The whole reason I went to Tomsk was to visit Partners in Health’s tuberculosis treatment operation to find out a little bit about how the operation is run on the ground level and to meet doctors with whom I might be able to work in the future. Since the visit was related to my medical side project, after writing a semi-formal proposal to the Russian Fulbright Office, I received funding for the plane ticket and for the hotel stay.
I landed in Tomsk around 6 in the morning. I was told in an email that the PIH people ordered a cab for me, and when I found it, I was surprised to find that Oksana Ivanovna, the Director of PIH Russia was sitting in it waiting for me. She had been on the same flight, although I don’t remember having seen her. It was cool getting a chance to talk to her right away and to explain in person what I was doing there and why I was interested in the Tomsk project. It was also pretty amazing to be chatting with a friend and colleague of Dr. Farmer, especially one who was so friendly and spoke such clear Russian that I didn’t feel lost. I think my conversation with Oksana was the last time in Tomsk that my Russian held up, because for the remainder of the trip it seemed to abandon me. My Russian is like that – it can be so fickle.
Oksana got off at the PIH office and I was driven on to my hotel. I got there around 7, so I had a few hours to rest in my room (kindly booked by one of the people in the PIH office) before meeting Nina, one of the TB doctors (in Russian, they use the term phthisilogist for a doctor who specifically works with TB patients). I had asked the PIH people via email to see how the patients in rural areas were treated. Partners in Health uses a treatment program called DOTS which stands for direct observed therapy short course, in which health professionals must personally watch as a patient takes the daily cocktail of TB meds. The medicines, often including an injection right in the booty (can you imagine that? a daily shot in the butt?), are either administered when the patient visits the clinic, hospital, or dispensary, or are delivered personally.
Nina and I drove from the hotel to the dispensary, where we met a nurse, Mariana, and we all clambered into one of the jeeps provided by PIH (with money from the Global Fund) to make navigating Russian “roads” possible. We headed out of the city and drove about an hour to a nearby village of about 1,000. Our first stop was the FAP, which is a Russian abbreviation for first aid/obstetric point, a kind of rural clinic that provides basic primary care. Nina and the nurse who accompanied us had to check on the progress of a few patients before making a few house calls.
After checking a few things at the FAP, we made our way to a few different patients’ houses to check up on them and give them instructions. A few hadn’t been coming for their medications, one needed to provide some sort of identification (though he had to use his military card because he lost his passport a long time ago), and one had to be given instructions for a lab analysis that needed to be done.
It was cool to see a snapshot of village life. People in the two small towns we visited seem to live without running water and I think without electricity. The trip also made me aware of the many logistical difficulties involved with trying to treat patients who often disappear into the Russian countryside. Even finding their houses can be tricky, because many of the streets and houses aren’t marked. People give directions like “Over there by an old shed sort of by the school” or “on such and such a road, but you have to go around the other way because the road fell apart last winter.” Plus, every other dog seems very angry. This one wasn’t…
After tracking down all the patients, we headed back to Tomsk and I finally lost the will and ability to stay awake and talk to my hosts. Nina saw the tired look on my face and encouraged me to sleep on the way back, and I marveled at how I could sleep like a little baby in the back of a jeep rolling down the jankety roads of Siberia with three people I had met only a few hours before.
The one condition for receiving financing for my trip was that I had to speak at the American Center there, so after my morning with Nina, I spent the afternoon at the library of Tomsk State University giving a lecture on health care management in the US. What do I know about health care management? As much as I could get from a little web research, and my notes consisted of the Wiki articles on HMOs, Medicare, Medicaid, and case management in the US. I actually learned a lot, but when it came time for my speech, I didn’t even use my notes and just kind of spoke about what I had understood and my general opinions about health care and how the American system walks the line between providing people with solid care but charging too much for it (although I pointed out that many people go without care). I think the audience was surprised to hear someone criticizing the American system, although there is always that inference that if the American system has so many problems, what state must the Russian system be in. The lady in charge of me had planned for a 30 minute talk, but after I got rolling and people asked questions, a whole hour had gone by.
By the time I got to the PIH office to meet back up with people, only Nina was left and the others had gone on to other work. I sat and had some tea, then went back to my hotel to rest, still only running on a few hours (or probably more like minutes) of sleep here and there. I made plans with the ETA in Tomsk, Madeline. We had a nice dinner at an Uzbek place, where the staff was unusually friendly and even attempted some English when saying goodbye as we left. I had some great grilled steak with vegetables and some pumpkin soup, and after dinner, Madeline and I stopped by a cafe by her dorm for some ice cream. I was lucky once again to have some company, and it turns out she and I are going into a similar situation next year after finishing in Russia: returning to the place where we grew up for grad school (Boston for her).
The next day, I was back in the jeep disembarking from the dispensary, this time with Nastya, a nurse, to deliver medications to patients throughout the city. Despite the more urban setting, some of the places were much worse than in the country side. We had about 20 different patients on our list, and so that morning, I saw more of Tomsk than of any other Russian city I’ve been in, although probably not the nicest parts as one of the doctors at the dispensary commented to me later. Nastya was a fun person to travel with and a perfect person for the job: cute, perky, yet stern when necessary. It was fun to see the friendly, yet distanced relationship she seems to have developed with these patients who she sees daily. Even she was disturbed by some of the sights and smells we encountered, including about two dozen fish hanging up to dry in a window (strong fish smells at 9 am are never fun) and a plastic sack full of half-rotting meat which Nastya firmly asked be removed from the table before she unpacked the medicines. I was a little worried by the two patients that required us to wear respirator masks, but I did as I was told and put it on correctly before stepping into the houses. Nastya told me you can’t do it too early, otherwise the neighbors get suspicious and start to hassle the patients.
It was a lot like shadowing at regular clinics and hospitals, except the patient visits were more like house calls (the old-fashioned way) and some were extremely brief and business-like. More than anything else, it reminded me of Operation Others, a community service organization I did in high school where we delivered Christmas food packages to people after raising money throughout the year through activities and fundraisers. Even though all we were really doing was riding around in the jeep and stopping into people’s houses, after three hours I was tired from bouncing over so many potholes and I had to admire Nastya and the driver for doing this six days a week.
One of the questions I had about the PIH site here was how they managed to be so successful in a country where the medical system lags behind that of other countries, and the best answer I can come up with is that (besides having American funding), everyone I came into contact with seemed to work American hours. Whether it’s Spain, France, or Russia, everyone seems to have a little bit more free time and a more relaxing work schedule than in the States, but that certainly did not seem to be the case for the PIH people in Tomsk.
After my morning with Nastya, I was dead tired, and since Nina was tied up at the dispensary, I headed back to the hotel to find some lunch along the way and have a little nap. After I woke up, I stopped by the PIH office to meet some of the other colleagues. Salman, a Boston-based doctor who met Paul Farmer through his wife and her work in the slums of Peru, was there on a work visit, and it was fun making his acquaintance and having the chance to speak English. He was with a guy from Novosibirsk, a scientist who is involved with getting internal support for PIH. Oksana Ivanovna encouraged me to sit in on a meeting they were having, and although the Russian was pretty face-paced, I got a general idea of what was going on and it gave me an inside look into some of the details that go into making an operation like this stay afloat.
After that it was a little awkward because I wasn’t sure if they had anything else planned for me, and I was so tired that I had a hard time coming up with good questions. After everyone met in a different room of the office to interview a prospective employee, I thanked everyone, made plans with Oksana for our ride to the airport in the morning, and left.
For the rest of the evening, I walked around Lenin Prospekt and enjoyed the increase in temperature. It was still pretty cold even then, especially after the balmy weather in Moscow. That morning it was in the 40s and even after it warmed up a little bit, I was chilly in the outer shell of my winter coat. In that respect, Siberia did not fail to meet my expectations.
Overall my trip was a success, although that last lay over in Moscow was a little much and by the time I was on the plane headed back to Ufa with a terrible headache, I was HURTING.
Not only did I get a chance to directly observe how the DOTS program is administered, I got to meet the doctors who make it happen in person. Although I am still not sure what I will do next summer, Oksana Ivanovna made it sound like they were perfectly willing to let me come and do my summer primary care rotation there in Tomsk. At this point, I’m not sure how likely that is, but at least the offer is there.
As a whole I admire what PIH is doing in Tomsk, and I know I only saw a tiny percentage of the total number of patients who receive assistance from the organization and their foreign donors. The work of international non-profits is never simple, however, and any time a program is dependent on foreign aid, one has to question the likelihood of it being sustainable and whether in the long run it benefits the recipient country. Such work in a poor country like Haiti is one thing, but Russia is a different matter altogether. Russia is not a poor country, and walking along the Stoleshnikov Pereulok with its fashionable boutiques and word famous brand name stores is a reminder that Moscow is now home to more billionaires than any other city in the world. Clearly, their money isn’t trickling down to the poor TB-inflicted in Tomsk, which is why organizations like PIH are prompted to do what they can to treat the underserved. One has to wonder, though, that if the money continues to come from the US, whether the members of Russia’s upper class will ever take the initiative to look after their own.