Humanitarian and Medical Mission to Odessa, Ukraine
Psychiatrist Dr. Stephen Kramer, Professor, Director of Adult Psychiatry Inpatient Services and Director of Neuropsychiatry and Forensic Service tells his story of a recent trip to Odessa, Ukraine, sponsored by Jewish Healthcare International (JHI).
For the second time in 5 years, Dr. Kramer, with his wife Rochelle, took a volunteer mission trip to the Ukraine. Established to enhance the quality of and increase access to healthcare services for vulnerable communities, JHI brings together healthcare volunteers from both the United States and Israel. Focusing primarily on the Former Soviet Union and Eastern Europe, JHI has a proven success record of helping thousands of impoverished members of the Jewish community gain access to healthcare while improving the quality of healthcare for the entire community.
Here is the account of Dr. Kramer’s week-long experience as a volunteer on this humanitarian and medical mission.
I delivered one lecture to the home health workers and 3 to the volunteer physicians. None of the abstracts had been attended to by the translators, though they had been received. The slide sets not been reviewed, either, prior to the seminars. Three physicians from the local polyclinic who specialize in psychiatry requested permission to attend my lectures and this was granted. They asked few questions but I provided my business card and asked them to contact me by e-mail if I could be of assistance in their learning. I had the opportunity to attend some of the lectures of all the participants and they were all of excellent quality and focused on the needs of the attendees. One half of the attendees were from Odessa, and the remainder from southeastern Ukraine including the Crimean peninsula. Many of the questions dealt with the practicalities of keeping their clients on medication regimens, and the costs of treatments discussed. There was some evidence of increasing familiarity with the medical literature and accepted practices elsewhere.
Our trip to the medical library was very unique though disheartening. Although the classes are held in English (and we were informed that the textbooks used are in English), none of the librarians speak English. There were rows of card catalogs filled with references to individual papers and few computers were visible, limited to the librarian work areas. The acquisitions department received medical texts in English (editions were outdated) provided by Ukrainian charities throughout the world. We were informed that a new 3-storey library was being constructed and would open in one year, and would include computer stations for the students; however, we saw no evidence of such construction near the medical school. The chief librarian was not available (we were informed she was attending an important meeting) and the assistant who toured with us was quite informative after she became comfortable with us.
I performed 3 consultations at the Hesed (charitable welfare organization). The first was for a woman with an endocrine encephalopathy and treatment resistant depression. Her psychiatrist attended some of my lectures. She requested permission to attend my lecture the next day and this was granted, but she did not appear. The second consultation was for a husband whose wife had a dementiform encephalopathy due to strokes and diabetes. She had developed a paranoid state and I discussed adequate dosing of medications and caretaker burnout with him, which he seemed to appreciate greatly. The final consultation was for a woman with schizoaffective disorder and multigenerational loss in her family history. Although not much could be done for her in the consultation, this generated a productive discussion with my translator on the interaction of personality disorder and severe psychiatric illness.
My visit to the Jewish Hospital was cancelled on short notice and a visit to the local polyclinic was hastily arranged. The clinic director emphasized the importance of Hesed support for their operations and the focus on epidemics, currently tuberculosis and influenza, that place a strain on their resources. The clinic has 72 physicians, including 18 general practitioners. Subspecialty areas are GI, endocrine, and limited diagnostic testing. They have 1150 diabetics with 10% having severe forms, and only one on dialysis. There are 2 dialysis centers run by urology clinics in the city. An HIV clinic is available in the suburbs. Physician recruitment is very difficult due to the low pay, and only the older, less well-trained physicians consider these assignments. Many patients receive one to 4 hour intravenous infusions for their illnesses. No psychotherapy is available. Exams appear to be cursory with words of general encouragement provided and little medical information provided to the patient. There are no psychiatrists at the clinical so referrals are made to a psychiatric clinic in the suburbs.
The neurology clinic, housed in a building owned by the city several blocks away, was recently sold, and the clinic will merge with the psychiatry clinic in the next few months. I was able to watch several patient visits and the care provided would easily be managed by a nurse practitioner or physician assistant in other countries. The EEG room looked like a horror chamber though EKGs are now computerized with remote processing and interpretation. Insulin for diabetics is provided free of charge to patients and is imported from Western Europe. Pharmacies are available on the first floor of the building, one for alternative medicines and herbal agents, and the other for “prescription” agents which are actually available without prescription. Direct to consumer advertising now takes place producing a quite dangerous situation regarding medication side effects and drug interactions.
The children’s rehabilitation center is housed in a new building with a very inviting atmosphere including play areas and computer stations for rehabilitation and training. Unfortunately, many of the therapies provided there for cerebral palsy and neurovascular disorders are ineffective though the staff strongly supported their activities. Services are provided free of charge, though those who can pay anything have a sliding fee scale.
The visit to the warm house was especially moving as we saw men and women proudly display their numerous medals related to the Great Patriots War and the war in Afghanistan. Both commercial and homemade liquors flowed generously as we sang and danced together.
Clinical consultations are hampered by our lack of familiarity with the locally available medications. I was able to get a copy of the closed formulary approved by the Hesed and am having this translated. Perhaps we can supply this information to future volunteers so they can be better prepared for answering the questions regarding medication choices and treatment modalities. From the information I could gather, data from the World Health Organization is not reliable in this regard.
In this mission I was able to compare the local circumstances following the Orange Revolution to those prior to it thanks to my visit 5 years ago. What impressed me the most was the continued corruption, fear of administrative authority, and dependence on Moscow despite increasing democratization. What was different this time was the increased openness of the staff and clients of Hesed services in discussing their own observations in this regard. All were less defensive in sharing their thoughts and more openly critical of the medical service delivery shortcomings. A psychiatrist in the Crimean peninsula who had attended my lectures before returned and promised to keep in touch again now that his computer was repaired. I provided him with a CD of all of my lecture slides which he accepted with tears and obvious appreciation.