They died
The New Year's tragedy in Novokuznetsk is a symptom of the system
Author: Tatyana Rybakova
The deaths of nine infants at a Novokuznetsk maternity hospital, which shocked the country, became a national news story: the Investigative Committee opened criminal cases, and the hospital's chief physician and the head of the intensive care unit were detained and later released under house arrest. However, cynical as it may sound, it wasn't the deaths of the newborns themselves that prompted the media coverage and, most importantly, the government's response, but their sheer number. Moreover, had it not occurred during the New Year holidays, when news coverage was thin, this incident might have remained a local emergency. Because the situation at the Novokuznetsk maternity hospital is typical for the entire Russian healthcare system, and especially for maternity hospitals.
New Year's tragedy
So, during the New Year holidays, nine babies died in Novokuznetsk Maternity Hospital No. 1: four girls and five boys. Another eight children, according to Ministry of Health Kemerovo Oblast, are in serious condition. The first death, as the press discovered, occurred on January 4, and on January 8, three infants died at once. The last child died on January 10. However, the first publication – in a local publication, – news of the mass death of newborns at the maternity hospital only emerged on January 12, when work began. The maternity hospital was officially closed due to the coronavirus quarantine, but a source at the facility told reporters that the real reason was either high infant mortality or a staff shortage, and the maternity hospital was being inspected by the local Rospotrebnadzor and the Ministry of Health. The following day, the newspaper found outthat six babies died in the maternity hospital. Later, as information became more precise, and federal authorities became involved in the story The media, the death toll increased and the scale of the disaster became apparent.
However, even today, much remains unclear. Before his arrest, the hospital's temporarily suspended chief physician, Vitaly Kheraskov, managed to tell RT that no common cause for the infants' deaths at the maternity hospital had been identified, and that the infants themselves were mostly severely ill—with pathologies and premature—as Maternity Hospital No. 1 receives such newborns from across the region. The regional Ministry of Health also supported the chief physician's version: officials asserted that all the deceased infants had intrauterine infections, and one of them had primary immunodeficiency. However, after the initial publication, a flood of messages from former maternity hospital patients and their families began appearing on social media, attesting to the tragedy's predictability. Citizens spoke about the shortage of mid-level medical personnel—nurses were working in their place—about the low qualifications of doctors who, despite the purchase of new equipment, continued to use the old one, about the rudeness of the staff, about the dirt and poor condition of the maternity hospital building, etc. It turned out that shortly before the tragedy, medical personnel, including the head doctor, had left en masse I had an acute respiratory viral infection — however, maternity hospital staff insist that the sick people had no contact with the babies and did not approach the incubators in the intensive care unit.
Was the Kuzbass tragedy an accident, or was it the fault of the staff? I won't speculate, but my hope that the investigation and trial will establish the truth is slim: we've become accustomed to results depending not on facts, but on whether the system needs scapegoats. However, one cannot help but agree with obstetrician-gynecologist and medical doctor Renat Kurbanismailov, who told a Kuzbass newspaper: "This is a catastrophic situation not just for one maternity hospital, but for all of Russia." And I'm not talking just about the obstetrics system, although maternity hospitals have been the epicenter of this catastrophe since Soviet times, where the healthcare system's problems are most acutely evident. I'm convinced of this both by my own experience and by the stories of the specialists I interviewed.
Either altruists or weak professionals
"This incident in the maternity hospital is outrageous. Maternity hospitals always have stricter aseptic conditions, medical examinations, and organ monitoring, and the staff is far more responsible than in other hospitals," says Maria, who worked as a nurse during her training, including in the maternity hospital's intensive care unit. According to her, even a single fatal case is treated as an emergency and thoroughly investigated. "Even when several cases of conjunctivitis were recorded in children after discharge from a single maternity hospital, it was recorded and threatened with serious investigation," she recalls. At the same time, Maria notes that maternity hospitals always have more altruistic doctors and nurses than regular hospitals. "Perhaps it's due to consumables and/or a shortage of nursing staff. That's where hospital-acquired infections come from," she speculates.
Maria's talk of altruism is not without reason. She worked as a nurse in public hospitals while studying at university from 2000 to 2004, in pediatric surgery and at a maternity hospital, specifically in the neonatal intensive care unit. She planned to become a neonatologist-resuscitator. Ultimately, she went into private medicine, into cosmetology. Why? "Because the state of healthcare at the time was such that the people who remained in public institutions were either altruists or those who weren't professionally qualified to work in private medicine," says Maria. The main reason, she says, was the humiliating salaries, difficult work schedule, and working conditions. "For example, you're given one pair of size XL gloves per shift. One for every procedure during the shift. But in private practice, you have an unlimited supply and in your size," the former nurse explains.
The situation improved later, but now it seems to be going backwards, says Maria. “I recently spoke with a classmate. She’s been working for many years at the regional children’s hospital as the head of the neurology department. It’s a very difficult department. She’s an altruist. Now, she’s the only doctor in the department. No one who comes stays long,” she says. And this situation, according to Maria, isn’t limited to the provinces. “In St. Petersburg, in 2022, you only had to see an ophthalmologist at a state clinic (for the military department medical examination). The next appointment was in a month. Because the same ophthalmologist works at several clinics. This also indicates that even the fancy new state clinic in St. Petersburg doesn’t attract specialists. Most likely, the reason is low salaries,” Maria concludes.
Maria's words are supported by statistics. The latest data available is for 2023, but it appears that real wages, adjusted for inflation, have clearly not increased. According to the data RosstatGeneral practitioners in Russia earned between 70 and 90 rubles a month. For specialist doctors in hospitals, Rostrud offers a salary range of 80-120 rubles depending on specialization. Nurses, according to Ministry of Health, earn 40-60 thousand rubles. There are no official figures for nurses, but All-Russian People's Front Reported salaries of 30-40 rubles. The doctors interviewed said these figures are generally accurate, but can vary greatly from region to region and often depend on the head physician of the medical facility.
"In poorer regions, doctors' salaries can be much lower—I know doctors in Kabardino-Balkaria who earn 30 rubles. Furthermore, the head physician prepares the final payroll—it's believed they know which specialists perform best. However, in reality, at our clinic, for example, the head physician rewarded favorites, while ignoring the 'overly smart' ones with bonuses and putting them on inconvenient schedules," says Dmitry, who worked as a nurse in hospitals during his medical studies, and later as a therapist and general practitioner.
That's not what they teach
According to Dmitry, the tragedy at the Novokuznetsk maternity hospital happened during the New Year holidays for a reason. "You probably know the rule: don't go to the hospital before the holidays. Not only are there fewer staff available during the holidays, but they also tend to assign people the management doesn't value. These are either those 'super-smart' ones—in which case you're lucky—but more often, they're those who, to put it mildly, aren't particularly good specialists. And if we're talking about junior staff, they're often the kind of people I wouldn't allow anywhere near a medical facility," says Dmitry.
Novokuznetsk residents who visited the maternity hospital also reported poorly qualified and rude staff. They said that during holidays and evenings, babies were "squeezed out"—a practice no longer used in Europe. The staff wanted the birth to be over quickly and rested.
However, the rudeness and low qualifications of doctors are widely discussed. According to Dmitry, the healthcare system itself contributes to this in many ways. “In our country, the percentage of specialist doctors is higher than in Europe, but there is a huge shortage of general practitioners. No one wants to stay here: there is no prestige, the work is brutal, salaries are low, and there is no opportunity to earn extra money. What do you expect from a doctor if the clinic hands out appointments at 15-minute intervals? An old woman comes to see me—and they are the main visitors to clinics—she needs five minutes just to undress. The old people answer slowly, confused. Then another five minutes to get dressed. And in those 15 minutes, you not only have to interview and examine the patient—you also have to fill out a form in great detail. In reality, almost all this time you are frantically typing on the computer keyboard, half-listening to what the patient is saying. It’s good to have a couple of minutes left for the examination: to look down the throat, listen for wheezing. Or take the patient’s blood pressure. “Everyone is next,” says Dmitry.
According to the OECD and the Ministry of Health, Russia is indeed experiencing a shortage of general practitioners: 45-55 per 100 people, or 10-12% of the entire medical corps. Meanwhile, EC 85-95 general practitioners per 100 thousand population or approximately 33% of the entire medical corps, and in USA – 115-125 per 100 and 30-45%, respectively. Meanwhile, specialized physicians in Russia account for 380-390 per 100 of the population, or 75-80%, while in the EU it's 240-260 per 100, or 60%, and in the US it's 190-210 per 100, or 65% of the physician corps.
Dmitry is currently preparing to obtain his medical license in a European country and knows the reason for this imbalance firsthand. "The system is completely different in Europe—here, the majority of visits begin and end with the general practitioner. Here, it's not someone who hasn't completed specialist training, but a general practitioner—and accordingly, the requirements and status are the same. And the knowledge, of course. With my many years of practice in some of the best medical institutions, I now have to spend all night poring over materials like a fourth-year student," he says. In Russia, the general practitioner has been turned into a dispatcher, merely regulating the flow of patients: who should be referred to a specialist, who should be hospitalized, and who should simply be sent home. "That's because in Russia, they still operate under the system built by Semashko. But he built it when there was widespread illiteracy, unsanitary conditions, and widespread infections! And in modern society, focusing on specialized medical care is like hammering nails with a microscope: expensive and ineffective," Dmitry believes.
Many Russian expats also notice differences in healthcare systems. Incidentally, they don't always like them. For example, in Europe, people don't go to the doctor with a cold, much less have one come to their home. House calls are practically nonexistent: if something's bothering you, go to a clinic; if the condition is acute, go to an emergency center. You can only call an ambulance if you can't be transported; otherwise, you risk being fined for making an unjustified call. Fever? Drink chamomile tea—a universal remedy among European doctors. Temperature above 38,5–39°C? Take paracetamol or ibuprofen. Even with COVID, it was recommended to seek medical attention only if breathing worsens or other dangerous symptoms appear. As for children, a cold isn't considered a reason to refuse to go to kindergarten or school: throughout the cold season, children have runny noses and coughs, and no one, including their parents, is bothered. It's believed that this is how the immune system trains. Minor issues—heartburn, for example, or a feeling of heaviness in the right side—are often resolved with private medical treatment, or more accurately, an ultrasound. An ultrasound technician can not only operate the equipment but also determine whether a visit to a specialist for a thorough examination is necessary, or whether adjusting your diet and taking simple digestive aids is sufficient.
As I've already mentioned, people from Russia aren't always happy with this system. I'm sure all visitors to expat chats can recall the panicked posts of parents whose children's ambulances refused to attend their children with a fever of 39 degrees Celsius, suggesting they try home remedies. And everyone—from Israel to Germany, from Serbia to the UK—complain about long waits to see a specialist and queues at clinics or even hospital emergency rooms. But they acknowledge that if something truly serious has happened, everything will be treated very quickly, very well, and without a queue. This is precisely how modern medicine works: leaving citizens to cope with common illnesses on their own, while persistently and responsibly treating chronic conditions, it really comes into its own in unusual and emergency situations.
Sister! Sister!
This cry is common in Russian hospitals. And it often goes unanswered for a long time. It was not for nothing that they said of the Novokuznetsk maternity hospital that the duties of nurses were performed by orderlies. According to Rosstat and the Ministry of Health, the ratio of mid-level medical personnel in Russia is 805 per 100 people, compared to 920 in the EU and 1240 in the US.
In the US, doctors often delegate their authority to nurses—incidentally, nurses here often have higher education. In Europe, nurses also perform far more functions: they report to the doctor on the patient's behavior and condition, take the patient to examinations (and perform some of them themselves), and communicate with families. Yes, there is a shortage of nursing staff there too: this problem is especially acute in Eastern Europe, where nurses and orderlies (here they also have medical education) are actively leaving to work in more developed EU countries. However, I recall my own hospital experience and the experiences of my relatives in hospitals in Serbia—from the capital's clinical center to a small provincial hospital. There were far more nurses everywhere than in Russia, but fewer doctors.
But nurses are still quitting. In the last five years alone, the number of mid-level medical personnel in Russia has fallen from 851 per 100 people to its current level. And this figure includes private medical institutions. Meanwhile, according to the Ministry of Health, the public healthcare system currently faces a nursing shortage of 63,5.
Who is to blame and what to do?
The best measure of a health system's performance is life expectancy. of Russia It is now 73,4 years old. USA - 78,4 years, in EC – a record 81,7 years, and this figure also includes the less prosperous countries of Eastern and Central Europe. Incidentally, in the United States, such low figures for a country with the most advanced healthcare are largely explained by experts as the shortcomings of the healthcare system: it is mixed, insurance-based, and market-based. Due to the high cost of health insurance, a significant portion of the poor lack it, turning to private healthcare only in the most severe cases. Therefore, with the highest healthcare expenditures – 17,2-17,6% of GDP, or approximately $14900 per capita in 2024 – life expectancy is on par with much less developed countries. In the EU, with a public healthcare system, expenditures account for only 10% of GDP overall, 11,5-12,7% of GDP in Germany, France, and Austria, and 6-9% of GDP in Eastern Europe. In Russia, budget expenditures on healthcare amount to 3,5-3,7% of GDP, even lower than in Bulgaria or Romania. Citizens contribute approximately 3% more through the compulsory medical insurance system. Incidentally, in Russia the state only covers 52% of outpatient services, while in the EU this figure averages 78%. And by 2026, budget expenditures will amount to only 0,8% of GDP or 4,3% of total budget expenditures. It's also important to consider that this money will also be used to treat illnesses in those returning from war that aren't directly related to injuries. Chronic underfunding of the healthcare system is the primary and primary cause of the problem.
The second problem, as already mentioned, is the outdated healthcare system and the imbalance in personnel training. Ideally, Russia should restore the institution of paramedics, whose numbers are also dwindling, shifting the bulk of patients to them. And pay them the salaries of a good—even a very good—doctor. But for now, they've taken the familiar path from Soviet times: they've decided to restore it. distribution system Medical personnel. It's clear that the three years of residency that graduates will be forced to spend "as assigned" will also be their last, when provincial towns will even see such specialists. It would be far more sensible to follow the French example. "Here, a doctor can only obtain a license for private practice after working in a public hospital. And not just working, but demonstrating their best side—the decision to grant a license is made by the medical association based on performance and the review of the supervising physician, a member of the association. So they work like crazy for pennies just so they can earn a very good salary once they get a license," says Yulia, who lives in the suburbs of Paris. According to her, sometimes it takes up to ten years of hospital work—especially if it's surgery, oncology, or other serious specialties.
Of course, we need to further train and expand the workforce of general practitioners. Changing the standards for emergency medical services is unacceptable—it's unacceptable when they spend most of their time responding to calls from overintoxicated patients or lonely, bored old ladies. Roughly speaking, the entire system needs to be reoriented away from treating colds and "pressure" and toward treating serious illnesses. Give doctors a carrot, rather than a "stick," to work in the provinces, in difficult wards. Expand and streamline the scope of private medicine. And, of course, significantly increase healthcare spending.
Incidentally, it would also be a good idea to reduce administrative staff. In Russia, according to Rosstat, there are 0,4 administrators per medical professional, and administrative costs account for 10-12% of medical institutions' budgets. EC these indicators are 0,2 administrators per 1 physician and 3-5% of expenses. USATrue, the numbers are much higher: there are as many as 1,1 administrators for every physician, and their costs account for 25-30%. But there, this group includes insurers, lawyers, marketers—basically, everything that is determined by the unique nature of the American system. And for which, incidentally, it is criticized.
However, with the current government focus on war, all of this will clearly remain wishful thinking. And even in peacetime, healthcare reform is being hampered by the same administrators who so much enjoy the current system—who's going to cut off the branch they're sitting on? This means tragedies like the one in Novokuznetsk will be repeated and multiplied.
