by Marianna Grigoryan and Gayane Mkrtchyan
After 12 years of trying without success to start a family, Karina Marsuradze made up for lost time on a cold winter day in 2004.
Karina (she is Armenian, and her husband is Georgian) gave birth to triplets—two girls and a boy in the Margarian Hospital of Yerevan.
The babies were helped into the world by modern medicine hardly available in Armenia (if anywhere in the region) before independence. At the Scientific Research Center of Maternal and Child Health Protection, the Marsuradzes received artificial insemination that led to their "three-in-one" joy.
"After Armenia gained independence, Armenian medicine had significant achievements as a result of international cooperation," says professor George Okoyev, director of the research center. "In Soviet times the 'Iron Curtain' had an extreme reach."
The doctor says Armenia had good healthcare, but admits that little was known about what the rest of the world was experiencing.
The Marsuradzes' good fortune is the result of cooperation with a French-based reproductive healthcare institute. Prior to independence, the Marsuradzes would simply have endured fate's consequence and suffered the social stigma of a childless Armenian couple. No such fertilization was available in Soviet Socialist Armenia.
"Our (Armenian) doctors specializing in this field are armed with all the knowledge required, but the effectiveness of our cooperation with French specialists cannot be overlooked," Okoyev says. "We created the wherewithal that had long been available in many civilized countries."
The lifting of the Iron Curtain raised opportunities for Armenian healthcare specialists to benefit from training and accessability to equipment that had been denied them in their closed society.
The Scientific Research Center of Maternal and Child Health Protection was among those to benefit, when French-Armenian Andranik Hakobian, the head of "Liberation" NGO in France, initiated projects between the two countries.
The Center established cooperation with Marseilles-based "Institute of Human Reproductive Performance" headed by Professor Jean Pier Frankubalm, who came to Armenia with embryologist Jean Louise Spaque, bringing an ultrasound scanner, an incubator, a device for freezing sperm and embryo, and instruction for the latest methodology.
Today, the center is considered one of the best reproductive clinics in the region.
Since 2004 many couples who had lost hope of becoming parents were granted that happiness by the center's exclusive capacities. (The center itself was founded in 1931.)
The center is but one example medical professionals point to as a positive impact of independence—and changing technology in general—on healthcare in Armenia.
And while Diaspora intervention is largely responsible for the improving conditions, the State—under pressure since the disappearance of socialized medicine—has also has taken on some of the burden of realizing a healthy populace.
The recent years that have enjoyed double-digit economic growth in Armenia have seen the State's allotment for healthcare nearly triple. According to RA Ministry of Economy and Finance data, in 2002 the amount of money allocated for healthcare was about $36.5 million. By this year, the allocation had risen to $93.8 million.
When comparing Soviet and post-Soviet times, members of the medical profession positively point out that during recent years State care for doctors has increased significantly.
"If previously medical personnel didn't receive their salaries for months, in recent years not only has the financing of medical institutions increased, but it is also provided on time. Changes in the field are obvious," says Ministry of Health advisor Ruslanna Gevorgian.
Financing of institutions has not yet reached the international standard of payment for doctors; a few hundred dollars a month would be considered top pay, leading many to accept "gifts" for their special attention.
But even modestly paid (by Western standards) personnel see advances in their profession.
"As compared to the Soviet times the situation is incomparably better," says Rafael Baghdasarian, head of the dialysis department at Republican Medical Center. "What we have now cannot even be compared with what we used to have in Soviet times, be it methods, equipment or treatment efficiency."
Comparisons are relative, however, and one patient's account of superior treatment may be matched by another's horror. The days have not totally passed, when hospital patients are required to provide their own medicines. (One Yerevan woman tells of having surgery just three years ago when—during the operation—she had to make a phone call to her brother so that he could bring money for a special drug the surgeon needed.)
As in the HMO vs. private insurance debate in the United States, Armenians in need of medical aid essentially get what they pay for. A considerable difference, though, between today and 15 years ago, is that there is something worth paying for—depending, often, on location or whether the hospital is private or public.
While patients readily complain about the "hidden" costs at places where hospital management is still unrealized, at modernized facilities such as Yerevan's Nairi or Erebuni hospitals, fees are paid in total to an administrator without expectation of additional gratuity.
DARK AND LIGHT
Fifteen years have not completely erased traces of the past . . .
The Vagharshapat Hospital in Etchmiadzin even smells of the past. Faded and dingy blankets cover overly worn beds that could hardly bring rest to the well, to say nothing of the infirm.
Dull wards needing renovation are stocked with cabinets from a bygone era, a couple of equally-aged refrigerators, and sinks that have rusted.
In the hospital's neurology department hall there is a creaking wooden bench, where patients gather to watch a USSR-produced black-and-white "Horizon" TV. They twist an antenna from side to side to attempt clear reception.
"We understand that it's hard for the State, but the hospital should be repaired at least slightly," says senior nurse Lusik Aloyan. "Lavatories are in such an awful state that we are ashamed ourselves. People have no desire to get treatment at our hospital and in most cases they go to the capital. Those who do come here are mainly those who cannot afford to go to Yerevan."
But even in the capital, quality is inconsistent. In the Republican Hospital in Yerevan (now Armenia Republican Medical Center), some departments remain "Soviet" even now.
Despite poor working conditions and poor pay for professionals, patients and medical personnel say that, especially during the last few years, the state of medicine in Armenia has reached a high level.
Contrasting the unappealing conditions described above, at Diagnostic Medical Union, patients enter a well-repaired, light, airy and comfortable institution and, according to systemized procedure, are directed to the appropriate consultation.
The center is private, but not newly so; it was the only for-pay diagnostic center in Soviet Armenia since its founding in 1984, using equipment supplied by the Gulbenkian Foundation.
After independence "we bought all the equipment and medical machinery needed for our work," says Marina Ordian, the medical director. "Our center was famous yet in the USSR, and was unique in the region even then, but especially after independence the situation has gotten even better. We assisted in training of other centers through our experienced specialists. Recently we have acquired a magnetic resonance tomography scanner that gives greater opportunities for bone marrow and spinal disease diagnosis."
The Union is comprised of three centers (Yerevan, Goris, Gyumri), where patients can find more than 400 diagnostic machines and other laboratory equipment. Some 75 doctors, plus 70 other personnel, did more than 80,000 examinations last year, with some patients getting complete physicals at a cost of about $145 each.
DRESSED UP AND COMPLETELY HEALTHY . . .
Sixty-year-old Khackik Manukian's skin is yellowish. He is skinny and exhausted, yet he smiles when asked for how long he has been getting dialysis for his failed kidneys. The answer, is that Manukian is the only known Armenian to have been treated for the ailment in both Soviet and independent Armenia.
"All the others have died," he says.
Manukian is an exception from the days when kidney failure was a death sentence.
According to the doctors in the Dialysis Department at Republican Medical Center, few people took dialysis even though it was available in Soviet times, because the procedure was so unreliable and even risky.
Doctors who have worked during both periods say that, previously, there was hardly a week when they didn't lose at least one patient. And even the "successfully" treated ones hardly lived more than a few months.
Department head Baghdasarian says the success of treatment was frighteningly low, because the medicine was of poor quality and had many side effects. He says, too, that Soviet-era dialysis machines sometimes "would explode from inside right in the middle of the procedure, immediately killing the patient." Doctors themselves referred to the 1965-model machine as "Killers".
Today, though, using European-made equipment (at a cost of about 14,000 Euros each), it is no longer exceptional to extend a patient's life indefinitely.
"To compare today's equipment and medication with what we had then is the same as comparing a half-naked person suffering from dozens of diseases, to a dressed-up and completely healthy person," says Manukian.
At present, there are six dialysis centers in Armenia, one of them for children, where every week about 400 patients undergo treatment. Far from a death sentence, three dialysis treatments per week now give patients a chance to live normal lives.
Dialysis patients get a supplement for their treatment. The State pays about $50 of the $130 cost.
CARE FOR THE GREATER COMMUNITY
In nearly every sphere of medicine, freedom of movement and communication has brought improved facilities and methodology—most of it Diaspora based.
In its 14-year history the California-based Armenian EyeCare Project, for example, has brought 50 ophthalmologists as trainers to Armenia, has trained some 100 eye doctors here and abroad, treated about 150,000 patients and, in 2003, launched its Mobile Eyecare Clinic, which makes laser surgery and other procedures available in regions where hospitals have hardly even an eye chart.
Further, AECP set up specialty departments in the Malayan Ophthalmological Center that have attracted patients from throughout the former Soviet Union and the Middle East.
Likewise, Diaspora-Homeland cooperation has produced the Armenian-American Wellness Center, one of independent Armenia's most valuable healthcare assets. The state-of-the-art center was established in 1997 by American-Armenian philanthropist Rita Balian, with local assistance from National Assembly Member Hranush Hakobian.
The center's purpose is to prevent breast cancer through early diagnosis.
"The Center was founded right in the first years of independence and became one of the greatest achievements of our healthcare system. Even today, we are still the only one in the region," says the Center's Executive Director Khachanush Hakobian. "We discover the new developing disease in its early stage, extract the new growth by means of surgery, subjecting the woman to minimum trauma, preserving her breast, and, most importantly, saving her life."
Over it first nine years, the mammography center examined more than 70,000 women. About 2,000 cases of cancer were found early enough to manage the disease. Those cases have been monitored for more than five years and have offered a means of prevention previously unavailable in Armenia.
"They keep constant contact with us. This in itself is an achievement—just imagine 2,000 families haven't lost their mothers," says director Hakobian.
Far from seeking accolades, cardiologist Hrair Hovaguimian has, nonetheless, become a hero to heart-disease patients in Armenia.
In 1992, when hospitals hardly had lights, much less modern facilities and equipment, American-Armenian Hovaguimian asked the Ministry of Health for a clinic to provide heart surgery.
He was assigned a small ward in the Nork-Marash Children's Hospital. And, like independent Armenia, the little clinic grew, developed, branched out, and is now unique not only to Armenia but to the region. People from neighboring and distant countries now come to Yerevan for heart surgery.
While locals may grumble at having lost "free" healthcare and sometimes confuse a doctor's fee with a bribe, an objective view of changes in Armenian healthcare cannot overlook the advances in diagnostic services available in improved, clean and efficient hospitals.
"Presently, there are diagnostic centers, such as Arapkir, Nairi Diagnosis, Erebuni Medical Center, we are proud of," says Ministry of Health advisor Gevorgian. "Arapkir Medical Center is unique with its quality and services providing kidney transplants. This is also a significant achievement for a newly independent country like Armenia."
In 2001, medical professionals, led by Frieda Jordan of California and Sevak Avakian of Yerevan, opened the country's first Bone Marrow Registry Center, supported by First Lady Bella Kocharian, which helps Armenians worldwide connect for life-saving genetic matching to combat blood diseases. Since then 10,500 donors have been found (with 630 patients waiting for a match).
Other disciplines of medicine—from dentistry to urology—have registered similar advances.
With positive changes, however, a number of problems and difficulties are yet to be overcome.
PAST AND PRESENT
Every field of life in Soviet times was clear. People knew what the next day would bring. Social problems were rare and—when they did occur—were managed by state institutions.
Medical doctors were respected, if only for the difficulties they had to overcome to earn their license through the rigorous Soviet education system.
"Soviet society appreciated its people's health and took care of them," says neurologist Armenuhi Badalian. "If a person didn't have a high salary, he or she nonetheless knew that there would be free medical service."
Under the Soviet regime, healthcare, like many other services, was free. But "free" was a relative notion.
In the majority of cases, a patient visiting a doctor expressed "gratitude" in the form of money or expensive presents. But, even so, healthcare during Soviet times is recalled with great affection even now.
"There was a strong system in Soviet times, the polyclinics worked well. If a person had a complaint he would go to a doctor without a second thought, knowing for sure that no one would play games with health and it would not cost a fortune," says Yerevan resident Aramayis Martirosian, 68. "I need surgery now, but have to save for years to be able to afford it."
Problems in healthcare appeared after independence, when the socioeconomic crisis was compounded by the war in Karabakh.
"A cruel period started. Chaos ruled everywhere. There was no clarity in state-hospital and hospital-patient relations," says Andranik Serobian, M.D. "The state was in quite a difficult situation; adequate medications and equipment were extremely scarce."
As a result—and shockingly for "independence"—a period began when patients needing surgery were asked (and sometimes still are) to bring their own medications and bandages.
Consequently, the number of citizens seeking medical attention dropped drastically. And as a further consequence, preventative care dropped to its lowest point, from which recovery remains slow.
"One of the advantages of Soviet healthcare was disease prevention," says Ruslanna Gevorgian. "Polyclinics worked with high effectiveness, discovering in time problems that would otherwise become a reason for future diseases. Healthcare in those years worked well."
The flow of patients to polyclinics remains slow, along with services ensuring timely discovery and prevention of deseases.
For example: In 1980, at the bloom of the Soviet regime, Armenia reported 723 new cases of tuberculosis. By last year, new incidence of TB had tripled, to 2,006.
Worldwide, doctors agree that the increase of TB is conditioned by social hardship. However, in Armenia, the main precondition, specialists say, is non-efficient work of preventative services.
Doctors say a few factors contribute to the increase, including improper heating, diet, and the fact that the disease has mutated worldwide.
"I remember how in Soviet times a car with an x-ray unit was visiting even the most remote villages and as a result finding out whether or not there were problems. The disease was detected in its early stage, which assisted the patient's full recovery and saved the state money," says Dr. Serobian.
Similar disturbing trends are seen in the detection of cancer.
Gagik Bazikian, head of of the oncology department at the V.A. Fanarjian National Center of Oncology, says that each year more than 5,000 new cases of cancer are discovered. Often discovery comes too late for effective treatment.
"People turn to a doctor's help very late, when they can't take it any longer," says Bazikian. "In this case the effectiveness of therapy is very low, whereas in Soviet times all this was well systemized."
According to the cancer specialist, during the last 15 years, more than 75,000 new cases of cancer have been found. He says it is a high ratio for a country of Armenia's size. According to World Health Organization reports, for example, Armenia has the highest rate of breast cancer in the region, and highest lung cancer occurrence in all of Europe. The increase is about twice as high as in the 1980s.
The Soviet health system wasn't driven by humanitarian motives. It recognized, rather, that it was cheaper for the state to pay to prevent disease than to pay for treating it. It is a lesson yet to be widely applied in the teenage democracy.
PRIVATE AND PUBLIC
In the mid-1990s, private healthcare was introduced in Armenia. Part of the evolution of a free-market society, it also was a result of dissatisfaction by both patients and professionals over the condition of public health.
But the transition, too, brought as much discontent as satisfaction.
Within the framework of the public system, medical assistance was available to those suffering from certain diseases such as cancer, or from mental disorders. The larger public was faced, for the first time, with paying for healthcare.
It could be argued that the custom of "showing gratitude" was replaced with a more transparent system of simply paying for services. The general public, spoiled by 70 years of free everything, did not see it that way.
Doctors and patients being used to "free" medical assistance created new methods to serve their goals.
"Often a doctor avoids registering the patient, instead pocketing the money given for medical assistance. You pay less than is foreseen by the state and receive the same medical assistance. It's hard to resist that temptation," says Yerevan resident Albert Arakelian.
NO ONE EXPECTED THE TRANSITION TO BE SMOOTH
"The system change didn't mean we would avoid corruption," says neurologist Badalian. "Our mentality has to change."
But a changing mentality has not been rewarded by changing salaries.
Karine Baghramian is a part-time nurse at a hospital in Etchmiadzin. She works about 80 hours a month, for which she makes about $18—less than 25 cents an hour. By comparison, average pay for a (full time) nurse at the Diagnostic Medical Union in Yerevan is about $50 a month.
"If one's salary is so low that it is not even enough to cover the transportation expenses to go to work, how could she possibly not be expecting something from patients? Today the only hope for most of us is the patient," she says.
But that same patient becomes a "hope" at every level—from the hospital janitor to the surgeon.
"If you have health problems, first of all you turn to all your relatives and acquaintances for them to recommend a 'normal' doctor who would be able to diagnose correctly and would not make up different diseases for which you must pay for treatment," says Etchmiadzin resident Naira Vardanian.
Vardanian recalls a friend that was operated on a few years ago, and then it turned out she didn't need that surgery at all.
"If the state paid doctors properly, they wouldn't consider patients as a source of income, and patients, in turn, would have more trust in doctors," says Badalian. "To be a doctor is a very responsible and important profession without having to think of other means of earning money. The hardship and tension of medicine is more than enough."
The economics of earning a living collide with the Hypocratic Oath, when a general practitioner has to decide whether to refer a patient to a specialist.
"Polyclinics try to accept as many patients as possible, prescribing in-patient treatment at hospitals only to a small number of people, regardless of whether the patients need it or not," Badalian says. The neurologist and others say that every doctor keeps a patient under his/her control as long as possible—sometimes at risk to the patient—to avoid losing the patient to a specialist.
Specialists in the field agree that, as institutions have become better equipped, the healthcare system remains in need of change that will benefit medical personnel and the public.
The prevailing opinion is that the best option for a proper healthcare system is the transition to medical insurance, paid by employers as part of an employment package.