 years ago it was not a myth--the lowest person could get adequate care at a hospital or clinic," Konchalovsky said. "But now there is no way to say that the level of health care here is adequate."