331 Articles Health Care in Today RICHARD G. FARMER, MD, MACP, Washington, DC, and ARAM V. CHOBANIAN, MD, Boston, Massachusetts

Although one of the smallest of the new independent states of the former , the Republic of Armenia has an ancient tradition and a strong ethnic identification, greatly enhanced by the dias- pora. In addition to the problems following the dissolution of the Soviet Union, Armenia has had to contend with a draining in Nagorno- and the after-effects of a devastating earthquake in 1988. Humanitarian efforts have ranged from emergency supply deliveries to longer-term sustain- able health care partnerships. The government, through the Agency for International Development, has organized such partnerships, partially as a result of a multinational mission in 1992 and a subsequent hospital-to-hospital program developed by the American International Health Al- liance. We describe the current state of health care in Armenia and some of the problems that need to be addressed to improve health care services to its citizens. (Farmer RG, Chobanian AV: Health care in Armenia today. West j Med 1994; 160:331-334)

T he dramatic events following the dissolution of the sibility to health care services for the entire population, Soviet Union affected the health care system of its 15 free of charge, is theoretically possible. The medical com- republics as it did all aspects of the society. In December munity has been isolated, however, and a rigid hierarchy 1991, US Secretary of State James Baker requested that has developed in the system over the years. Despite the humanitarian and other forms of to the new indepen- breakup of the Soviet Union politically, this system re- dent states of the former Soviet Union be organized and mains largely intact because virtually all health care coordinated. As a result, a coordinating conference was workers have known no other. Almost all have trained in held in Washington in January 1992 and attended by rep- their local region, and ethnic Russians are often in posi- resentatives of more than 50 countries. Five working tions of authority, particularly in Central Asia. The "sys- groups were established for food, shelter, energy, medi- tem" begins centrally, at the Ministry of Health or the city, cine, and technical assistance. A delegation was formed at the state or oblast, or at the district or rayon, from that consisted of some 30 health care professionals repre- whence the budget issues, and spreads peripherally. senting 14 countries and international organizations. Ten One of the great shocks to the management of the sys- republics were visited during the period of February 27 tem has been its separation from Moscow, as well as, of to March 31, 1992, to survey firsthand the medical and course, the disruption of the system that has been provid- other health care needs of the new republics and to for- ing equipment, supplies, and especially drugs. Until 1991, mulate recommendations based on the following four budgets were centrally determined and health care facili- points of the action plan determined at the January 1992 ties were given a fixed amount of money based on the conference: number of beds in hospitals and number of visits in poly- * Emergency medical needs; clinics. This formula sometimes varied for special cir- * Developing international health care partnerships; cumstances such as "institutes" created in one or more * Assessing pharmaceutical manufacture, vaccines, fields, such as cardiology. The per capita population allo- and medical supplies, and the possibility of private and cation has changed rapidly, and more leeway has been joint ventures in the health care support area; and given to the managers, most of whom are physicians * Technical assistance needs including help with without any management training. Increased freedom in management and financial planning. management has been offset by the loss of central fund- ing from Moscow. Health Care in the Former Long-term centralization has resulted in gigantic hos- Soviet Union pitals, with 1,000 to 2,000 beds being common, and poly- The republics of the former Soviet Union have a clinics that see more than 1,000 patients a day, six days highly centralized and well-organized health care system per week, in two 6-hour shifts. At the periphery of the with a large number of health care professionals. Acces- system are smaller hospitals and polyclinics, down to

From the Bureau for Europe, US Agency for Intemational Development, Washington, DC (Dr Farmer), and the Office of the Dean and Department of Medicine, Boston University School of Medicine, Boston, Massachusetts (Dr Chobanian). Reprint requests to Richard G. Farmer, MD, Senior Medical Advisor, Bureau for Europe, US Agency for International Development, 320 21 st St NW, Washington, DC 20523. 332332WJM,IMApiApril 1994-Vol194-o 160,10 No. 4 Health CaeiCare in.-Armenia-Farmerrei-Farmer-- et- al feldsher (first-aid) stations, with thousands of nonphysi- population served. Some of the hospitals are tied to a state cian workers. It is here that primary care, including pre- system and funded by the federal government, and others ventive care, immunizations, and maternal and child care, are municipal hospitals that are supported by cities. Un- takes place. Patients are then transferred "up the line" as der the Soviet system, some of the most advanced institu- needed. Extensive ambulance systems that provide care tions were linked to Moscow and received their support on site are also common. There is no patient choice, little from Moscow. Their funding was recently taken up by the quality control, not much continuing education, and little federal government, and they are being added to the fed- of the medical educational structure familiar in many eral system. Many of the hospitals, particularly those in other countries. A small but growing private health care the major cities, deal primarily with specific specialties- sector coexists with this hospital-clinic system. In many pediatrics, obstetrics, infectious diseases, otolaryngology, of the newly independent states, private practice is al- cancer, rehabilitation, and specialized surgery, for exam- lowed, but often only in specialties not requiring hospital ple. As in the other newly independent countries, Arme- privileges. nia has a large number of polyclinics and other outpatient facilities, but these generally are not well integrated into Health Care in the Republic the hospital systems. Networking between medical insti- of Armenia tutions continues to be poor, and links between the med- Nowhere have the adverse effects of the breakup of ical school and teaching hospitals are not well developed. the Soviet Union been felt more severely than in the The medical facilities typically are more than 20 years newly independent Republic of Armenia, which has also old and in fair or poor repair. Some new hospitals and had to cope with the devastating earthquake of 1988 and clinics have been built since the earthquake as a result of the war between Nagorno-Karabakh and . Our contributions from foreign countries and charitable orga- brief summary of the current health care system in Arme- nizations. Modern equipment is often lacking in the hos- nia is based on visits as part of the previously mentioned pitals. For example, as of 1993, only one computed Medical Working Group Experts delegation to the new tomographic scanner was present in all of Armenia. Since states (R.G.F.) and as a member of a team of experts the earthquake and war, routine medical supplies such as sponsored by the American International Health Alliance sterile bandages, disposable needles, syringes, surgical that traveled to Armenia in September 1992 with the in- gloves, intravenous solutions, and many medications are tention of developing hospital-to-hospital medical part- in short supply. There is also a serious need for such items nerships (A.V.C.). as autoclaves, anesthesia equipment, and large generators The Republic of Armenia has a population of about of electrical power. The last have become particularly im- 3.4 million, with about two thirds living in an urban set- portant because of the frequent disruption in electricity. ting. Life expectancy at birth in 1989 was 69 years for Armenia has many physicians and nurses. There is men and 74.7 years for women.' About 30% of the popu- currently approximately 1 physician for every 250 inhab- lation is younger than 14 years.1 itants, a number that is greater than that in most western Cardiovascular disease ranks as the major cause of countries. Salaries for physicians are low, only slightly death, followed by cancers and pulmonary diseases.2 Ac- higher than that of average workers. The quality of physi- cidents represented one of the major causes of death in cians varies. Under the Soviet system, strict medical 1989,' and their number remains relatively high, in part school admission policies were not practiced, and fre- because of the ongoing war. Infant mortality has been in quently more than 1,000 medical students were admitted the range of 20 to 25 deaths per 1,000 live births,3 lower per year to the Medical Institute. Armenian med- than the rates in many of the new independent states other ical leaders are well aware of the need for establishing ad- than , but higher than the values reported for devel- missions and accreditation policies and are in the process oped countries. For instance, infant mortality in the of developing these. They also have begun reducing med- United States is 9.8 per 1,000 live births (World Health ical school class sizes. Students usually are admitted to Organization data, February 1994). Maternal mortality in medical school out of high school, with an average of five Russia is also high, probably reflecting the use of abortion years being spent before a medical degree is obtained. Ba- as the most common method of family planning-an av- sic science training in medical school appears adequate, erage of five abortions per woman. Contraceptives are although students receive little hands-on clinical experi- only infrequently used in Armenia. ence while in medical school. Until recently, immunization practices in Armenia Some medical school graduates may elect to have two were broadly similar to those in the United States, with years of residency. Specialty training following residency almost all children immunized against poliomyelitis, is of varying length. Training is not standardized, and ac- measles, diphtheria, pertussis, and tetanus. Because of the creditation board examinations are nonexistent. war and resultant blockade, however, vaccines are in short Improved primary care and public health services are supply and immunization programs have broken down. needed. Not surprising, considering the dire economic Essentially no vaccines are currently being produced in conditions, immunization programs have suffered greatly, Armenia. and other disease prevention programs are generally lack- Armenia has a large number of hospitals throughout ing. Cigarette smoking is prevalent despite a high inci- the country, with an abundance of hospital beds for the dence of cardiovascular and pulmonary diseases. WIM,IM April-..Ai 1994-Vol-Vol 160, No. 4 Health Care in Armenia-Farmer et al 333

Health care is financed primarily through a public sys- cause they were outdated or did not have understandable tem. Previous estimates are that only 3% of the gross na- generic names. For example, there were antibiotics with tional product is spent on health care, although the current 238 different names, written in 21 languages, and often figure is uncertain. Hospital support from the government unknown to the health care professionals on location. The is small, but is the major revenue source. The total sup- availability of drugs remains a serious problem. In view port in 1992 for each of two large hospitals in Yerevan ap- of the marked inflation and the devaluation of the ruble, pears to have been less than $500,000 (US). Funding of which by mid-1993 had fallen to a value of less than hospitals depends both on the number of beds occupied 0.001 of a US dollar (versus about $1.3US before the dis- and the total number of personnel. Because of the lack of solution of the Soviet Republic), purchases of medica- other employment opportunities, officials are reluctant to tions, equipment, and supplies with foreign are eliminate jobs from the hospitals or elsewhere within the now difficult, if not impossible. health care system. The war-induced blockade, which has prevented most New initiatives are being developed to provide pri- truck and rail passage to and from Armenia, has further vately financed medical care to the public, although pri- complicated the situation. The past two winters were ones vate practice represents a small segment of health care. of bitter hardships. The fuel supply was blocked much of The Diagnostica Corporation is a leader in this regard and the time. When the Medical Working Group Experts del- is now offering health care insurance to private sub- egation visited in March 1992, there had been unusually scribers. It is contracting with certain hospitals for the cold weather with temperatures of -10°C (14°F) on al- care of their insured patients. most a daily basis. The huge concrete buildings had a The war with Azerbaijan and the earthquake of 1988 refrigerator effect, and all meetings were held with every- have placed additional stress on the health care system in one wearing overcoats and scarves. Furthermore, electric- Armenia. The genesis of the war over the Armenian en- ity was cut off about half the time, and lights (and electric clave of Nagorno-Karabakh dates back to the Stalin era. heaters) would go on and off sporadically. In this past The area is geographically surrounded by Azerbaijan ter- winter, the situation was even worse, with electricity av- ritory but contains a majority of Armenians. There were eraging no more than two hours daily. Food was scarce, about 200,000 of each nationality living in the other re- and food prices continued to rise rapidly. As a result, mal- public, but since the war, most have returned to their na- nutrition has become a serious problem, particularly in tive republics, thus increasing the burden of refugees. The children, and will remain so unless the blockade is lifted. territory had been assigned to Azerbaijan in 1923, and the In the earthquake zone, most of the inhabitants continue current war was perhaps precipitated by a petition in Feb- to live in huts and other temporary shelters. Refugees ruary 1988 by the residents of Nagorno-Karabakh that it from the Nagorno-Karabakh war zone add to the housing be made a part of Armenia.4 Since then, there have been problems. Drinking water in many areas has deteriorated many skirmishes and full-fledged battles, with thousands in quality, as have the proper handling and storage of of civilian and military casualties. foods. Severe infectious diseases of the gastrointestinal Added to the already existing burdens of geographic tract have increased greatly in frequency, and cases of isolation and the war in Nagorno-Karabakh, the earth- previously rare conditions such as brucellosis and botu- quake on , 1988, with a Richter scale reading lism are being seen in notable numbers. In addition, tu- of more than 9-greater than the San Francisco earth- berculosis is now rampant throughout the country. quake of 1989-created chaos. At least 25,000 people Despite these serious problems, however, there is died (official estimate provided by Minister of Health of some cause for optimism regarding the future of health the Republic of Armenia, Dr Ara Babloyan, oral commu- care in Armenia. A talented pool of professional person- nication, March 1992), with other estimates varying up- nel already exists in the country, and many persons are ward to more than 60,000.5 The most pressing medical available for further training. The Minister of Health, his problems immediately resulting from the earthquake in- associates, and most of the medical leadership in the cluded the trauma caused by falling buildings and other country appear dedicated to improving the health care objects, the problem of crush injuries that resulted in system and the quality of medical care in Armenia. The acute renal failure, and the need for medications. Armenian diaspora is assisting in these efforts by provid- Richards and co-workers summarized the experiences of ing substantial expertise and material aid. In addition, the a nephrology team from Great Britain,' who dialyzed as American University of Armenia, which has been estab- many as 70 patients a day. Of 800 patients admitted to one lished in Yerevan under the sponsorship of the University hospital, 460 had the crush syndrome. Many patients of California, San Francisco, will soon be providing grad- were sent to Moscow for treatment, but most were treated uate courses in public health and health care manage- locally. ment. Programs such as hospital-to-hospital partnerships The medication problem was more difficult to solve. that involve both public and private funding and the tradi- The immense task of getting a large amount of supplies to tional governmental aid programs such as those funded a distant location in the Causasus Mountains created stag- by the US Agency for International Development have gering logistic difficulties. An estimated 500 tons of drugs been established. and consumable supplies were sent,6 but only 30% were Working with the Armenian diaspora has greatly en- immediately usable, and 20% had to be destroyed be- hanced humanitarian efforts and health services planning. 334 WJM, April 1994-Vol 160, No. 4 Health Care in Armenia-Farmer et al

As a result, the degree of isolation being experienced in levels, from the first-aid station to preventive services, lo- Armenia is much less than that occurring in many of the cal hospital care, and specialty medicine, is an important other newly independent states, particularly those in Cen- part of the social fabric of the republics of the former So- tral Asia. An example of the identification of the Arme- viet Union. This tradition is admirable and should be pre- nian diaspora with the problems of the people in Armenia served. The importance of the health care system to the is described in the response of children and adolescents in stability of the new republics cannot be overemphasized. California to the 1988 earthquake.7 There was "strong This applies particularly to Armenia, which, if given identification" with the victims as well as anxiety, made peace and stability, has almost unlimited potential be- much worse when a similar earthquake occurred in the cause of its rich culture and the work ethic of the people. San Francisco Bay area less than a year later (T. Jones, "Double Jeopardy: Armenian Children in Bay Area Re- REFERENCES 1. Medical Working Group: Experts Delegation to the New Independent live Terror of Soviet Quake," Los Angeles limes, October States-Country Reports: Armenia. Washington, DC, Agency for International De- 22, 1989, vol 108, p A-3). velopment, 1992 A recent article compared this area to the "Wild 2. Yu PM, Netzer UL, Storey MA: Directions: An Introduction to the New In- dependent States With a Special Focus on Health Care. Washington, DC, National West'" with a real risk of "carving up" the health care sys- Public Health and Hospital Institute and American International Health Alliance, tem, often for profit.8 The need for a coordinated ap- 1993 3. Mezentseva E, Rimachevskaya N: Soviet country profile: Health of the proach to health care, recommended by the Washington USSR population in the 70's and 80's-An approach to comprehensive analysis. conference in 1992, is obvious, and developing hospital- Soc Sci Med 1990; 31:867-877 4. Rich V: Conflict continues between Armenians and Azerbaijanis. Nature to-hospital partnerships, as advocated by the medical ex- 1988; 332:477 perts group, is a valuable effort. The blending of pro- 5. Richards NT, Tattersall J, McCann M, Samson A, Mathias T, Johnson A: fessional experience, technical expertise, direct aid, and Dialysis for acute renal failure due to crush injuries after the Armenian earthquake. Br Med J 1989; 298:443-445 medical education can be of great benefit, particularly in 6. Autier P, F6rir MC, Hairapetien A, et al: Drug supply in the aftermath of the Armenia. Although the costs are substantial, they pale by 1988 Armenian earthquake. Lancet 1990; 335:1388-1390 comparison with defense costs that have characterized the 7. Yacoubian VV, Hacker FJ: Reactions to disaster at a distance-The first week after the earthquake in Soviet Armenia. Bull Menninger Clin 1989; 53:331- post-World War II era. 339 The tradition of free and accessible health care at all 8. Delamothe T: Helping Russia. Br Med J 1992; 304:1232-1234