Letter from Henry Marsh, Consultant Neurosurgeon, Atkinson Morley's Hospital, Wimbledon, England

My first visit to Ukraine was in 1992, one year after the Soviet Union had fallen apart. With two other British doctors I had been taken to Kiev by a British businessman who was hoping to sell medical equipment in Ukraine , and who arranged for us to deliver a series of lectures on the equipment used for modern neurosurgery at the prestigious Institute of Neurosurgical Research in Kiev. We received a polite but suspicious reception from the many senior professors and surgeons we met. They clearly wanted to be seen as our neurosurgical equals, if not superiors, and were proud of their enormous Institute which, we were told, was the largest dedicated neurosurgical institution in the world, with eight floors and five hundred beds. It was also clear that they longed for the contact with the West which had been denied to all but the most senior of them in the days of the Soviet Union.They must have known, however, that their Institute - a specialized hospital that in the past had treated patients from the whole of the Soviet Union - was pathetically ill-equipped and inefficient by Western standards, and had since deteriorated even further since the end of the Soviet Union and the rapid decline of the economy in Ukraine. We were shown round the huge and cavernous building, and yet saw only a handful of patients and little, if any, evidence of clinical activity. In terms of equipment, apart from a relatively modern angiography suite there was only a single, battered stereotactic frame, one old-fashioned operating microscope and a few metal boxes of battered and ancient-looking operating instruments. Yet the senior professors showing us round made only a few euphemistic comments about 'economic difficulties' and it was clear that direct questions about what we were seeing were not to be welcomed. I left the building not only shocked and depressed but also angry and frustrated, although I could well understand why the Ukrainian doctors I had met were deeply reluctant to admit their humiliating situation to an affluent Western outsider like myself.

I was asked next day if there were any other medical visits I would like to make and I replied that I was interested in the treatment of trauma, which was not dealt with at the Institute ( which handled only elective cases). After some discussion my guides agreed, a little reluctantly I felt, and I was therefore taken to the so-called Emergency Hospital a few miles away in the outskirts of the city. I was told that this had been built ten years ago but it already looked derelict, and conditions were far worse than in the Institute of Neurosurgery. The hospital reeked of ammonia - the only disinfectant available at the time - and much of the building was in darkness. There were endless dark concrete corridors, a few battered pieces of furniture, and no medical equipment visible anywhere. The 'resuscitation room' in the Emergency Department consisted of a battered trolley without any medical equipment in sight whatsoever. While walking along one of these awful corridors a young doctor suddenly bounded up to me and started talking in broken English. He had never met a Western doctor before and had taught himself English by listening to the BBC. He explained that he was in charge of the department of spinal trauma and immediately said that the situation in Ukrainian hospitals was utterly terrible.

This was Dr. Igor Kurilets, and the beginning of my work with him and his colleagues over the next ten years. When we started working together he was an obscure doctor working in one hospital in Kiev, with scarcely any equipment at all, treating only a couple of hundred patients a year. At the time of writing this he is now probably one of the most famous doctors in Ukraine, whom patients travel to see from all over the country, with a fully equipped modern operating theatre, treating thousand of patients every year. They receive treatment which is directly equivalent to what they would receive in the West. He has become something of a national figure, and has been seen on national TV countless times. Yet this success has only been achieved at immense cost and in the face of intense opposition from many members of the senior medical and administrative hierarchy. He has been declared to be a schizophrenic, he has been sacked twice, has received many threats, has been denounced by a series of 'Official Enquiries', and there have been endless attempts to close his department. Yet more and more patients come to see him and his team because they know that they will receive excellent care, and surgery if necessary, at his hands.It is probably this very success with patients that has made him so many enemies with those of his colleagues who have been unable to compete with him.

Ukraine is still profoundly influenced by its Soviet past, indeed some would say that an entire generation will have to die before real change and progress can occur. The Soviet Union did not encourage initiative or independence in its subjects - obedience and conformity were all. For seventy years people like Igor Kurilets were killed, imprisoned, exiled or cowed into submission and silence. These same attitudes survive to the present day, albeit in a slightly less extreme form. Dr.Kurilets' difficulties have been entirely typical of what happens to those who openly criticize the system and try to change things. What has been unusual is that he has survived so far and is still working. That this has been possible has been the result of several influences - the support of his patients and the media, his contacts with the West, and his own outstanding courage and determination.

The co-operative work between Igor Kurilets and his team in Ukraine and between Henry Marsh and his colleagues in the West has had three phases.

1. Exchange visits between Ukraine and UK where Dr.Kurilets and his doctors could observe and learn modern medical techniques in the UK and where Henry Marsh and his colleagues could learn at first hand in Ukraine the difficulties facing their Ukrainian colleagues.

2. The collection in British hospitals of surplus medical equipment and taking it out to Ukraine. Medical equipment has to be built to a high standard but for commercial reasons will often be deemed obsolescent long before its useful life is over. As a result most hospitals in the West are full of perfectly usable, modern equipment that is not used. Hospital administrators are often very sympathetic to requests for this equipment to be donated for charitable use. Aid of this sort is only a temporary solution to the problems of countries such as Ukraine, and must be combined with technical training and support. Nevertheless, its value in saving lives and helping patients is not to be underestimated. Transporting the equipment out to Ukraine has not always been easy but through a combination of help from the British Embassy and taking the equipment out personally , we have been able to equip Dr.Kurilets and his colleagues with an entire modern operating theatre at minimal cost.

3. The establishment of an Internet link so that clinical problems can be quickly discussed and appropriate advice on the interpretation of scans and XRays can be given.

Trying to establish effective, sustainable, long-term co-operation between Western doctors and their colleagues in the former Soviet Union is not, in my experience, easy. Yet the potential for co-operation, and for improving health care in those countries is immense. There are various, quite specific reasons as to why this kind of work can be so difficult..

The Cold War attitudes of the old Soviet Union often still survive - both in Russians and Ukrainians and in visiting Westerners. The medical system of the Soviet Union, with its huge Research Institutes and many specialized departments, was designed to look much better on paper than it was in reality. Although treatment was in principle free to all, in practice patients had to pay 'under the table' for much of it, and the privileged elite enjoyed much better treatment than those below them. This is no different from the West,of course, where wealth also buys one better treatment but in the Soviet Union there was much propaganda and dishonesty from the ruling elite which claimed that these differences did not exist. In its increasingly desperate and ultimately unsuccessful attempt to remain a world power, the authorities in the former Soviet Union had to erect a huge edifice of deception and pretence that the social institutions of the country were as advanced as its space and military technologies, when the reality was that the huge expenditure required to keep up with the West in the arms and space races had a disastrous effect on the country as a whole. This tendency to deny reality, and to pretend that things are much better than they really are, persists to the present day. Many Ukrainian doctors I have met will tell me that Ukrainian medicine is as good as anywhere else in the world and yet this is clearly an absurd claim with life expectancy in the country steadily worsening and with reports of epidemics of diseases such as diphtheria and hepatitis. Problems clearly cannot be solved if they are not initially admitted and identified. However, nobody likes to admit their problems to strangers and successful co-operation always requires trust and mutual respect.

Trust takes time to develop and if one wants to see any real progress from working with ex-Soviet colleagues one must be prepared to commit oneself for many years. This means regular visits and accepting many set-backs in the hope that they are only temporary.

There is little money available for work of this kind in countries such as Ukraine. Annual per capita health expenditure is about $100 compared to $1800 in the UK and $2500 in the US. Financial support is obviously essential. However, it is also important that one's Russian or Ukrainian colleagues meet some of the costs of the co-operative programme themselves so that they do not develop the mind-set of being passive recipients which can turn professional co-operation into humiliating charity. On my visits to Ukraine I have always stayed in my colleagues' apartments and it has been agreed that all my expenses, and the expenses of the many Western colleagues who have accompanied me, should be met by our Ukrainian hosts. Money has also been required to buy medical equipment which we have not been able to find free and second-hand in the West. Nevertheless, provision of equipment must be seen only as a pump-priming exercise. If the work is to be sustainable in the long term our Ukrainian colleagues must find their own solutions to their economic problems.

It was partly for this reason that Dr.Kurilets and his team have now left the government's Emergency Hospital and are running a private clinic run on a commercial basis. Government finances in Ukraine are in such a poor state that it proved impossible to continue to practice modern neurosurgery in an almost derelict hospital, especially in the face of continuing hostility from the administration, who felt threatened by Dr.Kurilets' independence and, at times, almost revolutionary progress. The concept behind the new private clinic goes back to the 'Free' Hospitals found in the UK before the NHS was created. Patients pay for treatment according to their means and there is charitable support for poor patients. In our case part of the charitable support takes the form of visits and medical advice ( now largely conducted over the Internet) from Western specialists. We are still aiming to supply vital pieces of medical equipment if it proves impossible to obtain them locally. This concept - of a private clinic providing free treatment for poor patients - is a new one in Ukraine. It has already been hugely successful in terms of the numbers of patients treated although the financial viability of the scheme is yet to be proven. We hope that it might prove a model for the country as a whole.

Although Ukraine has free, democratic elections there are many differences from the Western democracies. However successful one's new medical clinic might be, one must have political patronage at some level in the government if it is to survive. Ukraine, as with all the countries of the former Soviet Union, is governed by a huge governmental bureaucracy in direct descent from the all-powerful Communist Party of the past. There is still a strongly feudal element to the way the country functions and the rise of the mafia and 'gangster capitalism' reflects this. At the moment Dr.Kurilets' new clinic has the strong support of the local chief medical officer for the suburb of Kiev where the clinic is located.

FUTURE PLANS.

1. We hope to continue the annual exchange visits between Ukraine and the UK and USA that have been a feature of our work for the last ten years. There is little point in bringing doctors from Eastern Europe to the West for more than a few weeks. If they stay for too long they will incur hostility and jealousy on their return home and they also become deeply depressed by what feels like an insurmountable gap between what they have seen in the West and what is practical in the East. Short visits for many doctors, combined with as much support and technical help on their return as possible, is probably more helpful than long visits for a few doctors. Eastern European doctors who have spent long periods of time in the West tend either never to return or to be dismissed or sidelined on their return.

2. We have now established a strong Internet connection. With financial support in the past from the UK government we have equipped some of our colleagues in Ukraine with PCs and scanners. They regularly send us scans and data on difficult cases via the Internet and we can give them accurate advice as to how to deal with the problem. This has been a great success and we are anxious to extend the link to other countries in the former Soviet Union. We already have contacts with the paediatric neurosurgical hospital in St.Petersburg, although our colleagues there need better computer equipment. Greg Foltz and Henry Marsh are planning on visiting St.Petersburg later this year to see what can be done to improve this connection.

3. The treatment of children with hydrocephalus has been revolutionized in the West in recent years by the use of endoscopic surgery ( "keyhole surgery"). If successful it means that children can be cured of the problem whereas in the past it meant the children remained dependent on an inserted "shunt" - a length of valved plastic tubing - that would often require further operations that were not without significant dangers. Little, if any, endoscopic surgery is carried out in countries like Ukraine for children with hydrocephalus. Since shunts are very expensive, many children with hydrocephalus are not even treated, leading to death or long term brain damage. We plan to help our Eastern European colleagues develop paediatric endoscopic surgery. We have found a hospital in Lviv, in Western Ukraine, with some limited endoscopic equipment which we can probably adapt to use in children with hydrocephalus. If we are successful in Lviv we hope to encourage neurosurgeons elsewhere to learn the technique and help them acquire the necessary equipment. The equipment is fragile and we will have to train the operating theatre staff in its care and maintenance as much as the surgeons in its use. In May, Henry Marsh, Richard Hatfield and Greg Foltz will be travelling to Lviv to carry this plan forward. They will also be taking with them an Olympus operating microscope, generously provided by the University Hospital of Wales, to Lviv. The plan is to install this in a privately run hospital there. The hospital's management has agreed that in return for this equipment they will provide free treatment for a specified number of poor patients who cannot afford to pay for their own treatment.

4. We intend to continue to look for surplus equipment in Western hospitals which could be put to good use in the countries of the former Soviet Union.

We want to demonstrate that co-operation between Western doctors and their colleagues in the former Soviet Union, at a direct personal level and not only at the level of large organizations, can produce enormous benefits to patients.

We want to show that being open and honest about the problems facing doctors and patients in the former Soviet Union, although painful, is not only necessary if one is to set about solving these problems but immensely effective if one has a close working relationship with Western colleagues based on trust and mutual respect.

Kiev

Lviv