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Rapid Responses: Rapid Responses published:
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Nuclear Weapons in Europe – Another Post-Communist Health Hazard
- Nick Wilson (10 December 2004)
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Effect of Multiparty System of Government in Health Development
- Murali Vallipuranathan (11 December 2004)
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TB in immigrants
- Ulf R. Dahle (13 December 2004)
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Maternal education seems to be the most important social factor in relation to pregnancy outcomes and infant growth in transitional Russia
- Andrej M Grjibovski, Lars O. Bygren (14 December 2004)
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Transition related health problems in post-communist Eastern Germany
- Friedrich Wilhelm Schwartz, Kurt Buser (11 February 2005)
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Re: Transition related health problems in post-communist Eastern Germany
- Dr. Herbert H. Nehrlich (12 February 2005)
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SOCIOECONOMIC HEALTH INEQUALITIES IN POST-COMMUNIST LITHUANIA
- Antanas Jurgelenas, Diana Mieliauskaite, Rima Filipaviciute (2 March 2005)
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Reconsidering aspects of East Germany’s health care system reform after reunification: what is to be learnt 14 years later?
- Dirk Meusel, Ulf Maywald, Isabel Hach, and Wilhelm Kirch. (10 March 2005)
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Georgia to Georgia: the Engagement of Academia in International Development in the Newly Independent States of the former Soviet Union
- H. Kenneth Walker, MD, Bijan Falollahi, PhD, Zviad Kirtava, MD, PhD, Judith Wold, PhD, RN (17 May 2005)
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Post-communist countries lose their doctors
- Malgorzata M Bala, Wiktoria M. Lesniak (30 June 2005)
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Decentralization in the Post-communist transition
- Aleksandar Dzakula (2 July 2005)
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Nick Wilson, Senior Lecturer, Public Health Wellington School of Medicine, Otago University, Wellington, New Zealand
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In their editorial, McKee and Fister appropriately highlight many of the major health issues in the post-communist countries of Europe [1]. Yet another critical threat to health remains the nuclear weapons in various European countries, and particularly Russia. A recent estimate is that Russia has 7800 operational nuclear warheads in its arsenal [2] of which about 4400 are strategic warheads. This relic of the Cold War poses risks of accidental explosions or of missile launches, since some of these weapons are on high alert status. There is also a risk that actual weapons and fissile materials associated with them could be stolen and sold to terrorists. Maintaining the system for producing and maintaining nuclear weapons is also a drain on national economies – with less financial resource available for health and other essential services. European countries need to rapidly accelerate progress towards a nuclear-weapon-free Europe. In particular, the relevant nuclear weapon states (Russia, France, and Britain) need to meet their obligations for nuclear disarmament under the Nuclear Non-Proliferation Treaty. Other European countries that have United States nuclear weapons on their territories (Belgium, Germany, Italy, Netherlands and Turkey [3]) need to follow Greece (another NATO member) in having these removed. Without such actions European and other populations will continue to be threatened by weapons that are not able to deal with the real security threats now facing the world. References 1) McKee M, Fister K. Post-communist transition and health in Europe. BMJ 2004;329:1355-1356. 2) Norris RS, Kristensen HM. Russian nuclear forces, 2004. Bulletin of the Atomic Scientists 2004;60(4):72-74. http://www.thebulletin.org/article_nn.php?art_ofn=ja04norris 3) Norris RS, Kristensen HM. U.S. nuclear weapons in Europe, 1954- 2004. Bulletin of the Atomic Scientists 2004;60(6):76-77. http://www.thebulletin.org/article_nn.php?art_ofn=nd04norris Competing interests: The author is an active member of International Physicians for the Prevention of Nuclear War (IPPNW) - New Zealand Branch. |
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Murali Vallipuranathan, Medical Officer Department of Health, 385, Deans Road, Colombo-10, Sri Lanka
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In addition to the important health issues highlighted by McKee and Fister (1), Post-communist transition includes a change from single party system of government to multiparty system of government elected by the democratic process. It is important to study whether this changed method in the formation of government has contributed positively to the development of health sector in these countries. Since Sri Lanka gained independence in 1948, successive democratic governments have been formed by two alternative parties. Whenever the government changes, top officials in charge of the government health sector, health policies, priorities, allocations and programmes get changed. This phenomenon of drastic change in health sector whenever the goverment changes is common to all the democratic countries with multiparty system. Whether these periodic changes in health sector associated with the changing governments have contributed positively to the health sector development remains obscure. In this context, information from the countries undergone the post- communist transition will help the readers and policy makers to compare the appropriate government systems conducive to the health sector development. References 1) McKee M, Fister K. Post-communist transition and health in Europe. BMJ 2004;329:1355-1356. Competing interests: None declared |
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Ulf R. Dahle, Senior Scientist Norwegian Institute of Public Health, POBox 4404 Nydalen, 0403 OSLO, Norway
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EDITOR – Before the second world war there were no medicines to cure tuberculosis (TB). Only 50 years later, strains of TB resistant to all major anti-TB drugs have emerged. Many areas of the former Soviet Union have been found to harbour high incidences of multidrug resistant tuberculosis (MDR-TB). In many western countries, an increasing number of cases of TB among foreign-born residents has resulted in a change from the expected downward trend. The last years an increasing amount of people have left the new states of the former Soviet Union, and a public concern that increased immigration may result in increased transmission of infectious diseases, such as MDR-TB, has risen in neighbouring Scandinavian countries. More than 30.000 former Soviet citizens have arrived Norway since 2001. Only four of these were diagnosed with MDR-TB on arrival and their infections were not transmitted to other people in Norway. There is little evidence that increased immigration and imported TB threatens the public health in the neighbour countries of the former Soviet Union. TB is rarely transmitted from immigrants and from a global point of view, it is far more threatening to our public health that epidemics is uncontrolled, than it is to take part in controlling it. As long as TB remains a major health problem in some parts of the world, no nation can expect to eliminate this disease. Competing interests: None declared |
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Andrej M Grjibovski, PhD student Department of Biosciences, Karolinska Institutet, 14157, Huddinge, Sweden, Lars O. Bygren
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Social resilience is the ability of human communities to withstand external shocks or perturbations to their infrastructure, such as environmental variability or social, economic or political upheaval, and to recover from such perturbations (1). Countries of the former Soviet Union appeared to be more vulnerable to the contemporary processes than the countries of the Central Europe, which gradually show some signs of recovery from the crisis. At the same time socio-economic determinants of health in the former Soviet Union received less attention than in the Central European countries despite the social changes in Russia, Ukraine and other former Soviet republics have been more profound than in the Central Europe. For example, no studies on socio-economic determinants of pregnancy outcomes, which are known to be strongly influenced by socio-economic factors, have been published in international peer-reviewed journals based on the Russian data. To overcome this we studied social determinants of fetal growth, preterm delivery, and infant growth in Severodvinsk, a town in northwest Russia with a population of 233,800. The Northwestern part of Russia is one of the areas that have been exposed the most to social and economic transition and which have suffered the most since 1990 (2). All of 1559 pregnant women registered at municipal prenatal care centres in 1999 were enrolled in a cohort and followed through delivery and their infants were followed up during one year. The study revealed clear social gradients in pregnancy outcomes in relation to socio-economic factors (3, 4). The variations in foetal growth indices and in spontaneous preterm birth rates were found to be among the largest in Europe. Maternal education was found to be the most important social factor influencing pregnancy outcomes in the area even after known or suspected explanatory mechanisms were included into analyses. Poor housing conditions, stress, and smoking also had significant negative influence on pregnancy outcomes. Prevalence rates of stunting, underweight, and wasting at 12 months of age were 1.1%, 1.1%, and 0.5% respectively. This is considerably lower than previously reported from Russia and may reflect relatively good overall socio-economic conditions in the town. However, positive trends between infant linear growth and maternal age and education were observed. Moreover, social variations in infant growth tended to increase during the first year of life (5). The Severodvinsk study contributes to the understanding of the importance of social determinants of pregnancy outcomes and infant growth during the time of transition. Social variations indicate existence of considerable inequalities in maternal and child health in northwest Russia that might even further increase with age. Moreover, social variations may be larger in big cities, where the levels of inequalities are higher. Recognition of the existence of social inequalities in health is an important step advocating for development of the policies directed to reduce these inequalities. From the perspective of science, there is a need for revealing the mechanisms behind social disparities in pregnancy outcomes in Russia. 1. Adger W. Social and ecological resilience: are they related? Prog Hum Geogr 2000; 24:347-64. 2. Walberg P, McKee M, Shkolnikov V, Chenet L, Leon DA. Economic change, crime, and mortality crisis in Russia: regional analysis. BMJ 1998; 317:312-8. 3. Grjibovski AM, Bygren LO, Svartbo B, Magnus P. Social variations in fetal growth in a Russian setting: an analysis of medical records. Ann Epidemiol 2003; 9: 599-605. 4. Grjibovski AM, Bygren LO, Yngve A, Sjöström M. Large social disparities in spontaneous preterm births in transitional Russia. Public Health 2005; in press. 5. Grjibovski AM, Bygren LO, Yngve A, Sjöström M. Social variations in infant growth performance in Severodvinsk, Northwest Russia: community- based cohort study. Croat Med J 2004; 45: 757-763. Competing interests: None declared |
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Friedrich Wilhelm Schwartz, Hannover Medical School D-30625 Hannover, Kurt Buser
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The fall of the Berlin Wall in 1989 marked the beginning of the end of communism in Eastern Europe and in Eastern Germany as well. As McKee and Fister[1] pointed out, there are certain epidemiological and demographic parameter constellation characteristic for the following process of political and economical transition. Transition to democracy and market economics in the post-communist countries we observe these constellation characterised by low or even decreasing life expectancy (especially for men), and further more high prevalence figures for alcoholism and obesity, also in the post-communist “Länder” of Eastern Germany. These observations are especially interesting because Eastern Germany underwent - different from other Eastern Europe countries – no deconstruction of its health care sector with shorter or longer periods of severe dysfunction: in East Germany the health care sector, the system of West Germany was simply adopted. In spite of that fact, life expectancy at birth is still lower in Eastern Germany than that in West Germany; nevertheless the difference between East and West Germany has becoming smaller at the end of the nineties[2]. Alcoholic disease is another feature of the typical transition process. The discharge in Hospitals because of alcoholic disease are discriminating between both parts of Germany too [3]. In East Germany the discharge number of people with alcoholic disease is greater than in West Germany. This difference remains in 1994 and in 1999. Another health problem is adipositas as a risk factor for many diseases [4]. The percentage of the population with adipositas (BMI > 29,9) is also higher in East Germany than in West Germany. This difference is staying over 10 years after the fall of the Berlin Wall. In medium terms an equalisation process is recognisable. But from a health system sector standpoint it is remarkable that in spite of the same well equipped (curative) health sector health care does not strongly modify mainly life style linked health effects in a post-communist transition exposed population. For East Germany the end of this transition process is observable. References 1 McKee M and Fister K. Post-communist transition and health in Europe. BMJ 2004; 329:1355-1356. 2 Statistisches Bundesamt (2003) Bevölkerung Deutschlands bis 2050. 10. Koordinierte Bevölkerungsvorausberechnung. http://www.destatis.de 3 Bundesministerium für Gesundheit und Soziales: Statistisches Bundesamt. Krankenhausstatistik – Diagnosedaten der Krankenhauspatienten. Gesundheitsberichterstattung des Bundes. http://www.destatis.de (25.1.2005) 4 Robert Koch Institut (2003) Gesundheitsberichterstattung. http://www.gbe-bund.de Prof. Dr. Friedrich Wilhelm Schwartz Dr. Kurt Buser Hannover Medical School Department of Epidemiology, Social Medicine and Health System Research. Carl-Neuberg-Str. 1 D-30625 Hannover Competing interests: None declared |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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Further to Dr. Schwartz's comments I would like to add the important fact that, during the communist decades of East Germany, considerable selective treatment was carried out when it came to the elderly. If an elderly person was in productive employment he/she was valuable to the system and deserving of medical treatment when needed. If retired, thus a drain on the public purse, the situation changed drastically. Diagnostic examinations like X-rays were often not done with the simple explanation that "at this age there is no need for X-rays." People also were not discouraged from travelling to the free world after retirement and no one cared if they stayed there. Purely an economic policy. Life expectancy and health in general between the two regions, East and West Germany ought to gradually become similar, although there are enough negative circumstances in the East still to lead people to a higher consumption of alcohol, something that was, under the communist regime, not discouraged. It is also worth mentioning that programs existed in East Germany to improve and maintain the health of people who were still working. Fitness was encouraged and subsidies for sports freely available. Factory workers were given breaks during working hours during which they exercised. All this apllied only to those who were part of the workforce. Competing interests: None declared |
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Antanas Jurgelenas, senior research worker Institute of Experimental and Clinical Medicine at Vilnius University, Zygimantu 9, LT-01102,Vilnius, Diana Mieliauskaite, Rima Filipaviciute
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Lithuania is characterized not only by a high level of social inequality, but also by low social care expenditure. Social care expenditure comprises 25% to 35% of gross national product in European Union countries whereas only about 15% in Lithuania (1). Post-communist transition has had an impact on health (2). The expanding market economy and low social care expenditure force the inhabitants themselves to cover part of costs required for health needs. People with low income are sometimes unable to do this. Since at the turnover of the centuries about 16 percent of Lithuanian inhabitants lived below the poverty level, this has been a precondition for appearance of new so-called disaster zones and new marginal groups, which in turn lead to social health inequalities not only between low and high income groups, but also to income differentiation among social structures. According to the most popular index of social inequality, the Gini coefficient of social inequality in Lithuania is relatively high. The mentioned coefficient re-equaled 0.354, or 35.4%, in 2002. It means a polarization of middle class with a simultaneous decline of income differentiation within the richest and poorest groups of population (1). This process was accompanied by an increasing of health problems. According our data analysis the prevalence of self reported health problems among rural population is 72.2% and urban population – 60.3%. A higher prevalence of self reported health problems (69.7%) was estimated in females compare to males (57.6%). The prevalence of health problems was dependent on social structure: it was higher in females compare to males, as well as in rural compare to urban population. At the low income rate level the prevalence of health problems was 3.9 times as much in rural population, and 2.4 times as much in urban population. Comparison of health problems prevalence at low and high income level was 3.2 times as much in females and 2.3 times as much in males. The lowest inequality of health problems prevalence at low and high income level rate difference (6.8) was found in rural population and the highest – in females (15.1). Health inequalities between urban and rural population are predetermined by a different income level related to investments, market and social care possibilities. Despite the fact that recently Lithuania has shown high tempos of economical growth, the social development of the country is insufficient. Social inequality has been strongly influenced by the fact that even 17% of the working population is engaged in agriculture and nearly one third of the rural population lives in rural districts. The economical processes of globalization have reached Lithuania, and they interfere more strongly with rural inhabitants, mostly because of agricultural policy, lower education and retraining possibilities. The rural population is more advanced in age, therefore its morbidity is higher. An access to health services has became worse in rural districts. The health reforming in Lithuania has affected the rural population. These conditions, acting in accord, produce health risk factors, which generate health-related inequalities between urban and rural population. In general, the pivotal role play income differences between the urban and rural populations in post-communist Lithuania. REFERENCES 1. Lazutka R. Population‘s income inequality. Filosofija. Sociologija 2003; 2: 22-9 (in Lithuanian). 2. Mc Kee N, Fister K. Post-communist transition and health in Europe. BMJ 2004;329:1355-1356. Competing interests: None declared |
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Dirk Meusel, Scientific Coordinator Medical Faculty , Dresden University of Technology, D-01277 Dresden, Ulf Maywald, Isabel Hach, and Wilhelm Kirch.
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Many substantial improvements in public health outcomes for the former GDR (German Democratic Republic) since its reunification have been reported elsewhere. [1, 2] Nevertheless, if a reunification is considered as a process of learning from each other rather than an unmodified transfer from West to East [3], aspects of the GDR health care system have been neglected in the process of reunification and reappear in recent discussions on Germany’s health care system reform. One component of primary health care in the former GDR were state owned health centres (called polyclinics) that housed generalists and specialist doctors as well as dentists. This integrated model of primary health care incorporated important approaches for cost saving and efficiency: (1) facilities and laboratories were shared; (2) alternative treatment and prevention strategies were applied in a coordinated mode; (3) the referrals from generalist to specialist could be better monitored; and thus (4) the medical story of the patient better be kept under surveillance. Since being opposed to the West German concept of independently contracted doctors paid on an item of service basis, polyclinics did not survive as an integrated model of primary health care in Eastern Germany after 1995, as it already was correctly predicted in 1992. [4] Nevertheless, the term of integrated health care is re-emerging in discussions on the recent need to reform Germany’s health care system. In 2000, the paragraphs §§ 140 a-h were introduced to SGB V (German Social Code Book V) that enable the operation of integrated health care centres with several objectives: (1) to intensify the cooperation between generalist doctors, specialist doctors and hospitals; (2) to enhance the unsatisfactory communication between the various therapeutic and treatment institutions; and (3) to clearly reduce health care costs, which are frequently exaggerated by repeatedly applying the same medical examination without having mediated the results to all involved doctors. [5] Against the background of its slow implementation, which is mostly reasoned in traditional conflicts of interest and the absence of direct financial incentives, the GMG (German Health Care Modernising Act) of 2003 further extends § 95 SGB V with the possibility of integrated health care centres to be run by independent management companies. Thus, the legislator clearly recognised the cost saving aspects of such centres, which are certainly not identical but similar in conception to the polyclinics of the former GDR. If preserved through reunification, polyclinics would have been one working example of how integrated health care centres can operate. References:
[1] Nolte E, Shkolnikov V, McKee M. Changing mortality patterns in East and West Germany and Poland. II: Short-term trends during transition and in the 1990s. J Epidemiol Community Health 2000; 54: 899-906.
Competing interests: None declared |
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H. Kenneth Walker, MD, Professor of Medicine Emory University School of Medicine, Atlanta, GA 30303, Bijan Falollahi, PhD, Zviad Kirtava, MD, PhD, Judith Wold, PhD, RN
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A consortium of academic communities in Atlanta, Georgia, USA, (Emory, Georgia State, Georgia Tech, Grady Hospital and Morehouse School of Medicine) has been working with a similar group and the Ministry of Health for the country of Georgia since 1992. This partnership has produced a series of accomplishments. Forty medical school graduates of Georgia have received postgraduate specialty training or their MPH degrees in Atlanta. A Western type BBA and MBA school was established in Tbilisi, Georgia, and a faculty of 63 Georgians trained in Atlanta teaches a student body of 800. A learning center teaches healthcare workers how to get up to date medical information from the Internet. Nursing school and healthcare management schools staffed by Georgians trained in Atlanta are being established. A Women's Wellness Center in Kutaisi teaches breast health, perinatal care, preventive healthcare and reproductive counseling. The research infrastructure of the country is being built up with collaborative activities in AIDS and tuberculosis funded by the National Institutes of Health. Young Georgian scientists receiving training in Atlanta are being taught how to be competitive for grants. An Emergency Medical Services Training Center was established, and trains hundreds of policemen, firemen and others in on the scene resuscitation. Numerous student exchanges have occurred between Atlanta and Tbilisi. One Atlanta medical student demonstrated that 64% of newborns in Tbilisi were significantly hypothyroid due to a lack of iodinated salt in the country, resulting in corrective efforts by the government of Georgia and international organizations. The partnership illustrates these principles: • Academic communities provide a uniquely rich resource for establishing sustainable, long-term development and reform in countries exemplified by Georgia • Information technology has been a key resource for this effort • Georgia's geographical position produces a fertile environment for broadening the scope of knowledge crucial for establishing sustainable development programs in regions characterized by diversity and instability These activities have received funding from the US Agency for International Development and other organizations. Competing interests: None declared |
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Malgorzata M Bala, PhD student Jagiellonian University Medical College Institute of Public Health; Grzegorzecka 20; 31-531 Krakow, Wiktoria M. Lesniak
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The political transition in post-communist countries has affected not only health of the populations but also health care systems. Health care reform introduced in Poland in 1999 influenced the organization of health care, however the work environment of Polish physicians has not changed for the better. After EU accession it is seen that many MDs emigrate from Poland and look for a job in Western European countries, particularly UK and Scandinavia (almost 500 Polish physicians registered in UK in 2004, 30 times more than in the previous year). Why do so many physicians decide to leave their native country after democracy was won? First of all due to low salaries, especially in hospitals. And by low we mean significantly lower than average salary in public institutions (in a public hospital physicians typically earn about 300 euro per month after tax). Such money are not enough for earning one’s living, so physicians (particularly young MDs) can not be fully independent and have to seek financial support from their families. Many doctors cope with this problem by being employed in several places, and some look for job positions in pharmaceutical industry (doctors working as sales representatives are probably rather unusual in other countries). Secondly, the residency system is poorly developed, so after graduation lots of physicians are denied the possibility of specialization. Sometimes the only way to specialize in the field of interest is to emigrate from Poland. Not only financial reasons matter. Standard of living and the working conditions seem better in Western European countries. Physicians can stick to just one job, which means shorter working time and less patients. In Western European countries the access to new technologies of diagnosing and treating patients is much better. The variety of professional development opportunities is also important. Both for clinicians and for scientists. Competing interests: None declared |
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Aleksandar Dzakula, Research fellow Andrija Stampar School of Public Health,; Rockefellerova 4, Zagreb, Croatia
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Decentralisation of the health system is one of the measures that appeared in all transition countries in the 1990’s. In most countries the decentralisation was urged by the necessity to reform the inherited model of health organisation and to achieve the final goal – efficient and fair health system. Croatia has special experience in decentralisation, it is primarily due to geographical, political and administrative circumstances present in Croatia, and especially to the experience of the decentralised health system, which existed in Croatia during the socialist regime in the 1980’s. First, Croatia is a country with extreme differences between its regions. Croatia has three big geographic and climate regions, elongated shape and the coast with 66 inhabited islands. The income per capita in the richest region is ten times the income in the poorest region. Second, the decentralization reforms were not based on the problem analyses and resource assessment, but on the maintaining the framework within which they were implemented. Such implementation of the changes resulted in complete change of the essence of the local health system, whereas the given framework imposed limitations on the development and changes, instead of fostering them. Third, the decentralisation was implemented without having organised a local network of professionals that would work on the local level, and will be able to manage local health needs. The decentralisation is always a challenge in the health system and is mostly looked at as a series of political and organisational measures. Unfortunately, the expectation of the decentralisation to ensure successful professional activities is often overlooked in the analyses. Furthermore, the measures and the purpose of the decentralisation are often not recognised as important elements of political culture. Thus primary purpose of decentralization, health care based on the real priorities and resources, remains marginal Competing interests: None declared |
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