WHO-Europe had its big meeting in Moscow this month. It was an amazing mixture of bureaucratic exercises, real health care politics, and interaction with local events. You may not find the details of this meeting on the WHO website, but if you wonder what it was about you may go to see the programme buried here along with wonderful documents like this major paper for the session “Addressing key public health and health policy challenges in Europe” – filled with the right words but making almost no sense, in my humble opinion.
On the dramatic side, claims by the Russian government that funding of health care is quickly increasing, health care is blossoming, mortality is decreasing, and the birth rate is increasing were applauded. Yet, meanwhile, members of groups supporting HIV infected people chained themselves to the fence of the Ministry of Health and walked to Red Square with a bear (the symbol of the ruling party). Why is it that HIV/AIDS therapy may not be available when the new healthcare funding is announced? Quite simple: the overall funding is insufficient and the bureaucratic machine effectively blocks the use of the funds for sick people. Recently responsibility for HIV/AIDS problems were taken from the office of the influential chief of the epidemiological/consumer protection agency, Gennady Onischenko, and subordinated to the Ministry of Health.
Antiretroviral drugs are currently in short supply in 20 regions of Russia, and during 2010 only about 50% of patients needing antiretroviral therapy will have received it. HIV activists have created a special website to monitor the inadequate drug supply in regions of Russia (www.pereboi.ru). The situation was no better in 2009, when physicians delayed the initiation of therapy and used inadequate doses and the Russian government broke a collaboration with the Global Fund through its very successful project in the Open Health Institute (www.ohi.ru).
On the comic side, the first day was celebrated by the appearance of Prime Minister Vladimir Putin. He is famous for being late everywhere, and he was late this day. At one moment all wireless connections were broken, security staff penetrated the hall, everybody was asked to sit still in their places, and after half an hour of waiting Putin appeared in the hall to tell us how wonderful the development of health care is in Russia. Leaving the hall later, he took the chairman’s gavel from his health minister Tatiana Golikova and said that it is the instrument used to induce “rausch narcosis” (a rapid kind of general anaesthesia, for example induced by a high concentration of chloroform, to allow quick intervention). Did this offensive joke allude to induction of unconsciousness by other means in the KGB? When he left, the conference halted again for half an hour. Muscovites are accustomed to such breaks – sometimes they are stuck for two hours on streets blocked by the military and secret service to open the way for the Prime Minister.
The second day opened with a morning lecture by Michael Marmot. Those who attended said that it was the greatest event of the meeting. Professor Marmot spoke on the subject of social determinants of health (he had chaired the group which prepared the technical report for WHO meeting on the subject). Later that day Margaret Chen again addressed the problems with the swine flu pandemic. She said: “WHO is under scrutiny for its response to the 2009 influenza pandemic. To some, the response measures now look excessive compared with the moderate impact of the pandemic… We are grateful for the moderate impact. Had the H1N1 virus mutated to a more deadly form, we would be under scrutiny of a different kind, for having failed to protect large numbers of people. Response plans, put together during years of nervously watching the highly lethal H5N1 avian influenza virus, prepared the world to anticipate a much more severe event. Scaling down these plans proved difficult, in part because no one could answer, with certainty, a fundamental question. Is it safe to do so? Are we sure? Do we dare? The phased approach to pandemic alert, introduced in 1999 as a strategy for reducing public anxiety, actually had the opposite effect. It dramatized the steps leading to the declaration of a pandemic in the eyes of the public and the media. Adjusting perceptions to match a much less severe event proved problematic.” I think that the last point is just great.
Later Dr Chen could not resist the temptation to say that it is a pity that in some unhappy countries the ministries of health are led by people without medical education. Of course, it is not applicable to Russia, said she – while gently touching the hand of Russian minister of health (an economist by education and an accountant by experience).
On the farcical side, Russia enacted a new law this year demanding that all new drugs be tested in Russia as a prerequisite for their registration. It was done against all possible critiques from the expert community, and it puts the Russian government in a difficult situation regarding prospective drug applications. To register new drugs without trials in Russia is illegal, and to do new trials means delay in registration. Despite this, Minister Golikova – who was largely responsible for this law – used the conference to invite European participants to create international agreements on the mutual recognition of trials done in European countries. I did not see the faces of the discussants, but can imagine how surprised they were with this idea.
Vasiliy Vlassov is a Professor of medicine at the Higher School of Economics, Moscow. His research interests are in epidemiology, evaluation of diagnostic tests, public health, and especially health care delivery with scarce resources. He is the co-founder and current president of the Russian Society for Evidence Based Medicine.