“Check the little heart”. How does the train clinic travel on the Trans-Siberian Railway?
In tens of thousands of populated areas in Russia there are no medical institutions. Where they do exist, there is often a shortage of staff. In an attempt to provide access to medical care, the authorities are resorting to unconventional schemes.
A BBC correspondent spent several days on a medical train that travels along the Trans-Siberian Railway. There are four elderly women standing in line at the eye doctor’s office. They are standing because there are no chairs or seats available. The ophthalmologist works in a double compartment of a regular passenger train, while the queue waits in a narrow corridor.
A mobile clinic of Russian Railways travels along the Trans-Siberian section. “For dozens of settlements and tens of thousands of residents, this is the most comprehensive medical consultation they will receive for the entire year. Until the team comes back.”
The line forms in the corridor of the car. The train “Academic Fedor Uglov” is based in Irkutsk and every year it makes 10-12 such trips in different directions of the Irkutsk region, Buryatia and Transbaikalia. Since the beginning of August, after picking up thirty specialists and junior doctors in Chita, he has been moving east, stopping here and there for a day or two. In mid-August the medical expedition was extended by a week because the demand for medical services was greater than expected. One of the stops fell on the village of Zilovo – 400 kilometers east of Chita. Like many settlements, Zilovo exists thanks to the Trans-Siberian Railway – there is no other work here except the railroad. Ticket cashier Natalia Koritskaya came to be examined by all the doctors at once. “It’s expensive to travel to Chita for examinations,” she says. “The last time I came here in 2019, they found a problem, gave me a referral, and then I went to Chita and had an operation. That’s why I came again.”
An ophthalmologist is one of the most sought-after doctors in the medical field. We explain quickly, simply, and clearly what happened, why it matters, and what happens next. The number of episodes should remain: episodes. End of podcast advertising story. “I went to the cardiologist to check my heart. And to the optometrist – to check my eyes,” says Larisa Kondratyeva, standing in the second car in line at the registration desk. Her friend Olga Shevchuk wants to find out why her eye has turned red and also wants to check the condition of her thyroid. Shevchuk has access to an ultrasound room and an endocrinologist in two adjacent cars. The train also has a laboratory and an X-ray room. “Those who wanted to be vaccinated against COVID were given “Sputnik Light”. It was possible to be vaccinated earlier, but the supply of “Sputnik” was limited. However, there is no apparent frenzy of demand for the vaccine”. At the entrance to the office, assistant conductor Andrey is waiting for a phone call. He doesn’t seem to be forced to get vaccinated, but he doesn’t have a strong desire to do so either. “I haven’t been examined, but now I’m going to be vaccinated, and maybe I’ll get symptoms. Who will answer?” – asks the railroad worker angrily. He says he went to the hospital in Chita (not with COVID) and there were “a lot of conversations” that filled him with fear. Andrey doesn’t know which tests would help him calm down. Outside the train window you can see a village spread out among the hills in the valley of the White Uryum River. More than three thousand people live here – by the standards of Eastern Siberia, it is quite a large settlement. A short stretch of its central road is paved, and deep potholes in other places slow reckless drivers, so as not to endanger the herd of goats that scours the roads in search of new forage. On one of the hills you can see a red spot of bare land. At the beginning of the summer, prospectors arrived in Zilovo. For three years they will wash the ground in search of gold.
Zilovo – a large settlement by local standards Nature was not kind to the gold miners – at first their camp was washed away by floods from the hills. The camp was fortified, and sometimes the village is shaken by the thunder of explosions. The Zilovtsy miners have not yet been offered jobs, but locals say that the miners will give the local administration 15 million rubles every year – a decent sum for the local budget. The houses in the village are mostly old, blackened by rain and wind. But on the northern outskirts of the village there are also a dozen new buildings. The residents of Zilovo are grateful to Vladimir Putin for them: in 2010, during a memorable trip from Khabarovsk to Chita in a yellow “Kalina” car, the then prime minister stopped in Zilovo and listened to complaints about dilapidated housing. After the visit, a swimming pool was built in the village and the hospital was repaired. Among the doctors in this hospital, there are currently only a surgeon, a cardiologist, a gynecologist, and two therapists. There is also a dentist, but she doesn’t have a drill. She says, “Should I treat your teeth with my fingers? – complains Valentina Grivtsova, a former teacher at the Zilovskaya school. – She can only extract one tooth. Valentina has lived here for 20 years. In all those two decades, the local health care system has “left a lot to be desired,” and Grivtsova no longer expects it to improve: “Girls, they say it used to be better. There were more specialists, a laboratory, a physiotherapy room. There was a maternity hospital, but it was closed, and now you have to go to Chernyshevsk or Chita. It takes one hour by car to get to the district center of Chernyshevsk on the highway, and four hours to get to Chita. You can also take the train, but it’s impossible to make a round trip in one day. Half of Russia’s 160,000 rural settlements have 100 people or less. Such villages are not even subject to regulations on the presence of medical centers. In theory, there should be such centers in every village or settlement with a population of at least 300 people. “In addition to a paramedic station, larger settlements are required by the Ministry of Health to have “mobile health units,” explains Larisa Popovich, director of the Institute of Health Economics at the Higher School of Economics. “There are regular trips made by trains, boats, medical buses,” she says. “It is solved differently in different regions. There are thematic pick-up buses with fluorographs or mammographs, dental clinics. They visit settlements according to the schedule. In Zabaykalsky region, there is also a schedule for bringing residents to district centers for examination and dispensary, there is a special route bus. The most important thing here is proper organization: either they go to them or they are brought to the centers. At least this is recommended, and in some regions it works”.
It is possible to get an x-ray on the train and have enough time to see a specialist. In total, this should result in the required 9.1 annual visits to primary health care facilities for each Russian citizen. However, individual stories in the cars of the traveling clinic contribute to a bleak picture. 40 kilometers from Zilovo there is a settlement called Zhireken, which is even bigger – with over four thousand inhabitants. There used to be a mining and processing plant in Zhireken, where molybdenum ore was mined. And at that time, says Vera Ryazantseva (name changed), there was a hospital in the village with 17 doctors. In the early 2010s, the price of molybdenum began to fall, the mining and processing plant closed, and the hospital fell into disrepair. That’s why Vera spent money on a taxi and arrived at the medical train. She said, “We have no one here, the last general practitioner has left, and now only the dentist and pediatrician remain, there is no help available. It is also possible to go to the Chernyshevsky District Center. “It takes a long time to wait in line there,” Vera complains. “If such a train came to us, everyone would be very happy”.
Doctor Borodin is the permanent head of these trains. “If there is a shortage of medical personnel in the major centers, it is a disaster here,” says Evgeny Borodin, the director of this mobile multifunctional diagnostic center. During a month-long trip through Transbaikalia, he can see how much worse the health situation is for the population far from Chita. “In general, there are many neglected cases in the periphery. People are not systematically screened, and when they are in trouble, they rush to the center,” he says. “We have a district doctor, a therapist and a paramedic on site – that’s it. So as far as my specialty is concerned, I mainly see dental pathology. The ophthalmologists are overwhelmed by the number of patients who need eye microsurgery, lens replacement, and glaucoma treatment. There is also a lot of gynecological pathology. During this trip, we have already detected two cases of tuberculosis and four suspected cases of oncological diseases”. Borodin is the permanent head of these trains and spends most of the year on such trips, while the remaining positions in the medical brigade are filled by shift teams of doctors working for two weeks. After work at 6 p.m., young doctors and nurses from Chita go to the village and consider a simple assortment of one of Zilov’s grocery stores. They spend their free time with a few cans of beer, waffles and a piece of smoked salmon. All products are brought from Chita. The new brigade has already traveled several hundred kilometers by train, and the people of Chita know that conditions in Zilovo are not the worst. “In many places, pharmacies have closed and there is no way to get medicine,” says one of the medics.
In Zilovo, 204 people visited the medical train in two days. According to Borodin, this is about the average daily workload – his colleagues do not accept more than 150 patients a day. Many of those who came took tests or had ultrasounds and X-rays, and then – with unprecedented speed for these places – managed to get the results to a specialist and a referral for treatment. Whether they will be able to recover with this direction is still a question.
The first stop of the medical train in Transbaikalia this year was the village of Bada, 370 kilometers west of Chita. There were many more people who wanted to see a doctor than in Zilovo. Queues formed on the platform. Tatyana Elizova stood in one of them with her 15-year-old daughter. The girl has a complex form of astigmatism, Tatiana hoped to see an ophthalmologist. She didn’t make it. “There were queues from five or six neighboring villages, people were taking their places from six in the morning. It was impossible to get in,” she sighs. Elizovo is located in the village of Zakulta, fifteen kilometers from Bada. About 400 people live in Zakulta, which is divided by a federal highway. The nearest hospital is 70 kilometers away in the village of Khilok. It is possible to get an annual checkup there, but the rural ophthalmologist could not do anything about the complicated astigmatism. Tatiana sent her daughter to a private clinic in Chita, and after an examination and a week of treatment, two sets of lenses were made for 30,000 rubles. But my eyesight still needs to be checked. Now I have to go back to Chita – by minibus and train. State medicine did not help Tatiana either. Last year she was diagnosed with glaucoma. She asked for a referral for a free operation in the Chita regional hospital, but was told that such operations were not performed in the Chita budget medical system. The glaucoma treatment at the RZD hospital cost the 57-year-old pensioner 40,000 rubles.
Popovich from the Institute of Health Economics at the Higher School of Economics does not see the economic feasibility of having a full-fledged medical institution even in a large village. “What is the point of building a polyclinic in a village of a thousand people? There, doctors of each specialty will see only one or two patients a year,” she explains. “What kind of specialist, for example, is an outpatient surgeon who only sees one or two fractures a year? In reality, the main problem is the creation of industrial centers to provide medical care and the logistics to transport patients to them. There should be a local system for early diagnosis. And the main problem is the incomplete coverage of Russian territories by mobile communications. Where there is cellular communication, telemedicine can work actively”. This is a promising vision for solving the problem of unavailability of primary health care in the vast, sparsely populated territory of Siberia and the Far East. At present, reality does not fit well with these plans. The medical train did not stop at the Zudyra station, where the Trans-Siberian Railway, a federal highway and the Beliy Urum River converge. The village consists of three wooden communal houses inhabited by former and current Russian Railways employees who serve the station. A handful of pensioners from Zudyra were given a car to take them to the parking lot of the mobile clinic in Zilovo.
The village of Zudira is left without a bridge – now only accessible by boat. The road was not easy. In June, after a week of rain, the White Uryum washed away the bridge that connected the village to the highway. The foundation of the bridge lies in the dark water – two railroad tracks twisted like wire by the force of the water. The bridge is unlikely to be rebuilt this year. Residents cross the turbulent river in rubber boats.
Recently, Tatiana Kostyukova, a young mother, returned to Zudyr by boat in the same way. She held her son in her arms. The helicopter took her to Chita to give birth, and she spent a month in the maternity hospital. In mid-August, she returned by car at night: “They transported me along the river with flashlights at 10 p.m. Can you imagine, with a newborn!”
But no one came to Tatiana for the patronage examination required by the rules. So 21-year-old Tatiana, her schoolboy brother and her 40-year-old mother, Evgenia Smirnova, who also gave birth this summer, set off for Zilovo. “The doctor did not come to us, they said: come yourself. So everything we were supposed to do at home, we do here,” she says.
Women who give birth are taken away by helicopter and return alone with their babies. There is no pediatrician on the medical train, so the family went to an understaffed rural hospital. The therapist examined the infants, but didn’t have time to see the schoolchild, who needed a certificate by September 1. Soon the whole family will have to go to the district center for tests. “I am supposed to stay at home for a year to take care of the child. And here we have to go to Chernyshevsky in the freezing cold, rain and downpour. I have to pay four and a half thousand for a taxi!” cries the girl.
Why don’t they want to leave their village? “There is work,” Kostyukova explains. “Even if we move… Where will I work, where will my husband work? We both work for the railroad. And they won’t transfer us, all the positions are filled somewhere else. With the participation of Maxim Lomakin and Maria Kiseleva”