Sunday Report : A Prescription for Tragedy : Much-needed medical aid to Russia is mired in bureaucracy before it is burned.

The dump at Ulyanovsk, with its population of stray dogs and crows and its shacks for the homeless, is a surreal locale for the final chapter in a frustrating tale of how some American doctors tried to help some Russian doctors.

In a pit at the dump, customs officials recently burned a load of precious aid that Oklahoma City doctors had sent to Russia--desperately needed medical instruments and supplies worth up to $800,000. People who could have been saved will die as a result.

A small group of local officials formally witnessed the shipment going up in flames.

It was a long, difficult journey from the first good intention to the match that destroyed the hopes of Ulyanovsk cardiac surgeon Alexander N. Maltsev, who had waited almost two years for the medicine and equipment.

The shipment left Oklahoma City in mid-1997 and traveled via Los Angeles, Mexico and Ireland to arrive in Ulyanovsk, 435 miles east of Moscow, in early 1998. It sat in customs for 18 months while Maltsev worked to cut red tape. One of the reasons that customs officials finally gave for burning the valuable cargo? The “use by” dates on medicines had expired.

Customs authorities even sent Maltsev a bill to cover the cost of storing and burning the goods and a fine for failing to clear the shipment within two months.

“It’s just appalling. To dump it just doesn’t make sense to me. I don’t understand it,” said Dr. Tad Cassidy, chief of angiography and interventional radiology at Integris Baptist Medical Center in Oklahoma City, one of the doctors who organized and sent the aid. The shipment consisted of medicine and devices that are difficult to find in Russia, such as single-use sterile catheters for heart surgery and other lifesaving operations.

Exhausted by all the regulations, many Russians give up, but others seem energized by the challenge and find a way to get things done anyway. Maltsev is the second kind.

“The worst thing was that the Americans tried to do everything they could to try to help us, and we, getting it all for free, destroyed it as if we didn’t need it, or as if they’d sent us something harmful,” said Maltsev, Sasha to his American friends. “I’m deeply ashamed.”

Pattern Repeated Across Russia

This story sounds like a unique case of bureaucratic madness, but it is not. In the Ulyanovsk region, aid sent to an orphanage, a psychiatric hospital, a hospice for dying patients and a school either was destroyed, sent back or will be burned. International aid organizations based in Moscow describe a similar pattern across Russia.

The customs service, with its ever-changing regulations and its corrupt officials, poses enormous obstacles for anyone trying to do business in Russia. Companies can pay a bribe to make their customs problems disappear, but charities, trying to bring in aid, don’t have a budget for bribes.

Russian officials are suspicious of nongovernmental organizations--partly because some notorious Russian “charities’ have been used as fronts for tax dodgers and gangsters--and are loath to admit that their once-mighty country needs a handout.

Vladimir T. Chaya, deputy governor of the communist administration in Ulyanovsk, said the aid wasn’t needed and “offends our human dignity in this region. We don’t have a population in rags. We don’t have paupers.”

Questions about the burning of medical necessities appeared to make him angry.

“The noble Americans extended their hands in help, and we barbarians didn’t understand what it was. Well, maybe someone is interested in sending us humanitarian aid to put us in a difficult position so we have to destroy it and we look like savages with rings in our noses,” he said, pacing the carpet in his large office overlooking the town’s Lenin Square and the Volga River.

To fully absorb the tragedy, one must understand how the hospital system works in places like Ulyanovsk. People who need lifesaving operations that would be routine in the U.S. must find thousands of rubles to actually buy the instruments used in the operations. And few can pay.

“They say, ‘But doctor, where do I get the money?’ And how do I answer that?” Maltsev said. One of his patients, who had a brain aneurysm, was trying to raise the $1,300 he needed for surgical equipment. It took time. Before he got the money, he died of a massive stroke.

“Their medical system is a good 50 years behind ours,” said the Oklahoma hospital’s Cassidy, who visited Maltsev’s hospital in the fall of 1992. “They don’t even have adequate antibiotics. When I went there, they had their rubber gloves drying on the clothesline. The way they sterilized things was to boil them in water.”

While Maltsev was being interviewed, a call came from the hospital chief. Maltsev spent several minutes explaining that his team couldn’t do an operation because it had only 30 ampuls of a particular drug and needed 40.

Later in the day, Rosa Guryanova, 45, was in the operating theater waiting for Maltsev to clear a blocked digestive tract, having paid $330 for a balloon catheter. But doctors had already used and resterilized the single-use catheter several times--and during the preparations for her surgery, the balloon ruptured, so she had to go home without her operation.

Maltsev and Cassidy first met early in 1992 when the Russian spent time in Oklahoma City. Cassidy and a group of doctors from St. Luke’s Methodist Church in Oklahoma City made up their minds to help Maltsev’s hospital. In 1993 they sent six tons of aid, which went through Russian customs without a hitch.

But in March 1996 the customs regulations got tougher.

In May 1997 Cassidy, Dr. Lauranne Harris from St. Luke’s and others put together a load of medical aid, including some items donated by medical companies and some free company samples, worth about $800,000.

Harris found someone to truck it free to the local airport, where Southwest Airlines flew it free to Los Angeles. The shipment was taken to Long Beach Airport, where it spent several months waiting in a hangar until Volga Dnepr Airlines could collect it. Then it was flown via Mexico to Shannon Airport in Ireland, where it waited several more months. The aid arrived in Ulyanovsk early last year.

The Americans went to great lengths to try to meet customs requirements. There were thousands of items, and the weight and value of each piece was documented. But it wasn’t enough. Three times Maltsev had to go to customs to count every piece of equipment, a process that took eight to 10 hours.

“They didn’t have the documentation. That’s all there was to it,” local customs officer Victor N. Logachev said of the case.

Maltsev said he couldn’t bear to see the sort of equipment that lay almost within his grasp. “They were instruments that are so difficult to get here,” he said, “and for lack of them we can’t help our patients.

“To us, the aid was priceless. It was absolute riches. It was as if you were holding something in your hands which you dreamed of all your life and then at once it was taken from you. I was ready to kill those customs officials.”

Maltsev said most “use by” dates on the medicine were still good when the shipment arrived.

Customs Regulations Toughened in 1996

Customs officials claimed that Maltsev “didn’t show enough interest” in the load--because they had once called him only to find he was in Germany. In fact, Maltsev was taking a course there to improve his surgical skills, paid for with $3,000 from the Oklahoma City doctors.

One of the patients whose life could have been saved by the donated equipment is a 29-year-old man who suffered his first heart attack a year ago. The artery leading to his heart is now almost completely blocked. He doesn’t have much time left.

But Logachev, the customs official, makes no apologies for the destruction of the aid.

“My opinion is, you want to do something that requires customs clearance, you should know the rules of the game,” he said. “There are rules and we can’t get around it and that’s that.”

He conceded, however, that not one shipment of humanitarian aid has passed through Ulyanovsk customs without problems since the rules became more complex in 1996--including added requirements that significantly increased the documentation involved.

“Now we await every humanitarian shipment with horror, expecting we’ll have to destroy it,” said Logachev, whose office is decked out with new furniture and computer equipment. “Sometimes we deal with someone from a church, half-illiterate, who says, ‘Look, it’s free, and no one has to pay for it and our children need it.’ And we find it almost impossible to explain.”

About 62 miles west of Ulyanovsk, in the town of Barysh, is the Regional Psychiatric Hospital No. 1. A German correspondent, Bettina Sengling of Stern magazine, visited early this year and wrote about the conditions. There were no mattresses, so patients slept on the floor. Many patients were extremely thin, and some of the female patients were naked. There was only one warm room.

The article inspired a German charity, Maltese Hilfsdienst, to offer to renovate the entire institution. The charity even called the institution to check what color paint officials wanted on the walls. Details of the shipment were worked out. The Germans sent 70 beds and mattresses, nine showers, one industrial washing machine, four stoves, enough linoleum to cover all floors, chairs, 358 boxes of secondhand clothing, a wheelchair, paint, new toilets and a large cash donation.

Sengling believes her story angered powerful officials in Ulyanovsk’s regional administration. Apparently something frightened the hospital management. By the time the goods arrived, hospital officials no longer wanted them. Little or no effort was made to clear them through customs. In a phone interview, hospital director Boris T. Chikushkin admitted he didn’t bother to go to customs to see the aid.

“We didn’t ask for any humanitarian aid. Our patients have everything they need. They never complain for lack of anything. So we didn’t even look at what was in those boxes sitting in customs,” he said. “Whatever it was, our patients didn’t need it.”

The load was sent back, the transport cost charged to the donors.

Customs regulations make it so difficult--and expensive--to steer aid through customs that many organizations cannot afford to do so. Items like toys, soaps, detergents and electrical equipment have to be certified as safe for use in Russia by a regional standards committee--and these safety reports are expensive.

But the problem is not just a quirk of Ulyanovsk’s communist administration.

“It’s happened since the [August 1998 financial] crisis. People have been moved to go out and collect and send things,” said Moscow-based Jenny Hodgson of the British group Charities Aid Foundation. “People send things over which promptly get destroyed.”

Muscovite Valentina Kholodova wanted to dedicate her life to charity--but was defeated by customs officials. Hers was a small operation, the Foundation of Christian Charity and Education, which distributed clothes and medicine sent by a German group to the needy in Moscow.

Her charity has almost ceased to function. “It was a great pity,” she said. “And there was only one reason, and that was customs.”

Kholodova found that she was spending most of her time going from one government department to another, trying to get the required documents, pleading with bureaucrats and paying them for their services. If she couldn’t clear the goods within two months, she was fined.

“Toward the end of our activities [about a year ago] there were very great problems with everything, including clothes,” she said. “The biggest problem was receiving medicine. I tried everything. It was extremely difficult.”

In Moscow, the aid group Doctors Without Borders has also endured exhausting bureaucratic battles. “It’s absolutely impossible to bring medicines in,” director Mamar Merzouk said. “Now we are very careful about sending any material to Russia. They’re always very suspicious of humanitarian organizations.”

He cited the case of a British doctor who called him for help when customs blocked medicine to treat homeless people at railway stations. “But we could do nothing,” he said. “He either had to turn back or customs would destroy it.”

In Ulyanovsk, regional prosecutor Valery M. Machinsky was asked to investigate whether customs erred in burning the U.S. hospital aid. He found that they merely followed the regulations. But in his heart, he knows something is terribly wrong with the system.

“My private view--not as a prosecutor--is that this may be intended to show the world that we don’t need anything, that we have everything. And that is wrong. There was a time when we were a powerful and strong state, but now we are not, and many people need help.

“And why should we deny it to them because of feelings of false pride?” he said. “If people want to help, why should we stop them from doing it?”

Cassidy has an additional $100,000 in medical equipment sitting in his closet ready to send to his friend Sasha Maltsev. He knows the efforts of the doctors of Oklahoma City are helping only a tiny slice of the Russian population. But it seemed worthwhile--until he heard that the aid had been burned. Now he wonders if the effort is futile.

Despite all the difficulties, the Oklahoma City doctors haven’t given up on Maltsev, said Harris from St. Luke’s. “When there are people like him, there’s hope for Russia,” she said. “And it makes me feel good that he’s still trying. We’re going to keep on trying too. We’re not giving up.”

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Sergei L. Loiko in Moscow contributed to this report.