Amputation of common sense

Ilya Nikiforov, a soldier with the Russian 15th Brigade, has been hospitalized in numerous locations, from Belgorod to Moscow, after his leg was amputated. He is currently undergoing treatment at a hospital in Samara.

— I've just arrived back at my home unit, where I'm stationed. I lost my leg at Svatovo-Kremennaya. During the offensive from July 4th to 5th, — says Ilya"They haven't fitted me with a prosthesis yet, I haven't applied yet. I'm waiting, checking prices, but as far as I know, as military personnel, everything is covered by the Ministry of Defense. We don't spend any money. Prosthetists are already here, checking things out, and they'll take measurements and impressions later."

The Ministry of Defense provides prosthetics to all military personnel free of charge at its own expense. However, there is a catch. The price varies by region, and the quality of the prosthetics varies greatly. A wounded soldier typically receives a prosthesis and rehabilitation before undergoing a military medical examination, which determines their fitness for service. Afterward, they are discharged from the military, and the medical and social expert commission (MSE) at their place of registration makes the final determination of their disability level. The Ministry of Defense has a separate procurement platform for the initial prosthesis after injury. After the examination, the former soldier, like everyone else, is transferred to the SFR (Social Fund of Russia). 

The foundation provides people with disabilities with technical rehabilitation aids. You can find out the cost of any prosthesis, from a hand to a hip, at calculator.

Meanwhile, anyone in need has three options for acquiring a prosthesis: wait for the results of the Ministry of Defense auction, purchase it themselves and receive compensation, or use an electronic certificate with a monetary amount equivalent to the price of the prosthesis in each specific region. However, the price is so volatile that amputees from different regions of Russia receive prostheses that differ significantly in price. The infamous Federal Law No. 44 is to blame for this: under it, the manufacturer with the lowest bid wins the auction. It's like with Russian roads: the lower the bid for repairs or construction, the greater the chance of pocketing budget funds. Quality is out of the question here.

For example, item #08-07-09, "modular shin prosthesis, including for underdevelopment," cost 213,968.99 rubles for a Muscovite as of September 12th, according to the calculator on the SFR website. For a Khabarovsk resident, it was 74,902 rubles, and for a Tuva resident, it was 47,279.14 rubles. Residents of the Chukotka Autonomous Okrug were the luckiest, with a modular shin prosthesis there costing 628,311.31 rubles. In addition to the lowest auction bid, the price of the item at the most recently held auction also plays a role. For example, if a manufacturer in the Republic of Bashkortostan "won" with a price of 55,000 rubles for a modular shin prosthesis, then the starting price for participants in the next auction will be exactly 55,000.

In St. Petersburg, a similar product is half the price of a Moscow one — 129,398.96 rubles. In the Far East and Transbaikalia, the cheapest “shin” will cost in the Irkutsk region — 53,660.78 rubles. The most expensive is in Chukotka — more than 630 thousand rubles. In Siberia, residents of the Krasnoyarsk region are lucky — 298,963.33 rubles. Yakutia and Buryatia — 263,250 rubles and 245,247.6 rubles, respectively. But the state will provide a prosthesis to disabled people in Khakassia for 63,315.13 rubles, in the Omsk region for 70,565.93 rubles, in the Novosibirsk region — 86,674.08 rubles, in Kalmykia — 107,037. ₽.

The Urals region has an incredibly wide price range. For example, an amputee in the Sverdlovsk region will receive a lower leg for 83,365 rubles, while those in the Perm region will receive a lower leg for 418,549 rubles. In neighboring Bashkortostan, the same prosthesis will cost 55,000 rubles.

The same story is happening in the regions bordering Ukraine, where drones and missiles have been flying for a year and a half now. Affordable modular lower leg prostheses will be supplied to the Bryansk region at 98,195.1 rubles, the Rostov region at 54,968.58 rubles, and the Belgorod region at 113,100 rubles. A more market-appropriate price is listed for the Krasnodar region at 338,247.31 rubles, and the Kursk region at 290,365.83 rubles.

According to Ivan Khudyakov, director of the Moscow-based SalutOrto Prosthetics Center, the market price of a modular lower leg prosthesis depends on the individual doctor's and prosthetist's instructions, as well as the selected components. Generally, the price ranges from 150,000 rubles to 1 million rubles, and for the most advanced microprocessor-based prosthesis, the price rises to 2,5 million rubles. Khudyakov also notes that the Ministry of Defense, for example, manufactures lower leg prostheses in the most complete configurations, ranging from 500,000 to 900,000 rubles.

"To make a prosthesis for 54 rubles, you'll pay nothing but taxes, you won't even be able to find quality materials or pay the craftsman's wages. 54 rubles wouldn't even be enough to make a prosthesis out of a bottle for a pirate! There have been cases where, for example, Nizhny Novgorod, a well-off region, announced a tender for a prosthesis, and the Vladimir Prosthetic Factory won. People from Nizhny Novgorod were forced to travel to Vladimir. The first time, Vladimir residents came to get their measurements taken, and then they had to travel to another region themselves for fittings with craftsmen," says Mikhail Yashin, director of the Regional Public Organization "Society of Disabled Veterans of the Afghan War 'Moscow House of a Soldier's Heart,'" who lost his leg at age 19 after being wounded in the Afghan War.

According to him, the war today has simply exposed the problem of prosthetics.

"We have veterans of the Central Military District now, but what about veterans of the Afghan War? What about veterans of the Great Patriotic War? Veterans of the Caucasian Wars? Other local wars? Putin just spoke out and said we need to focus on rehabilitation, and suddenly all our COVID specialists became rehabilitation and post-traumatic stress disorder specialists. Veterans of the Afghan and Chechen wars are upset about the attention the Central Military District is giving them, all the benefits, the 'combat veteran' status—they're still fighting there, but they already have veteran status," says Mikhail Yashin. "There wasn't this kind of attention given to those who served in the Afghan and Chechen wars."

Yashin recalled that in 1905, after the Russo-Japanese War, a modern, so-called Semashko prosthesis was manufactured in Russia, which was used almost until the end of the 20th century.  

"But when I first got a prosthesis in 1985, that same 1905-model prosthesis was still being issued to veterans of the Great Patriotic War. Eighty-five years passed, the First and Second World Wars had passed, and only the Afghan War revealed the problem. We Afghans began to make a fuss about it. During the withdrawal of troops from Afghanistan in February 1989, the first thing the First Secretary of the Komsomol said was that the first 400 guys from Afghanistan would be sent to Czechoslovakia to get prosthetics."

The problem isn't just the cost of prosthetics. The Ministry of Defense doesn't have the right to discharge a wounded soldier until they are provided with technical rehabilitation equipment. Waiting for these resources can often take months, especially in the last year and a half, when the number of combat injuries has increased. Moreover, those undergoing amputation are young men who are expected to lead active lives after being discharged from the hospital. This means that a "wooden leg" is unlikely to be suitable for them.

The patient will receive a future leg or arm in the form of a modern prosthesis after his activity level has been determined.

Ivan Khudyakov, head of SalutOrto, who has been involved in prosthetics since 2018, cites three main problems that became more acute after February 24, when the industry, 90% dependent on foreign components, faced sanctions.

"Most prosthetic manufacturers don't have the resources to quickly ramp up production. We can't increase production tenfold in a week. We need to create conditions for increasing production capacity. For example, purchasing equipment with public funds. The equipment itself may be state-owned, but we, the manufacturers, should be able to use it on preferential terms. We can't compete with the military-industrial complex or mechanical engineering. For those who have the equipment, it's more profitable to produce parts for the aviation or automotive industries than for prosthetic manufacturing. The second problem is price: how much does a hip prosthesis cost in Moscow and Buryatia, Ufa, Khabarovsk, or Yakutia? For example, in Bashkortostan, a very large region with a population of 4,5 million, the price of prostheses is very low, even though a lot of it goes to the military-industrial complex. Prices are holding back the industry's development," Ivan Khudyakov shares. "The third issue is delays in compensation payments." For example, someone took out a loan to pay for a prosthesis, say, 400,000 rubles. By law, compensation should be provided within 60 days, and according to the latest law, it's 30 days. Meanwhile, Russians wait six months or more for payment. We have cases where someone received a prosthesis at the end of March, and it's already September, and they still haven't received compensation. This isn't the case in all regions. It's not the case in Irkutsk, for example, but it is the case in the Moscow region.

Over the past eighteen months, Ivan Khudyakov's company has produced 500 prosthetics, 12% of which have gone to war veterans in Ukraine. Sixty of them have been recipients, most of them young men between the ages of 25 and 40 with severe leg wounds. The wounded primarily receive their prosthetics while in military hospitals in the capital. After receiving their prosthetics, they are sent home to their respective regions.

There are three ways to obtain a prosthesis in Russia: first, submit an application to the Federal Service for the Protection of the Armed Forces or to the Ministry of Defense and wait for an auction; second, install the prosthesis yourself and receive compensation from the Federal Service for the Protection of the Armed Forces; third, use an electronic certificate, although the monetary value will be the same as that determined in the region based on the auction results. Over 50% of cases are obtained through the first option. With the second option, sometimes disabled people change their place of residence to receive a more expensive prosthesis for free. This requires registration in the region and a waiting period of about six months.

Supporters are helping to address the lack of government funding for prosthetics for those fighting in Ukraine. They're raising money. For example, Sergeant Sergei Tanygin of the 42nd Guards Motorized Rifle Division received prosthetics from the Ministry of Defense and from his fellow soldiers, who raised money for a prosthetic foot through volunteers. The prosthesis was manufactured by Ivan Khudyakov's company.

Sergei Tanygin, a 42-year-old resident of the Rostov region who served in the army for 18 years, was planning to retire a year before the war, but authorities were dragging their feet on the paperwork. As of February 24, 2022, he was still listed as a sniper in a sniper company. He fought in Chechnya, Georgia, and Syria. After friends started arriving from Ukraine with cargo shipments of 300 and 200 tons, he extended his contract for a year. His superiors were delighted and sent him to train as a tank operator.

"They told me you'd be training to be a tank crewman or an MT-LB. I said, 'What?' I'm not a tanker, not a technician. How can you send me to training? Well, that's the order they gave me. Crews are urgently needed, there's a lot of equipment left, and there's no one to operate it. It doesn't matter if you're a sniper, a paratrooper, or an artilleryman. They were taking you there for training... so I left the equipment and went into the assault aircraft—we had a dangerous line of work where equipment wasn't used," the soldier recalls.

Tanygin arrived at his base in Maryinka near Donetsk on May 22 and fought for a relatively short time. Until August 3, when a "petal" tore off his right foot.

"I stepped on a petal. They dropped them on us, we had one safe path we always used, then they spotted us. They have a lot of quadcopters and drones flying over their side, they're reading all the information, counting them, and dropping them. It's hard to tell, there's constant shelling, artillery, shooting, mortars. They're scattered depending on the terrain: green in the summer, yellow in the fall, brown ones like grass, so you can't see them. I was the first one to walk, the first one to find one. I stepped on one, and it immediately tore my foot off. I was conscious when it tore off, and I crawled a little off the path to the side. I'm crawling, thinking, 'No, I shouldn't go into the grass, there are definitely plenty of them there, I can still catch them with my hand,' and I started crawling back to the road, when my partner grabbed me and started pulling me out. I looked at my leg, it was gone. The guys quickly ran over and bandaged it—two tourniquets, promedol." The evacuation began: they pulled me through rubble, through minefields, little by little, it took me four hours from the moment of the explosion to the operating table.

After the operation in Makeyevka, Donetsk, there was a military hospital in Rostov-on-Don and then Moscow, where he waited 7,5 months for his prosthesis.

As Ivan Khudyakov explained, two months after an amputation, prosthetics can be applied—the sooner the better—but most of those wounded in the war wait in line at military auctions.

"I was as blind as a bat when it came to prosthetics, I knew nothing. I didn't do any research, didn't search anything online, I just asked the guys who were in hospitals, and how things were with prosthetics. They told me, 'Don't worry, the Ministry of Defense is doing everything,' but all the time—I was in hospital for a total of 7,5 months. The wound healed until October. And then I was constantly waiting in line, since we don't have our own materials and components from abroad, which are also scarce, they order in specific batches. Let's say they recruited 100 people, ordered them, they get prosthetics, recruited another 100 people and ordered another batch of components. While I was in hospital, some fellow soldiers came by and offered, 'Let's make you a prosthesis—we'll give you one ourselves,'" the soldier recounts. "I told them, 'Guys, I'll get one from the Ministry of Defense.' They said, 'Yeah, they'll give you a regular wooden one. We'll find the funds for as many as you need.' I agreed." They made me such a good hydraulic foot, for walking, for rest.

By March 2023, Sergei already had two prostheses: one from SalutOrtho and the other, a German-made Ottobock, funded by the Ministry of Defense. He doesn't know exactly how much he spent on them, but about 800 rubles from a private company and about 500 from the military department, which only actively supplies prostheses to three or four companies.

Ivan Khudyakov, Director of SalutOrto, notes the industry's continued high dependence on high-tech components imported from abroad, including Germany, Iceland, France, Japan, and the United States. Some components have been replaced with Chinese ones over the past eighteen months, but they are of very low quality.

"We've been actively working on import substitution since 2019, when there was no talk of SVO. A year and a half ago, dependence on imported components in prosthetics was 90%; today, in my expert opinion, it's 70%—we're talking about high-tech and functional products like feet and knee joints."

Currently, one of the Ministry of Defense's main partners in providing Russian troops with prosthetic arms and legs is the German prosthetic manufacturer Ottobock. The state, which sends its men to Ukrainian soil to fight the "collective West," still cannot replace these men's severed arms and legs without Western technology.

_{Cover photo courtesy of Ivan Khudyakov.}