PubL Hlth, Lond. (1979) 93, 31.-38
Aspects of the Anti-Cancer Programme in the Soviet Union Michael Ryan Ph.D. and
David Martin B.Litt.
University College of Swansea, Department of Socia/ Policy and Social .Work, Singleton .Park Swansea. G/amorgan Introduction In an article published fairly recently in Pravda, the Health Minister ofthe U.S.S.R. made tile claim that "The Soviet Union is the first country in the world to have created a governmental system for the campaign against cancer and a specialized oncological service for its population. 'u Whether this assertion could be supported by detailed investigation appears doubtful but anyhow to discuss its historical accuracy is to miss the point--namely that it fits a pattern of propaganda which emphasizes the outstanding concern of the Soviet state for the health and welfare o f its citizens. Rather than enquire into historical origins, it is clearly more fruitful to record the current incidence of cancer mortality and morbidity and to examine the organization o f the anti-cancer service as it exists today. A t the outset reference should be made to the fact that, in general, description and evaluation of the Soviet health service are rendered difficult by thecomparative dearth of published material which is accessible to Western researchers, even to those who can translate from original sources in Russian. (This point has been developed further by one o f the authors in a recent book. 2) However, this difficulty tends to be less acute in the case of developmentsor programmes--such as the oncological service--for which a shroud of secrecy is considered unnecessary.
Mortality and Morbidity Despite the fact that the Soviet Union does not publish detailed mortality data on an annual basis, it is clear that deaths from cancer must constitute a substantially larger percentage of all deaths in the 1970's than in the immediate post-war period at which time, apparently, the oncological service was inaugurated. Since then economic development on a massive scale, together with a range of associated influences, .has resulted in a sharp decrease in the incidence of infectious diseases and tuberculosis. I n the Soviet Union today, as in advanced industrial countries of the West, cardio-vascular illnesses are currently the great killers; in 1972, the latest year for which these data are available, they accounted for 48"7 ~ o f all deaths. The broad grouping of conditions termed malignant neoplasms comprised the next largest category. In the same year they accounted for 15.3 ~ of deaths registered in the Union as a whole.3 That percentage is certainly less than the corresponding figure for England, which stood at 20-7 ~o in 1971. However, the figure f o r England had risen from 15-7 Yo20 years earlier 4 and 0038-3506/79/010031 +08 8OI.00/0
~.) 1979The Societyof Community Medicine
M. R)'an mid D, Martht
32
it could be argued that, with the passage o f time, the Soviet experience will c o n t b r m m o r e closely to our own. This a r g u m e n t turns o n the facts that the chances o f dying f r o m certain f o r m s of c a n c e r are substantially higher in the older a g e g r o u p s and t h e d e m o g r a p h i c "'ageing" of the population which has happened in Britain is n o w also occurring in tile Soviet Union. Since the collective c a t e g o r y o f m a l i g n a n t neoplasms has been sub-divided in the statistics, it is possible t o give a picture ,of the distribution o f mortality by reference to p r i m a r y sites for t h e years 1971-72. T h e d a t a in question are s h o w n in T a b l e I. As can be seen, t h e largest percentage of d e a t h s .from cancer originated in the s t o m a c h in the case o f b o t h men and women. This c o n t r a s t s with the situation in England where the c o m m o n e s t site a m o n g males who died o f cancer was t h e trachea, lung or b r o n c h u s , while a m o n g females it was t h e breast. Whether t h e Soviet mortality rate for cancer o f the lung is .currently increasing c a n n o t be established but :in this context it is w o r t h noting t h a t the Health Minister expressed a l a r m a b o u t the g r e a t e r p r e v a l e n c e o f s m o k i n g a m o n g w o m e n . " A significant extension o f this dirty habit a m o n g w o m e n " , he wrote, " h a s p u t on the agenda yet a n o t h e r c o m p l e x p r o b l e m . . . ''~ TABLE 1. Deaths from malignant neoplasms in U.S.S.R., 1971-72 Mortality rate per 100,000 persons
Site of neoplasm
Buccal cavity and pharynx Oesophagus Stomach Intestine excluding rectum Rectum Other digestive organs Lmynx Trachea, Bracchus, Lung Other respiratory organs Mammary glands Cervix uteri Other and unspecified parts.of the uterus Other female genital organs Prostate Other male genital organs Urinary system Skin Bone and connective tissue Haematopoietic organs and lymphatic tissue Other localizations or localizations without indications Deaths from all malignant neoplasms Deaths from all causes
Standardized mortality rate per 100,000 persons Males Females
Total
Males
Females
1-8 6.3 39.8 4.6 4-2 I l-I 1-8 20-3 0"4 5.4 5.1 3-0 3-9 1-5 0-3 4-2 0.9 1-5 7-5
2-7 7-6 44.7 3-8 3-4 I i -4 3-5 34.9 0-5 0.3 --.-3-3 0.7 6-1 0.9 I-7 8.6
l'! 5. i 35.6 5-2 4.8 10.8 0.4 7.8 0-3 9.9 9.5 5'6 7-2 -I 2-5 0-9 t-3 6-6
3-6 10.5 59.9 5-0 4-5 i 5- I 4'6 46'6 0-5 0.3 ---4-6 0.9 8.2 1.1 2-1 I 0.0
0,9 4.1 29.5 4-3 3-9 9.0 0-3 6.5 0"1 8.6 8.2 4.8 6.2
6.0 129-6 836"6
6-1 140-2 898-5
5.9 120-5 783-4
7.2 I84-3 1119.7
5-1 101-9 660.6
-2-2 0.8 1-3 6-1
Note: The standardized mortality rate is calculated on the basis of the age and sex structure of the populationat I January 1972. Source: Sovetskoe Zdravookhranenie 4, 1974~ p. 94. Both crude a n d standardized mortality rates are given in Table 1. A c o m p a r i s o n o f the standardized indices reveals that males are 1-5 times m o r e likely t h a n w o m e n to c o n t r a c t cancer o f the l y m p h a t i c a n d h a e m a t o p o i e t i c tissue, a l m o s t 1.9 times m o r e likely to c o n t r a c t cancer o f the stomach, twice as likely to suffer f r o m cancer of the o e s o p h a g u s a n d 5-7 times m o r e likely t o suffer f r o m canc6r o f the trachea, b r o n c h u s or lung.
33
Anti-cancet" programme in the Soviet Union
Turni'ng t o the question o f morbidity, it can be said that despite the paucity of hard data there is .no doubt that malignant growths have been diagnosed in an increasing number of patients. This can be ascribed not only to the increasing proportion of elder'ly persons in the Soviet population but also to improvements in diagnostic competence a n d methods o f TAm:E2. Cancer morbidity in the U.S.S.R., 1972-3
Site of disease
Btaccatcavity and pharynx Lower lip Oesophagus StomacN Rectum Larynx Trachea, bronchus, 'lung Skin Mammary glands Cervix uteri All malignant neoplasms
Number of cancer Number of patients in whom cancer was diagnosed patients per 100 000 population :under for the first time surveillanceat the per 'I00 000 population end of 1973 Both sexes Males Females 2-8 10-0 8.2 47.2 4-7 6-4 39.2 38.4 --182.8
2.3 2-3 5-9 37.0 6-6 0.5 8.9 44.7 20.9 24-7 187-5
8-3 70-2 5-9 59-8 12-8 i 1-6 21-9 184-7 62-4 116-.1 675-2
Source: I. S. Sluckanko,G. F. Tserkovni, (I 976) Statisticheskaya btformatsO,a v upravlenff uchrezhdeniyarni zdravookhraneniya p. 82. Moskva; Meditsina. investigation. Data have been published for the years 1972-73 and these show that malignant ~eoplasrns were diagnosed for the first time in 182-8 males per 100,000 while the figure for ~v0rnen stood slightly higher at 187.5 per I00,000 persons. Table 2 gives a partial breakdown of these totals by site. I t can be seen that the total of diagnosed cases under regular surveillance amounted t o 675-2 per I00,000 persons at the end o f 1973. That is not far short of t~vice the figure recorded in 1961.
In.Patient Treatment Among international comparisons of anti-cancer programmes, the Soviet Union is likely to show up ~vell, even if only because its service is an easily identifiable element within the total health scheme. In this respect it conforms to the pattern of provision f o r certain other disease categories and for broad groups o f the population, most .obviously mothers and children. "There can be little doubt that the combined effects o f specialization (even a t the level of primary care) and disaggregation o f the population make for a far more fragmented health service than obtains in the United Kingdom. Some o f the disadvantages of this arrangement, as seen from a patient's viewpoint, are referred to later in this article. To identify theextent o f in-patient accommodation allocated to oncology is straightforward, since the data are published on an annual basis. The statistical year book covering the whole ~c0nomy (there is none for the health service alone) reveals that in 1950 there were 12,200 beds for cancer patients; these accounted for 1"2~o o f the total bed complement. By 1975 .the n u m b e r o f beds had risen very substantially to 50,600. However, this amounted to no ~ 0 r e than t.68 Y0 o f all beds, reflecting the vast increase that had occurred in the total
34
M , R ran apM D. Martht
complement. In facl the Soviet Union today has one of the most generous hospital-topopulation ratios in the world and this situation is inextricably linked with the fact that Soviet clirficians admit patients to hospital far more readily than do their counterparts in many countries including Britain. Although patients receive treatment in cancer deparlments of general hospitals, many .are admitted ~o the wards of single-purpose institutions known as oncological dispensaries. There are some 250 ofthese and their number will increase since current plans envisage taking the concept of such a unit to its logical extreme. That statement is made on the basis .of a resolution which was passed by the U.S.S.R. Council of Ministers (broadly speaking, the government) in April 1976. Among other things, the resolution called upon the health service to "take steps to develop the network of onco!ogical institutions, having in mind the establishment o f large oncological dispensaries, including in-patient facilities and nursing homes, and the improvement o f .existing dispensaries by the addition of radiology departments°'. ~ The c urren~ drive to provide larger units appears to reflect not only the emphasis on a high degree o f specialization among medical staff but also on the concept o f economies of scale in the use o f expensive capital resources. This is not the place to enter into detail on ~he subject of diagnostic and therapeutic equipment, but it is relevant here to note that for many years local irradiation therapy has been a major weapon used by Soviet clinicians in their fight against cancer. However, surgical intervention continues to be the main method oft'reatment while chemical and hormonal preparations are employed as well. In-patient accommodation is also located within the scientific research institutes devoted to the study of the aetiology, diagnosis and treatment of cancer. These institutes, which number20, mostly provide the highest level ofctinicaI practice in this field for the 15 republics which make up the Soviet Union. At the very-peak of the pyramid, as it were, stands the Institute of Experimental and Clinical Oncology Which, in effect, is the cancer research centre o f the U.S.S.R. Academy of Medical Sciences. Also widely known for its extensive research activity is the Moscow Oncological :Scientific Research :Institute named after P. A. Herzen. It is such institutes which are the f i r s t ~ a n d sometimes the o n l y I u n i t s to be issued with the latest and most sophisticated medical equipment. Examples cited by the Health M inister in the article quoted earlier include gamma-therapy machines and sources .of high energy radiation such as,betatrons and linear accelerators. He also referred to prototypes of apparatus incorporating the latest advances in nuclear physics and .to thermoradiographic equipment (teplovizor) which can be used in the diagnosis of the early stages o f several forms o f cancer. Although organizational data on hospital activity is rudimentary and infrequent by British standards, it is possible .to present a limited amount of basic information relating to cancer wards and hospitals. Thus the average duration o f ztay in urban units in 1973 was comparatively long, being 28-2 days per cancer patient as against an average o f 15.2 days for all beds excluding those devoted to psychiatry. In rural units the corresponding figures were 32-6 and 13"2 days. For the same year deaths and discharges per cancer bed numbered t 1-2 as against the average o f 20.9 for all beds (excluding psychiatric) in urban units. The corresponding figures for rural institutions were 7-.8 and 22-6. On a point of detail, itshould be mentioned that these data derive :from statistical returns for the main health service which is controlled by the U.S.S.R. Health Ministry and take no account ofthe practice of hospitals subordinated to other departments and ministries. 6 From lime to time Soviet medical journals publish figures :for case fatatity rates which deserve attention even if they are based on the experience o f just one hospital. The most recent, which were published in 1974, relate to an area of'Leningrad and apparently exclude
35
Anti-cancer programme ht the Soviet Union
cancer institutes and dispensaries. The fatality rate was high, being 36.0% of all cancer cases as against an average of 4-0','/o for all patients. But the source slressed that this high figure was to be explained primarily by reference to the presence in the wards ofpalients with advanced, neglected and incurable forms of this disease.; Out-Patient Care Passing on n o w t o consider provision for ambulant patients, attention must first be drawn to a major definitional issue. The Soviet health service, unlike il.s British counterpart, has not institutionalized the general -medical practitioner as the doclor o f first contact. It is certainly true that in urban areas two types o f d o c t o r on the staffofpolyclinics, general physicians and paediatricians, are assigned to specific neighbourhoods and are intended ~o give regular advice to families as well as much initial diagnosis and treatment. Nevertheless, they are themselves special~sts not generalists by training and work alongside other specialists to whom patients may proceed directly through a process of self-referral. Thus it is meaningful to say that even ~he delivery of primary medical care in the Soviet Union occurs within a context o f specialisms, albeit qui,te broad ones for the most part. That explanation can be followed appropriately by reference to a breakdown ofconsultations by patienls using the main health service in .t970. Included in the totals are out-patient visits to hospital units, contacts in polyclinics and the like and, almost certainly, contacts with the emergency service. As can be seen from Table 3 , ~ average each member of the urban population .had a sizeable total o f 10-6 o u t p a l i e n t ~ n t a c t s with a doctor. It is also evident that there was a marked disproportion between that figure and the one fo, the rural populati.on--3.4 per person~which largely arises from the comparative shortage of doctors in rural areas. Indeed, as is familiar, the Soviet health service continues to rely heavily on TABLE 3. Out-patient contacls per person in 1970 (including home visits) Specialty Total General Medicine Cardiofheumatology Endocrinology Infectious diseases Physiotherapy Surgery T r a u m o t o l o g y - - o r t hopaedics Urology Oncology Obstet rics--gynaecology Tuberculosis Neuropa~hology Psychiatry Ophthalmology ENT Dermalovertereology Curative physical culture & supervision o f persons active in physical culture & sport Paed]atrics Stomatology
U r b a n Population Total Aduhs Children
Rural Population Total Adults Children
10'6 3~05 0"08 0-07 0.09 0'! 1 0"84 0.18 0'06 0~07 0.71 0.25 0.37 0'll 0.56 0.61 0'56
10-7 4-04 0~06 0-08 0-10 0-12 0-98 0,21 0-08 009 0.94 0'25 0.47 0.12 0-56 0.60 0.56
10-4 0-11 0. ! 3 0,06 007 0-08 0.41 0.09 0.01 -0.02 0.25 0.08 0.10 0-54 0.(/4 0-59
3'4 ! "03 0"0! 0-02 0.02 . . 0.32 0.02 0.01 0"04 0-21 0" 14 0. t 0 0"04 0-16 0.t4 O. 15
3"8 1-3 ! 0.0 ! 0~03 003 . . . 0'43 0-03 0-02 0-05 0.32 0.17 0.15 0-05 .0"19 0-16 0-15
0.12 OqO O. 15
0-07 1-52 1.29
0-06 0-04 1-34
0-08 5-99 I- 15
-0.41 0-5g
-0-02 0.68
-1-18 0.39
Source: Popov, G. A. (1974). Prablemi Vrachebnikh Kadrav, Meditsina, Moskva. 1974, p. 100.
2"6 O.,14 --
0.10 0.0 I 0-01 0.08 0-02
36
M. Ryan and D. Marth2
doctor-surrogates known as feldshers for the provision o f initial diagnosis and appropriate treatment in many outlying areas. In the specialty of oncology an average of 0.07 contacts per urba~n person was registered while the corresponding figure for the rural population was 0"04. These contacts took place not only in the special-purpose units such as the oncological dispensaries but also in ordinary polyclinics. For some years now, the policy of the U.S.S.R. Health Ministry has been to lhvour the establishment of separate dispensaries in various fieldsmskin andvenereal diseases, ~uberculosis, psychoneurology as well as cancer--but some increase in polyclinic consulting rooms for these specialties has also occurred. In the guidelines for the development o f the health service over the years 1971-75, the Ministry indicated that towns and districts which did not possess self-standing dispensaries or the co~nditions for their establishment should create a set of appropriate departments or consulting rooms within their polyclinics. 8 In urban areas a sizeable proportion o f out-patient contacts are accounted for by health checks which are in effect obligatory for specific groups. Attendance at a polyclinic is ensured by various sanctions and it appears that even officially recognized writers cannot avoid spending one day per year going the rounds o f the various departments or consulting rooms. In respect o f cancer, specifically, the U.S.S.R. Health Minister has emphasized the impor:tance of regular annual inspections--"especially of persons of advanced age." Evidently the Soviet health bureaucrats consider that patients suffering from cancer witl benefit as a result of the earlydetection o f the disease and, presumably, t h a t a mass screening programme is also justified on grounds o f cost-effectiveness. However, it is not clear beyond doubt that conventional wisdom in this matter has been subjected to fundamental appraisal and subsequently endorsed. Whether the massive resources devoted to screening could be rather more effectively deployed in the field o f health education is a question which may not even have been asked with any insistence. That is not t o d e n y that attempts are made to remind the Soviet public of the well-proven connection between cigarette smoking and cancer of the lung. But, in the authors' opinion, the anti-smoking campaign is being waged at a significantly lower level o f intensity than in Britain.
A Patient's Viewpoint In order to convey some sense of what it is like to experience treatment under the anti-cancer service, a few extracts will now be quoted from a publication by a contemporary Soviet writer, Vladimir Soloukhin. Although his descriptions are conveyed through the medium o f a literary genre (a form of short story), there are strong grounds for assuming that they conveyan accurate account of reality. Among other reasons, Soloukhin's reputation rests in part on his precise observations o f the world in which he moves. Interestingly enough, in his story Solot,?~:hin first gains insights into the treatment o f cancer not as a patient but as a writer interested in what might be called the "human angle" of work carried out in a surgical department o f a Moscow institute. Among the impressions he .chooses to record is the attitude towards terminal cases displayed by the Professor in charge o f the department. (The man is named as Boris Alexandrovich Petrov and it can be shown that the biographical details given in the story correspond to those of just such a Professor working at the institute in question.) This doctor is quoted as saying to a woman patient: "It will go. At this stage o f t h e disease it's always like th~.t. That's normal. Lateronit wilt be better, completely alright.'" Shortly afterwards he explains to Soloukhin that the tumour was inoperable.and that the patient had not long to live. When challenged about his encouraging words he replies as follows. "'In the first place, as a doctor I do not under any
Anti-cancer programme in the Soviet Union
37
circumstances have the moral right to tell a patient I hat he will get worse and die soon. And., in the second place, she cannot get any worse. Anything is better for her now--even d e a t h . . . " As one of the authors was able to discover during a recent study-tour in the Soviet Union, such attitudes are very common, if no't universal. Anott~er revealing passage recounts lmw it happened that a small t12.:,a~ouron the writer's thigh went undiagnosed ,for three years, despite annual health checks carried out by basic specialists at the official writers" polyclinic (presumably situated in Moscow). At the firs't routine examination after the appearance of the turnout, Soloukhin says nothing about it and gives a negative reply to the surgeon's enquiry as to whether anything was bothering him. The next year he showed it to the doctor only to be informed "'It's probably a small nodule on a blood vessel." On the third occasion he was again told that it was nothing but was advised to show it to the cancer specialist (oncologist). However, Soloukhin explains that he did not follow this advice, either on account of the queue o f patienls or because the oncologis ~. t~ad left his room. It was some nine months later that the diagnosis o f cancer was made--and then only as a result of a chance encounter with a surgeon on a Black Sea beach in Georgia. To attempt to generalize from that single experience would o f course be a most hazardous undertaking, but it can at least be suggested tha,t, in .the absence o f a clearly structured referral system, what happened to the writer could happen .easily enough to others. And the views expressed by Soloukhin in a later passage certainly can be shown to be widely held; closely comparable sentiments cou,ld be quoted from other Soviet sources. The passage in question concerns the depersonalization of the doctor-patient relationship that has occurred as a result o f the development o f specialized medical technocracy. Soloukhin writes: There once existed the following medical maxim: "If a patient is not better after a conversation with his doctor, then it's a bad doctor." What are we tothink when doctors nowadays scarcely converse with patients ? Without saying anything, the first thing they do is send the patient off fo.r X-rays and tests. Without tests the doctor of today is deaf and blind. One"s way of life over recent years, any possible departures from normal life, the shocks which dlese days we call stresses, permanent inner disquiet (if it is present), its causes, positive and negative emotions, food, place of work, material discomfor~ or possible complexes--all these are areas into which the'doctor has neither the time nor the inclination to enquire. No matter what you complain of, you hear: "Tests, X-rays, electrocardiogram." A final and related point that can be made on the basis of Soloukhin's reporting concerns the compartmentalized outlook induced by the combined effects of the absence of a general medical practitioner and the fragmentation along narrow specialist lines of Soviet health care institutions. The writer relates how, two years earlier, he had suffered a sharp loss of weight and went to a large gastroenterological institute for advice. Tests indicated an excess ofbilirubin in the blood and diet was prescribed to improve the condition o f h i s liver. But in response to the question as to whether .the liver could have caused the loss o f weight he is told that it isn't.very likely. "'Then what did T', asks Soloukhin. "'Thethyroid gland perhaps ?" "'Perhaps", comes the reply, "but endocrinology is not our specialty. For the thyroid you have to attend another institute. ''9 In conclusion it must be emphasized that the quotations in the foregoing section have been selected not to contrive an unfavourable impression but simply to supplement the bland official accounts which implythat all is for'the best. Certainly there can be no denying that the Soviet Union has committed substantial resources, both of .money and manpower, to t h e developmentofits oncological service; the achievement is such as to command attention and respect. Having said that, however, it must beadded that large question marks hang over the organization ofthe programme and the related heavy emphasis on fragmentation and specialization in Soviet medical practice.
38
M. Ryan and D. Martin
References I. Pravda, 20 July 1976, p° 3. 2. Ryan, Michael (t978). The Organization of Soriet Medical Care, London: BasEl Blackweli and Martin Robertson. 3. Sorelskoe Zdravookhranenie, 4, 1974, pp. 92 and 94. 4. 77w Annual Report of the Chief Medical Officer of the Departmetst o f Health and Social Security for the Year 1971, HMSO, 1972, p. 26. 5. Iztvstiya, 18 April 1976, p. 2. 6. Popov, G. A. (1976). Ekonomieheslcie problemi I" upravlenii leehebno-prophylakticheskimi uchrezhde~li,"ami p. 160. Moskva: Medi~sina. 7. Sovetskoe 2dravookhranenie, I0, 1974, pp. 36-38. 8. G . L . Gomelskaya i drugie (1971). Ocherki razvitiya poliklinicheskoi pomoshehi v gorodakh SSSR, p. 180. Moskva, Meditsina. 9. $oloukhin, V/adimir (1975). Prigoror in ~Ioskva, 1, pp, 45-!07.
Aspects of the Anti-Cancer Programme in the Soviet Union Michael Ryan Ph.D. and
David Martin B.Litt.
University College of Swansea, Department of Socia/ Policy and Social .Work, Singleton .Park Swansea. G/amorgan Introduction In an article published fairly recently in Pravda, the Health Minister ofthe U.S.S.R. made tile claim that "The Soviet Union is the first country in the world to have created a governmental system for the campaign against cancer and a specialized oncological service for its population. 'u Whether this assertion could be supported by detailed investigation appears doubtful but anyhow to discuss its historical accuracy is to miss the point--namely that it fits a pattern of propaganda which emphasizes the outstanding concern of the Soviet state for the health and welfare o f its citizens. Rather than enquire into historical origins, it is clearly more fruitful to record the current incidence of cancer mortality and morbidity and to examine the organization o f the anti-cancer service as it exists today. A t the outset reference should be made to the fact that, in general, description and evaluation of the Soviet health service are rendered difficult by thecomparative dearth of published material which is accessible to Western researchers, even to those who can translate from original sources in Russian. (This point has been developed further by one o f the authors in a recent book. 2) However, this difficulty tends to be less acute in the case of developmentsor programmes--such as the oncological service--for which a shroud of secrecy is considered unnecessary.
Mortality and Morbidity Despite the fact that the Soviet Union does not publish detailed mortality data on an annual basis, it is clear that deaths from cancer must constitute a substantially larger percentage of all deaths in the 1970's than in the immediate post-war period at which time, apparently, the oncological service was inaugurated. Since then economic development on a massive scale, together with a range of associated influences, .has resulted in a sharp decrease in the incidence of infectious diseases and tuberculosis. I n the Soviet Union today, as in advanced industrial countries of the West, cardio-vascular illnesses are currently the great killers; in 1972, the latest year for which these data are available, they accounted for 48"7 ~ o f all deaths. The broad grouping of conditions termed malignant neoplasms comprised the next largest category. In the same year they accounted for 15.3 ~ of deaths registered in the Union as a whole.3 That percentage is certainly less than the corresponding figure for England, which stood at 20-7 ~o in 1971. However, the figure f o r England had risen from 15-7 Yo20 years earlier 4 and 0038-3506/79/010031 +08 8OI.00/0
~.) 1979The Societyof Community Medicine
M. R)'an mid D, Martht
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it could be argued that, with the passage o f time, the Soviet experience will c o n t b r m m o r e closely to our own. This a r g u m e n t turns o n the facts that the chances o f dying f r o m certain f o r m s of c a n c e r are substantially higher in the older a g e g r o u p s and t h e d e m o g r a p h i c "'ageing" of the population which has happened in Britain is n o w also occurring in tile Soviet Union. Since the collective c a t e g o r y o f m a l i g n a n t neoplasms has been sub-divided in the statistics, it is possible t o give a picture ,of the distribution o f mortality by reference to p r i m a r y sites for t h e years 1971-72. T h e d a t a in question are s h o w n in T a b l e I. As can be seen, t h e largest percentage of d e a t h s .from cancer originated in the s t o m a c h in the case o f b o t h men and women. This c o n t r a s t s with the situation in England where the c o m m o n e s t site a m o n g males who died o f cancer was t h e trachea, lung or b r o n c h u s , while a m o n g females it was t h e breast. Whether t h e Soviet mortality rate for cancer o f the lung is .currently increasing c a n n o t be established but :in this context it is w o r t h noting t h a t the Health Minister expressed a l a r m a b o u t the g r e a t e r p r e v a l e n c e o f s m o k i n g a m o n g w o m e n . " A significant extension o f this dirty habit a m o n g w o m e n " , he wrote, " h a s p u t on the agenda yet a n o t h e r c o m p l e x p r o b l e m . . . ''~ TABLE 1. Deaths from malignant neoplasms in U.S.S.R., 1971-72 Mortality rate per 100,000 persons
Site of neoplasm
Buccal cavity and pharynx Oesophagus Stomach Intestine excluding rectum Rectum Other digestive organs Lmynx Trachea, Bracchus, Lung Other respiratory organs Mammary glands Cervix uteri Other and unspecified parts.of the uterus Other female genital organs Prostate Other male genital organs Urinary system Skin Bone and connective tissue Haematopoietic organs and lymphatic tissue Other localizations or localizations without indications Deaths from all malignant neoplasms Deaths from all causes
Standardized mortality rate per 100,000 persons Males Females
Total
Males
Females
1-8 6.3 39.8 4.6 4-2 I l-I 1-8 20-3 0"4 5.4 5.1 3-0 3-9 1-5 0-3 4-2 0.9 1-5 7-5
2-7 7-6 44.7 3-8 3-4 I i -4 3-5 34.9 0-5 0.3 --.-3-3 0.7 6-1 0.9 I-7 8.6
l'! 5. i 35.6 5-2 4.8 10.8 0.4 7.8 0-3 9.9 9.5 5'6 7-2 -I 2-5 0-9 t-3 6-6
3-6 10.5 59.9 5-0 4-5 i 5- I 4'6 46'6 0-5 0.3 ---4-6 0.9 8.2 1.1 2-1 I 0.0
0,9 4.1 29.5 4-3 3-9 9.0 0-3 6.5 0"1 8.6 8.2 4.8 6.2
6.0 129-6 836"6
6-1 140-2 898-5
5.9 120-5 783-4
7.2 I84-3 1119.7
5-1 101-9 660.6
-2-2 0.8 1-3 6-1
Note: The standardized mortality rate is calculated on the basis of the age and sex structure of the populationat I January 1972. Source: Sovetskoe Zdravookhranenie 4, 1974~ p. 94. Both crude a n d standardized mortality rates are given in Table 1. A c o m p a r i s o n o f the standardized indices reveals that males are 1-5 times m o r e likely t h a n w o m e n to c o n t r a c t cancer o f the l y m p h a t i c a n d h a e m a t o p o i e t i c tissue, a l m o s t 1.9 times m o r e likely to c o n t r a c t cancer o f the stomach, twice as likely to suffer f r o m cancer of the o e s o p h a g u s a n d 5-7 times m o r e likely t o suffer f r o m canc6r o f the trachea, b r o n c h u s or lung.
33
Anti-cancet" programme in the Soviet Union
Turni'ng t o the question o f morbidity, it can be said that despite the paucity of hard data there is .no doubt that malignant growths have been diagnosed in an increasing number of patients. This can be ascribed not only to the increasing proportion of elder'ly persons in the Soviet population but also to improvements in diagnostic competence a n d methods o f TAm:E2. Cancer morbidity in the U.S.S.R., 1972-3
Site of disease
Btaccatcavity and pharynx Lower lip Oesophagus StomacN Rectum Larynx Trachea, bronchus, 'lung Skin Mammary glands Cervix uteri All malignant neoplasms
Number of cancer Number of patients in whom cancer was diagnosed patients per 100 000 population :under for the first time surveillanceat the per 'I00 000 population end of 1973 Both sexes Males Females 2-8 10-0 8.2 47.2 4-7 6-4 39.2 38.4 --182.8
2.3 2-3 5-9 37.0 6-6 0.5 8.9 44.7 20.9 24-7 187-5
8-3 70-2 5-9 59-8 12-8 i 1-6 21-9 184-7 62-4 116-.1 675-2
Source: I. S. Sluckanko,G. F. Tserkovni, (I 976) Statisticheskaya btformatsO,a v upravlenff uchrezhdeniyarni zdravookhraneniya p. 82. Moskva; Meditsina. investigation. Data have been published for the years 1972-73 and these show that malignant ~eoplasrns were diagnosed for the first time in 182-8 males per 100,000 while the figure for ~v0rnen stood slightly higher at 187.5 per I00,000 persons. Table 2 gives a partial breakdown of these totals by site. I t can be seen that the total of diagnosed cases under regular surveillance amounted t o 675-2 per I00,000 persons at the end o f 1973. That is not far short of t~vice the figure recorded in 1961.
In.Patient Treatment Among international comparisons of anti-cancer programmes, the Soviet Union is likely to show up ~vell, even if only because its service is an easily identifiable element within the total health scheme. In this respect it conforms to the pattern of provision f o r certain other disease categories and for broad groups o f the population, most .obviously mothers and children. "There can be little doubt that the combined effects o f specialization (even a t the level of primary care) and disaggregation o f the population make for a far more fragmented health service than obtains in the United Kingdom. Some o f the disadvantages of this arrangement, as seen from a patient's viewpoint, are referred to later in this article. To identify theextent o f in-patient accommodation allocated to oncology is straightforward, since the data are published on an annual basis. The statistical year book covering the whole ~c0nomy (there is none for the health service alone) reveals that in 1950 there were 12,200 beds for cancer patients; these accounted for 1"2~o o f the total bed complement. By 1975 .the n u m b e r o f beds had risen very substantially to 50,600. However, this amounted to no ~ 0 r e than t.68 Y0 o f all beds, reflecting the vast increase that had occurred in the total
34
M , R ran apM D. Martht
complement. In facl the Soviet Union today has one of the most generous hospital-topopulation ratios in the world and this situation is inextricably linked with the fact that Soviet clirficians admit patients to hospital far more readily than do their counterparts in many countries including Britain. Although patients receive treatment in cancer deparlments of general hospitals, many .are admitted ~o the wards of single-purpose institutions known as oncological dispensaries. There are some 250 ofthese and their number will increase since current plans envisage taking the concept of such a unit to its logical extreme. That statement is made on the basis .of a resolution which was passed by the U.S.S.R. Council of Ministers (broadly speaking, the government) in April 1976. Among other things, the resolution called upon the health service to "take steps to develop the network of onco!ogical institutions, having in mind the establishment o f large oncological dispensaries, including in-patient facilities and nursing homes, and the improvement o f .existing dispensaries by the addition of radiology departments°'. ~ The c urren~ drive to provide larger units appears to reflect not only the emphasis on a high degree o f specialization among medical staff but also on the concept o f economies of scale in the use o f expensive capital resources. This is not the place to enter into detail on ~he subject of diagnostic and therapeutic equipment, but it is relevant here to note that for many years local irradiation therapy has been a major weapon used by Soviet clinicians in their fight against cancer. However, surgical intervention continues to be the main method oft'reatment while chemical and hormonal preparations are employed as well. In-patient accommodation is also located within the scientific research institutes devoted to the study of the aetiology, diagnosis and treatment of cancer. These institutes, which number20, mostly provide the highest level ofctinicaI practice in this field for the 15 republics which make up the Soviet Union. At the very-peak of the pyramid, as it were, stands the Institute of Experimental and Clinical Oncology Which, in effect, is the cancer research centre o f the U.S.S.R. Academy of Medical Sciences. Also widely known for its extensive research activity is the Moscow Oncological :Scientific Research :Institute named after P. A. Herzen. It is such institutes which are the f i r s t ~ a n d sometimes the o n l y I u n i t s to be issued with the latest and most sophisticated medical equipment. Examples cited by the Health M inister in the article quoted earlier include gamma-therapy machines and sources .of high energy radiation such as,betatrons and linear accelerators. He also referred to prototypes of apparatus incorporating the latest advances in nuclear physics and .to thermoradiographic equipment (teplovizor) which can be used in the diagnosis of the early stages o f several forms o f cancer. Although organizational data on hospital activity is rudimentary and infrequent by British standards, it is possible .to present a limited amount of basic information relating to cancer wards and hospitals. Thus the average duration o f ztay in urban units in 1973 was comparatively long, being 28-2 days per cancer patient as against an average o f 15.2 days for all beds excluding those devoted to psychiatry. In rural units the corresponding figures were 32-6 and 13"2 days. For the same year deaths and discharges per cancer bed numbered t 1-2 as against the average o f 20.9 for all beds (excluding psychiatric) in urban units. The corresponding figures for rural institutions were 7-.8 and 22-6. On a point of detail, itshould be mentioned that these data derive :from statistical returns for the main health service which is controlled by the U.S.S.R. Health Ministry and take no account ofthe practice of hospitals subordinated to other departments and ministries. 6 From lime to time Soviet medical journals publish figures :for case fatatity rates which deserve attention even if they are based on the experience o f just one hospital. The most recent, which were published in 1974, relate to an area of'Leningrad and apparently exclude
35
Anti-cancer programme ht the Soviet Union
cancer institutes and dispensaries. The fatality rate was high, being 36.0% of all cancer cases as against an average of 4-0','/o for all patients. But the source slressed that this high figure was to be explained primarily by reference to the presence in the wards ofpalients with advanced, neglected and incurable forms of this disease.; Out-Patient Care Passing on n o w t o consider provision for ambulant patients, attention must first be drawn to a major definitional issue. The Soviet health service, unlike il.s British counterpart, has not institutionalized the general -medical practitioner as the doclor o f first contact. It is certainly true that in urban areas two types o f d o c t o r on the staffofpolyclinics, general physicians and paediatricians, are assigned to specific neighbourhoods and are intended ~o give regular advice to families as well as much initial diagnosis and treatment. Nevertheless, they are themselves special~sts not generalists by training and work alongside other specialists to whom patients may proceed directly through a process of self-referral. Thus it is meaningful to say that even ~he delivery of primary medical care in the Soviet Union occurs within a context o f specialisms, albeit qui,te broad ones for the most part. That explanation can be followed appropriately by reference to a breakdown ofconsultations by patienls using the main health service in .t970. Included in the totals are out-patient visits to hospital units, contacts in polyclinics and the like and, almost certainly, contacts with the emergency service. As can be seen from Table 3 , ~ average each member of the urban population .had a sizeable total o f 10-6 o u t p a l i e n t ~ n t a c t s with a doctor. It is also evident that there was a marked disproportion between that figure and the one fo, the rural populati.on--3.4 per person~which largely arises from the comparative shortage of doctors in rural areas. Indeed, as is familiar, the Soviet health service continues to rely heavily on TABLE 3. Out-patient contacls per person in 1970 (including home visits) Specialty Total General Medicine Cardiofheumatology Endocrinology Infectious diseases Physiotherapy Surgery T r a u m o t o l o g y - - o r t hopaedics Urology Oncology Obstet rics--gynaecology Tuberculosis Neuropa~hology Psychiatry Ophthalmology ENT Dermalovertereology Curative physical culture & supervision o f persons active in physical culture & sport Paed]atrics Stomatology
U r b a n Population Total Aduhs Children
Rural Population Total Adults Children
10'6 3~05 0"08 0-07 0.09 0'! 1 0"84 0.18 0'06 0~07 0.71 0.25 0.37 0'll 0.56 0.61 0'56
10-7 4-04 0~06 0-08 0-10 0-12 0-98 0,21 0-08 009 0.94 0'25 0.47 0.12 0-56 0.60 0.56
10-4 0-11 0. ! 3 0,06 007 0-08 0.41 0.09 0.01 -0.02 0.25 0.08 0.10 0-54 0.(/4 0-59
3'4 ! "03 0"0! 0-02 0.02 . . 0.32 0.02 0.01 0"04 0-21 0" 14 0. t 0 0"04 0-16 0.t4 O. 15
3"8 1-3 ! 0.0 ! 0~03 003 . . . 0'43 0-03 0-02 0-05 0.32 0.17 0.15 0-05 .0"19 0-16 0-15
0.12 OqO O. 15
0-07 1-52 1.29
0-06 0-04 1-34
0-08 5-99 I- 15
-0.41 0-5g
-0-02 0.68
-1-18 0.39
Source: Popov, G. A. (1974). Prablemi Vrachebnikh Kadrav, Meditsina, Moskva. 1974, p. 100.
2"6 O.,14 --
0.10 0.0 I 0-01 0.08 0-02
36
M. Ryan and D. Marth2
doctor-surrogates known as feldshers for the provision o f initial diagnosis and appropriate treatment in many outlying areas. In the specialty of oncology an average of 0.07 contacts per urba~n person was registered while the corresponding figure for the rural population was 0"04. These contacts took place not only in the special-purpose units such as the oncological dispensaries but also in ordinary polyclinics. For some years now, the policy of the U.S.S.R. Health Ministry has been to lhvour the establishment of separate dispensaries in various fieldsmskin andvenereal diseases, ~uberculosis, psychoneurology as well as cancer--but some increase in polyclinic consulting rooms for these specialties has also occurred. In the guidelines for the development o f the health service over the years 1971-75, the Ministry indicated that towns and districts which did not possess self-standing dispensaries or the co~nditions for their establishment should create a set of appropriate departments or consulting rooms within their polyclinics. 8 In urban areas a sizeable proportion o f out-patient contacts are accounted for by health checks which are in effect obligatory for specific groups. Attendance at a polyclinic is ensured by various sanctions and it appears that even officially recognized writers cannot avoid spending one day per year going the rounds o f the various departments or consulting rooms. In respect o f cancer, specifically, the U.S.S.R. Health Minister has emphasized the impor:tance of regular annual inspections--"especially of persons of advanced age." Evidently the Soviet health bureaucrats consider that patients suffering from cancer witl benefit as a result of the earlydetection o f the disease and, presumably, t h a t a mass screening programme is also justified on grounds o f cost-effectiveness. However, it is not clear beyond doubt that conventional wisdom in this matter has been subjected to fundamental appraisal and subsequently endorsed. Whether the massive resources devoted to screening could be rather more effectively deployed in the field o f health education is a question which may not even have been asked with any insistence. That is not t o d e n y that attempts are made to remind the Soviet public of the well-proven connection between cigarette smoking and cancer of the lung. But, in the authors' opinion, the anti-smoking campaign is being waged at a significantly lower level o f intensity than in Britain.
A Patient's Viewpoint In order to convey some sense of what it is like to experience treatment under the anti-cancer service, a few extracts will now be quoted from a publication by a contemporary Soviet writer, Vladimir Soloukhin. Although his descriptions are conveyed through the medium o f a literary genre (a form of short story), there are strong grounds for assuming that they conveyan accurate account of reality. Among other reasons, Soloukhin's reputation rests in part on his precise observations o f the world in which he moves. Interestingly enough, in his story Solot,?~:hin first gains insights into the treatment o f cancer not as a patient but as a writer interested in what might be called the "human angle" of work carried out in a surgical department o f a Moscow institute. Among the impressions he .chooses to record is the attitude towards terminal cases displayed by the Professor in charge o f the department. (The man is named as Boris Alexandrovich Petrov and it can be shown that the biographical details given in the story correspond to those of just such a Professor working at the institute in question.) This doctor is quoted as saying to a woman patient: "It will go. At this stage o f t h e disease it's always like th~.t. That's normal. Lateronit wilt be better, completely alright.'" Shortly afterwards he explains to Soloukhin that the tumour was inoperable.and that the patient had not long to live. When challenged about his encouraging words he replies as follows. "'In the first place, as a doctor I do not under any
Anti-cancer programme in the Soviet Union
37
circumstances have the moral right to tell a patient I hat he will get worse and die soon. And., in the second place, she cannot get any worse. Anything is better for her now--even d e a t h . . . " As one of the authors was able to discover during a recent study-tour in the Soviet Union, such attitudes are very common, if no't universal. Anott~er revealing passage recounts lmw it happened that a small t12.:,a~ouron the writer's thigh went undiagnosed ,for three years, despite annual health checks carried out by basic specialists at the official writers" polyclinic (presumably situated in Moscow). At the firs't routine examination after the appearance of the turnout, Soloukhin says nothing about it and gives a negative reply to the surgeon's enquiry as to whether anything was bothering him. The next year he showed it to the doctor only to be informed "'It's probably a small nodule on a blood vessel." On the third occasion he was again told that it was nothing but was advised to show it to the cancer specialist (oncologist). However, Soloukhin explains that he did not follow this advice, either on account of the queue o f patienls or because the oncologis ~. t~ad left his room. It was some nine months later that the diagnosis o f cancer was made--and then only as a result of a chance encounter with a surgeon on a Black Sea beach in Georgia. To attempt to generalize from that single experience would o f course be a most hazardous undertaking, but it can at least be suggested tha,t, in .the absence o f a clearly structured referral system, what happened to the writer could happen .easily enough to others. And the views expressed by Soloukhin in a later passage certainly can be shown to be widely held; closely comparable sentiments cou,ld be quoted from other Soviet sources. The passage in question concerns the depersonalization of the doctor-patient relationship that has occurred as a result o f the development o f specialized medical technocracy. Soloukhin writes: There once existed the following medical maxim: "If a patient is not better after a conversation with his doctor, then it's a bad doctor." What are we tothink when doctors nowadays scarcely converse with patients ? Without saying anything, the first thing they do is send the patient off fo.r X-rays and tests. Without tests the doctor of today is deaf and blind. One"s way of life over recent years, any possible departures from normal life, the shocks which dlese days we call stresses, permanent inner disquiet (if it is present), its causes, positive and negative emotions, food, place of work, material discomfor~ or possible complexes--all these are areas into which the'doctor has neither the time nor the inclination to enquire. No matter what you complain of, you hear: "Tests, X-rays, electrocardiogram." A final and related point that can be made on the basis of Soloukhin's reporting concerns the compartmentalized outlook induced by the combined effects of the absence of a general medical practitioner and the fragmentation along narrow specialist lines of Soviet health care institutions. The writer relates how, two years earlier, he had suffered a sharp loss of weight and went to a large gastroenterological institute for advice. Tests indicated an excess ofbilirubin in the blood and diet was prescribed to improve the condition o f h i s liver. But in response to the question as to whether .the liver could have caused the loss o f weight he is told that it isn't.very likely. "'Then what did T', asks Soloukhin. "'Thethyroid gland perhaps ?" "'Perhaps", comes the reply, "but endocrinology is not our specialty. For the thyroid you have to attend another institute. ''9 In conclusion it must be emphasized that the quotations in the foregoing section have been selected not to contrive an unfavourable impression but simply to supplement the bland official accounts which implythat all is for'the best. Certainly there can be no denying that the Soviet Union has committed substantial resources, both of .money and manpower, to t h e developmentofits oncological service; the achievement is such as to command attention and respect. Having said that, however, it must beadded that large question marks hang over the organization ofthe programme and the related heavy emphasis on fragmentation and specialization in Soviet medical practice.
38
M. Ryan and D. Martin
References I. Pravda, 20 July 1976, p° 3. 2. Ryan, Michael (t978). The Organization of Soriet Medical Care, London: BasEl Blackweli and Martin Robertson. 3. Sorelskoe Zdravookhranenie, 4, 1974, pp. 92 and 94. 4. 77w Annual Report of the Chief Medical Officer of the Departmetst o f Health and Social Security for the Year 1971, HMSO, 1972, p. 26. 5. Iztvstiya, 18 April 1976, p. 2. 6. Popov, G. A. (1976). Ekonomieheslcie problemi I" upravlenii leehebno-prophylakticheskimi uchrezhde~li,"ami p. 160. Moskva: Medi~sina. 7. Sovetskoe 2dravookhranenie, I0, 1974, pp. 36-38. 8. G . L . Gomelskaya i drugie (1971). Ocherki razvitiya poliklinicheskoi pomoshehi v gorodakh SSSR, p. 180. Moskva, Meditsina. 9. $oloukhin, V/adimir (1975). Prigoror in ~Ioskva, 1, pp, 45-!07.
