Correspondence
Societal and political will for cancer prevention in Russia Paul Goss and colleagues’ Commission is comprehensive and, in my opinion, largely correct in the assessment of Russian health care. However, some points should be commented on by an insider. Admittedly, some of the statements below, not supported by references, are opinion. However, it would be hardly possible to discuss societal and political will for cancer prevention without opinions and observations because there is not much objective evidence. Goss and colleagues stated that the Russian population was expected to decline by 30% over the next 50 years, potentially threatening the demographic, social, and economic prosperity of the region.1 This statement is probably an exaggeration. The 2010 census in Russia was rather perfunctory; many people did not participate and some did not know that it had taken place. Goss and colleagues also state that a gender gap in life expectancy has led to instability in marriage and a high proportion of widows.1 This gap, with a female predominance resulting from the shorter life expectancy in men, affects mainly elderly and middle-aged people, beyond childbearing age. In younger age groups, the male-to-female ratio is higher, partly due to the immigration of young men. The roles of preference for sons and sex-selective abortion in Russia are not known, but these factors have played a part in a gender imbalance at birth in Transcaucasia,2 from where some immigrants come to Russia. Although the role of alcohol in premature mortality cannot be denied, there is nonetheless a tendency to exaggerate it. Such exaggeration tends to veil shortcomings in the health-care system, www.thelancet.com/oncology Vol 15 July 2014
with responsibility for the low life expectancy, especially in men, shifted to the patients—ie, selfinflicted diseases caused by excessive alcohol consumption. The decrease in consumption of alcohol and heavy binge drinking over recent years is notable; the main causes, in my opinion, include an improved responsible way of life within a market economy, intimidation of and crime against alcohol misusers and people with alcohol-related dementia, including appropriation of their residences and other property, and the abundance of falsified alcoholic beverages sold legally in shops.3 Recent governmental anti-alcohol measures have been rather superficial; together with the accompanying rhetoric, they seem to be distracting public attention from the problems—corruption, shortages in health care, and social security—which the government does not tackle. The problems of the health-care system and medical education in Russia are correctly delineated by Goss and colleagues. However, one important factor should be mentioned: some former party and military functionaries, their children and protegees, have lead positions in universities, academies, health-care authorities, and medical institutions. Medical education, research, and practice require hard and meticulous work, leaving almost no leisure time. Some of the functionaries’ children are not accustomed to it. Besides, military and medical ethics are not the same. The low life expectancy in Russia, especially for men is a strategic advantage—including fewer health-care investments and pensions—and could be one of the motives for the generally inadequate cancer prevention and late detection. Middle-aged and elderly men are sometimes unwelcome in government polyclinics (outpatient facilities), and some personnel behave offensively towards them.
The predominance of middleaged and elderly women over men among the policlinic visitors is well known in Russia. In terms of cancer diagnostic methods, during the time of the Soviet Union, elderly patients were sometimes sent from one physician to another to delay or avoid an operation. Today, there are a set of diagnostic procedures that are covered by medical insurance. However, the patients are often advised to have additional diagnostic procedures (eg, CT, MRI, immunohistochemistry), sometimes with questionable indications and which often cause delays, for which they cover the costs. Despite the economic upturn in Russia, it will be naive to think that matters would improve spontaneously in the near future. Considering the shortcomings of medical research and education,4 and insufficient adherence to the medical ethics by some health-care organisers and medical professionals,5 a simple increase in funding is unlikely to be a solution. Measures for improvement of the public health system in Russia must include the invitation of officially authorised foreign advisers, managers, and experts and shortterm practice by Russian doctors abroad. I declare no competing interests.
Sergei V Jargin [email protected] Peoples’ Friendship University of Russia, Clementovski per 6–82; 115184 Moscow, Russia 1
2
3
4 5
Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, et al. Challenges to effective cancer control in China, India, and Russia. Lancet Oncol 2014; 15: 489–538. Michael M, King L, Guo L, McKee M, Richardson E, Stuckler D. The mystery of missing female children in the Caucasus: an analysis of sex ratios by birth order. Int Perspect Sex Reprod Health 2013; 39: 97–102. Jargin SV. Changing pattern of alcohol consumption in Russia. Adicciones 2013; 25: 356–57. Jargin SV. Some aspects of medical education in Russia. Am J Med Stud 2013; 1: 4–7. Jargin SV. Renal biopsy for research: an overview of Russian experience. J Interdiscipl Histopathol 2014; 2: 88–95.
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Societal and political will for cancer prevention in Russia Paul Goss and colleagues’ Commission is comprehensive and, in my opinion, largely correct in the assessment of Russian health care. However, some points should be commented on by an insider. Admittedly, some of the statements below, not supported by references, are opinion. However, it would be hardly possible to discuss societal and political will for cancer prevention without opinions and observations because there is not much objective evidence. Goss and colleagues stated that the Russian population was expected to decline by 30% over the next 50 years, potentially threatening the demographic, social, and economic prosperity of the region.1 This statement is probably an exaggeration. The 2010 census in Russia was rather perfunctory; many people did not participate and some did not know that it had taken place. Goss and colleagues also state that a gender gap in life expectancy has led to instability in marriage and a high proportion of widows.1 This gap, with a female predominance resulting from the shorter life expectancy in men, affects mainly elderly and middle-aged people, beyond childbearing age. In younger age groups, the male-to-female ratio is higher, partly due to the immigration of young men. The roles of preference for sons and sex-selective abortion in Russia are not known, but these factors have played a part in a gender imbalance at birth in Transcaucasia,2 from where some immigrants come to Russia. Although the role of alcohol in premature mortality cannot be denied, there is nonetheless a tendency to exaggerate it. Such exaggeration tends to veil shortcomings in the health-care system, www.thelancet.com/oncology Vol 15 July 2014
with responsibility for the low life expectancy, especially in men, shifted to the patients—ie, selfinflicted diseases caused by excessive alcohol consumption. The decrease in consumption of alcohol and heavy binge drinking over recent years is notable; the main causes, in my opinion, include an improved responsible way of life within a market economy, intimidation of and crime against alcohol misusers and people with alcohol-related dementia, including appropriation of their residences and other property, and the abundance of falsified alcoholic beverages sold legally in shops.3 Recent governmental anti-alcohol measures have been rather superficial; together with the accompanying rhetoric, they seem to be distracting public attention from the problems—corruption, shortages in health care, and social security—which the government does not tackle. The problems of the health-care system and medical education in Russia are correctly delineated by Goss and colleagues. However, one important factor should be mentioned: some former party and military functionaries, their children and protegees, have lead positions in universities, academies, health-care authorities, and medical institutions. Medical education, research, and practice require hard and meticulous work, leaving almost no leisure time. Some of the functionaries’ children are not accustomed to it. Besides, military and medical ethics are not the same. The low life expectancy in Russia, especially for men is a strategic advantage—including fewer health-care investments and pensions—and could be one of the motives for the generally inadequate cancer prevention and late detection. Middle-aged and elderly men are sometimes unwelcome in government polyclinics (outpatient facilities), and some personnel behave offensively towards them.
The predominance of middleaged and elderly women over men among the policlinic visitors is well known in Russia. In terms of cancer diagnostic methods, during the time of the Soviet Union, elderly patients were sometimes sent from one physician to another to delay or avoid an operation. Today, there are a set of diagnostic procedures that are covered by medical insurance. However, the patients are often advised to have additional diagnostic procedures (eg, CT, MRI, immunohistochemistry), sometimes with questionable indications and which often cause delays, for which they cover the costs. Despite the economic upturn in Russia, it will be naive to think that matters would improve spontaneously in the near future. Considering the shortcomings of medical research and education,4 and insufficient adherence to the medical ethics by some health-care organisers and medical professionals,5 a simple increase in funding is unlikely to be a solution. Measures for improvement of the public health system in Russia must include the invitation of officially authorised foreign advisers, managers, and experts and shortterm practice by Russian doctors abroad. I declare no competing interests.
Sergei V Jargin [email protected] Peoples’ Friendship University of Russia, Clementovski per 6–82; 115184 Moscow, Russia 1
2
3
4 5
Goss PE, Strasser-Weippl K, Lee-Bychkovsky BL, et al. Challenges to effective cancer control in China, India, and Russia. Lancet Oncol 2014; 15: 489–538. Michael M, King L, Guo L, McKee M, Richardson E, Stuckler D. The mystery of missing female children in the Caucasus: an analysis of sex ratios by birth order. Int Perspect Sex Reprod Health 2013; 39: 97–102. Jargin SV. Changing pattern of alcohol consumption in Russia. Adicciones 2013; 25: 356–57. Jargin SV. Some aspects of medical education in Russia. Am J Med Stud 2013; 1: 4–7. Jargin SV. Renal biopsy for research: an overview of Russian experience. J Interdiscipl Histopathol 2014; 2: 88–95.
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