Leo A. Bokeria is the chief heart surgeon of the Russian Health ministry and director of the Bakulev Cardiovascular Surgery Center at the Russian Academy of Medical Sciences (RAMN). He was born in 1939 and graduated from the Sechenov Medical Institute in Moscow and post-graduate courses. He has been working in the Bakulev Institute since 1968 and in 1994 headed the Bakulev Cardiovascular Surgery Center that united two institutes and an affiliate. Leo Bokeria is the author of numerous designs and guidelines in cardiovascular medicine and promoted their introduction into clinical practice. He is Russian Merited Worker of Science and full member of the Russian Academy of Medical Sciences in heart surgery, member of the RAMN governing board. He chairs the Pan-Russians National Health League public organization and a commission of the Public Chamber of the Russian Federation. He is a laureate of the Lenin and State Prizes and of the Triumph Prize. He was awarded with the Orders For the Merits to the Motherland II and III degrees, the Order For Valor, Dignity, Creation and Mercy. The Russian Biographical Institute has numerously named Leo Bokeria as the Man of the Year (in 1997, 1999, 2002, 2003, 2004, and 2006). He enjoys the Human Legend title, which is a joint award of the Russian government, the Union of Industrialists and Entrepreneurs, and the Third Millennium Foundation. Bokeria is a laureate of the international Golden Hypocrite Prize awarded to the best heart surgeons of the world.
FIGURES AND… HEARTS
– Mr. Bokeria, in late 2009 you celebrated your birth anniversary and our magazine cordially joins congratulations, as it is better late than never. We cannot bypass numerous medical problems in an interview with you. What is the current Russian situation with cardiovascular diseases?
– Unfortunately, the situation is over the top. We have at least 20 million people with various cardiovascular diseases. Among the countries, which the World Health Organization (WHO) constantly lists in the negative sense, we occupy the second place from the bottom by the number of cardiovascular diseases per 100 thousand of the population. Besides, we have major mortality rate resulting from the diseases that comprises 56.4 percent of total lethal outcomes.
The situation has somewhat improved with children with congenital heart disorders, as we can provide surgeries for 60 percent of them. As for ischemia that results in myocardial infarction, we can hardly provide 15 percent of surgeries, less than 20 percent for heart valve pathology, and even a smaller percentage for heart arrhythmia. And that concern patients who are far from pension age. We have 250 thousand people dying a sudden death a year. They would have survived if they had pacemakers timely implanted or defibrillators applied. But we have 18 percent of the required pacemakers and hardly one (!) percent of defibrillators. You will see no external defibrillators at railway stations, airports, and supermarkets. If the heart of a person unexpectedly stops, even medical facilities there can do nothing but make an injection.
In the early 1980s we were practically at the same health care level with the United States. But then we radically fell behind. The Americans carried out a total screening of their national health system. The results urged to radically improve the situation with nutrition, first and foremost. That exerted a major impact on national health in a brief spell of time. A series of mass medical programs has been launched: for high blood pressure, atherosclerosis, cholesterol… Besides, the country continued to increase the number of heart and vascular surgeries. The so-called sparing methods emerged, one of which is endovascular surgery, i.e. an operation without cuts. The Americans began to pay specific attention to motion activity. They designed and implemented dozens of heath preserving and improving projects, as well as rehabilitation of patients. As a result, the United States reported a radical drop in lethal outcomes from cardiovascular diseases and the number of people with heart disorders decreased.
– Did the changes take place in the United States due
to government effort?
– You know, in the United States the government gets little involved. Mostly non-governmental organizations make radical decisions there. At the government level they have coordinators, including from the health service. For example, there is such an interesting position as Surgeon General. He is in charge not only of surgery in the country, but also of the situation with tobacco smoking. The Surgeon General has a special status. He is like Russia’s chief sanitary doctor Gennady Onishchenko, however Onishchenko is in charge of specific health care spheres, while American Surgeon General is authorized to deal with absolutely any issue related to human health.
In the United States a law has been passed at the federal level that bans smoking in public places. If you go in New York and smoke a cigarette you will get such a big fine that will make you quit smoking once and for all. The Americans created in their cities cigar clubs for hard smokers. The United States exerts no strict federal influence or pressure and law compliance is observed by public bodies. It may be surprising for us, but laws are strictly fulfilled there.
MORAL SIDE OF POOR HEALTH
– And what about us?
– Many issues of priority significance for the preservation zof the nation, including health care, are not resolved in this country because, as it has become popular to say since the times Gorbachev, no mechanism for their fulfillment has been “written down”.
– And why has it not been ”written down”? Is it a difficult task?
– It looks as if people who do not want to have strict laws dominate the agencies that form legislative mechanisms. We resolved the problem with civil liability motor-vehicle insurance because it is beneficial for all. We resolved the problem with the “iron horse”, but are amazingly short-sighted in the national health issue. Take smoking, for example. Heads of enterprises have to resolve the problem all by themselves.
– What do we have to do to form a negative public attitude to smoking and alcohol drinking specifically among the young? How can we make young people aware and save them?
– No doubt, smoking and drinking among the young people occurs because of general public libertinism. It concerns not only the two vice. What about boyfriends and girlfriends? I can hardly imagine that minors can live together and parents would connive to it. When such “marriages” at the age of 14-16 develop into a mass phenomenon it means nothing but complete oblivion of moral principles in society. Indifference, impudence, ignorance and corruption paint a picture that can be called moral disease of the nation. The growing number of heart disorders is a result.
I was born in Georgia and spent my young years in the city of Poti. There were 31 houses in our street. All the boys played various sport games: football, basketball, volleyball… We all wanted to realize ourselves, specifically in sports. There was only one smoker in our street. He was 25 years old and just released from prison. Nobody communicated with him. As for alcohol drinking, there is a strict ban on that until a certain age in the Caucasus. None of the guys had a tattoo.
– What can you say about the Russian health care model? Is it perfect?
– We have an absolutely normal health care model. Our Health ministry is working properly and I say it sincerely, because I know they count every kopeck and provide the necessary funds for hospital needs.
Our model provides free medical assistance to every person in the most prestigious establishments of the Russian Federation. But the patient has to pass the whole way from district and city clinic to the regional level and then to Moscow and St. Petersburg. For example, the Bakulev center is a hundred percent free state-run establishment and we operate by quotas financed by the Health ministry. There is a very small share of paid treatment for those who cannot wait. The patient pays exactly the same quota amount as is financed by the state. The acting model of our health care system can be (and shall be) modified because the funds appropriated for its development do not cover the needs of the population.
INNOVATIONS IN MEDICINE
– What else is imperfect in our health care system?
– During World War Two many countries of the world began to develop specialized health care. They began to design equipment, devices and disposable medical tools for it. Unfortunately, our country did not join the changes and we had to import them after the war. We were looking back while the world advanced far ahead and it became clear we cannot domestically produce medical equipment because of its low competitiveness. And we also lack money for that.
I have been saying at all meetings: to properly insure every Russian citizen the quality of health insurance shall depend on the amount of invested funds. Which funds are used for insurance? A part is paid by the employer for each employee, another part is provided by the state for each citizen, and finally any person can add his or her own money if he is well-off. If not, the state helps again. When a major amount has been collected, a person can himself choose a hospital and doctor as information about good treatment quickly spreads by gossip. Thus, big numbers of patients go to where better treatment is offered. Businessmen see that a certain clinic is making real money. And entrepreneurs initiate small but competitive medical productions. They shall be small so that they can be easily modernized after some time. What does our clinic need, for example? We need dozens of thousands of medical goods. Production units fulfill our orders, a major base of medical tools, devices and equipment is created to decrease costs of all devices and tools and save huge customs duties on imported goods. In America the medical health industry occupies the second place after food industry. We shall also come to that. The question is when?
– Does domestic health care have any innovations?
– There are innovations, but mostly as model samples. There are a lot of them. Very good models are offered. But numerous years are necessary to transit from models to serial production. Soon after World War Two medical engineer and Professor Vyacheslav Gudov designed a vessel-sewing device. Before that surgeons sew vessels by hand. According to his method, the vessel shall be cut, open, cleaned up, folded back, and the device sews it with an even seam. So what? Our inventor went from one high office to another, but to no avail. Once he left in a group of academicians abroad for a symposium and demonstrated his device there. Western experts immediately began to produce it, while we remained with a model sample. However, we know how to spend money on imports.
Today our country is producing proper electric pacemakers that are as good as foreign ones. But look at our and foreign pacemakers and you will see the difference in medical culture. When you take a foreign sample you find a small instruction inside, which you study to learn the possibilities of the small device. It expands the knowledge of a doctor. And Russian producers send you a device with a short instruction consisting of five lines: use it as you like.
– Does your institute have its own production?
– We are a scientific center of cardiovascular surgery and we have a lot of theoretical designs and some have been implemented. We have produced a whole line of pacemakers for heart surgery. We designed a whole family of the so-called conduits to treat congenital and acquired heart disorders which we also use. We created an excellent hemostatic glue which we use for valve implants in heart surgeries. I have for the first time in the world implanted a tricuspid artificial heart valve to a patient. It was also designed by our center. We have designed a biological heart valve made of Glisson’s capsule (covering the external surface of the liver and taken from cattle). Naturally, the tissue of a patient possesses biological and immune inertia and good plastic characteristics however the use of autoplastic tissue is not always possible. Therefore we prefer the so-called xenogenic material from which xenopericardial sheets, valves, and valve-containing conduits are made. Lungs of pigs and calves are used as a raw material for them. Everything I have listed comprises laboratory, not commercial samples. However our institute annually saves up to 500 thousand dollars only on biological materials and valves.
CRISIS IS STRESS
– Did the crisis affect you clinic?
– It definitely did. But we are a budget-financed institution and it is easier for us. In general 142 thousand open-heart surgeries are to be performed in the country, while last year there were only 34 thousand (including seven thousand in our center). That is an issue of financing. Unfortunately, a great number of patients in the country cannot receive the treatment they need so far. There is a major demand for cardiovascular treatment and it only grows in the period of crisis, unfortunately. The number of surgeries we perform needs a concrete number of specialists. We cannot reduce anyone.
– What would you advise as a doctor to our readers in the time of crisis?
– Stress is a major test for a human being. Alarming expectations of some unfavorable developments are always harmful for health. Objectively speaking, not every person can cope with major stress loads. The whole XX century was horrible for Russia in that sense: war, revolution, famine, again war, perestroika, default… Today the crisis makes everyone think what is next. The situation is abnormal. Definitely stress results in heart disorders. There is a direct link between them. Stress causes high blood pressure that triggers bad consequences: blood-stokes and infarctions. I specifically make the warning for people to remember what we all have come to this world for. We came to realize ourselves. But to realize oneself in life a person does not need much, only the most important things for living while the rest can be considered excessive at least in the time of crisis. If we succeed to digest the morals and accept them, we shall live and progress despite the storms. The storms always end.
– We cordially wish you longevity for our own benefit! What is the secret of Caucasian longevity?
– I believe the term is a tribute to legends. The biggest number of long-livers per square kilometer is reported in… the Central district of Moscow. Statistics show it has the biggest number of people close to a hundred years of age or above the centennial. A research was held and established that longevity and quality of life considerably depend on the education level. In the Central district the level is much higher than in other districts of Moscow. We can say the Central district is inhabited by most educated people.
The “Caucasian longevity” term is attributable to highlanders. Fresh air, moderate food, normal day and night regime, low level of concerns characterize the living conditions of the people.
I was born in the town of Ochamchiri and moved to Poti at five years of age. I used to frequently visit my native place before, but I have not been in Ochamchiri since 1992. My parents are buried there. Last year my friends helped and I with my sisters had them re-buried to another place. Now I can visit the sacred place any time and I often do that. And what else does a man need? I have a small wooden house in Poti, which is a gift from the friends. I have not been there for two years. That is a very sad story for a man who always believed he was born in the happiest country of the world – the USSR.
By Yuri SHILOV