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Dermatopathology: Practical & Conceptual

October – December 2010 | Volume 16, No. 4

A comment

Jargin, Sergei V.

Background

In a recent communication entitled “Barriers to importation of medical products in Russia” [1] the complicated mechanisms of registration and customs clearance of medical products for importation to Russia was reported. Among other things, it was stated that bribes have been taken by civil servants of the Ministry of Health and Customs in the process of importation of medical products. Foreign manufacturers are in some cases informed about it, thus becoming embroiled in corrupt interactions. Mediator firms offer assistance in registration, certification and customs clearance of medical products. Besides that, a great number of customs brokers and brokerage firms are profiting from supposed difficulties revolving around importation of medical products. Here, a comment and a piece of documentary evidence from business correspondence is reported. All proper names and addresses have been omitted.

Comment

Artificially complicated procedures and bribery in the process of importation are well known phenomena in Russia. One can gain some insight simply talking about it with representatives of firms at international exhibitions of medical equipment and other products. Russian mediator firms have “Customs Departments” routinely dealing in such affairs. Bribery is sometimes overtly mentioned in business correspondence (Figs. 1A and B). The documents shown on these illustrations together with other evidence were forwarded to the Ministry of Health. As far as we know, no action has been taken. Moreover, the management of the mediator firm, where the informant was employed, was informed about his letter sent to the Ministry of Health, which resulted in his dismissal, threats, etc. This means that the authorities not only protect corrupt officials but also disregard the principle of the informant’s anonymity. The results of the corruption are increased prices for medical products on the internal market, which in turn impedes their availability to patients.

Fig. 1A and B

Photographs from business correspondence where bribery is mentioned directly or alluded to (underlined).

Another topic that should be mentioned is plagiarism. Limited access to foreign professional literature has been one of the causes of plagiarism in the former Soviet Union. In a sense, plagiarism serves as a substitute for the importing of foreign books. Some “handbooks” issued in Russia are in fact compilations of foreign editions sometimes containing verbatim copies without references given to the source. Such editions are often poorly illustrated or not illustrated at all; some of them contain mistranslations causing distortion of the meaning, which can be misleading for practitioners. [2-3]

Some physicians purchase foreign literature themselves. However, books ordered via post or express mail are detained by customs (if the total price is more than 10.000 rubles or about 250 euro), and an addressee must go personally to the customs office, pay the VAT (30% of the price) and a customs fee, and spend much time sitting in queues. Interestingly, the payment is received in another quite distant office, and the receipt is then “accepted” (stamped for some purpose) in the third office in another part of Moscow (Fig. 2 A-C). There is no reasonable explanation regarding why the fees cannot be collected in the same building. The procedure takes 2-3 days, but for a doctor living in a remote place it can be more complicated. An alternative is to hire a customs broker. The procedure is so intricate so that a busy doctor is, in effect, manipulated into hiring a broker. At the same time, it impedes the importing of professional literature, which is detrimental to health care.

Fig. 2A

Packing note for the book, Dabbs DJ. Diagnostic Immunohistochemistry. Philadelphia: Elsevier-Saunders, 2010. Price: 291 euro.

Fig. 2B

Instructions from Russian customs, according to which the addressee must pay for an additional 53 euro VAT and 250 rubles customs fee for a book. The addresses of the bank, where the payment must be made, and of the office, where the receipts are then “accepted” (stamped for some purpose) are given in Russian. Anyone who knows Moscow can confirm that these places are quite far away from each other. The Customs House itself is in the third office, more than 1 hour by Metro and other public transport from the first two offices.

Fig. 2C

Receipts for the corresponding sum in rubles with different stamps. In the author’s case, it took three working days to receive the book.

Discussion

According to my estimates, after practicing as pathologist abroad for more than seven years, an average tumor size in routine surgical specimens (stomach, large intestine, breast, uterus, prostate, skin and others) was at least 2-3 times larger in central Moscow clinics as compared to provincial hospitals in some Western European countries, which means that early detection of malignancies is less efficient in Russia. The relative quantity of colon polyps in departments of pathology abroad was much higher than in Moscow, where the polyps’ average size was larger.

Abroad, almost all mastectomy specimens were without muscle. In Moscow hospitals, the modified radical mastectomy (Patey) with the removal of the pectoralis minor muscle has been the standard method during the last 10-15 years, but the Halsted operation with the removal of both major and minor pectoralis muscles was applied as well. The Halsted mastectomy prevailed before; it was recommended by Russian-language textbooks of surgery and oncology for all types of breast cancer until the late 1990s. It has been presented as a single- [4] or a second-choice [5] treatment for breast carcinoma even in some handbooks issued after the year 2000. In an article from the 1990s, authored by oncologists from a leading institution in Moscow, [6] it is stated that Halsted mastectomy was used for treatment of the intraductal carcinoma in situ. The swing towards conservation in the treatment of breast cancer in the whole world, including less developed countries, remained largely unnoticed in the former Soviet Union for a long time. Furthermore, the negative appendectomy rate is higher in Russia than abroad because of persistence of outdated concepts of the “catarrhal,” “chronic,” and “non-destructive” appendicitis not requiring histopathological evidence of acute inflammation for the diagnosis. [7]

Partial gastrectomy for treatment of duodenal and gastric ulcers was applied abroad much more seldom than in Russia, and its volume was less extensive. An approach to surgical treatment of gastric and duodenal ulcers in Russia has been different from international practice since the 1930s. [8,9] Use of partial gastrectomy for ulcer treatment remains disproportionately high in many institutions as of today, [10] which is explained by technical problems, conservatism among surgeons, [8] and limited availability of medical therapy, in particular, eradication of Campylobacter pylori. [10] Vagotomy, extensively used in other countries, was not introduced into practice in the Soviet Union until the 1970s. Even today, vagotomy is not performed in many institutions, where gastrectomy continues to be performed. [10] In the 1960s, when gastrectomy (removal 2/3-3/4 of the stomach) was almost a single surgical treatment modality for ulcer (named “classical method” [13]), about 60,000 of such operations were performed yearly in ulcer patients, and significant complications became obvious. [9] Later, when the correctness of the Soviet concept of ulcer treatment was questioned, responsibility for the “hyper-radicalism” in surgery was, in a veiled form, ascribed to the renowned surgeon Sergei Yudin, who indeed advocated gastrectomy for ulcer treatment, including primary gastrectomy for perforated ulcers. [11] One of his arguments was the unavailability of qualified medical care and regular ulcer treatment in the Soviet Union of the 1940s and that a gastrectomy provided good chances of cure. [12] Yudin died in 1954, shortly after his return to Moscow after more than four years of detainment and exile in Siberia. However, instructive publications presenting gastrectomy as a main or single surgical method of ulcer treatment continued to appear long time thereafter. [13,14] In a textbook of surgery issued in the 1995, Billroth’s operations I and II with removal of 2/3 to 3/4 of the stomach are listed in the first place among the surgical treatment modalities of gastroduodenal ulcers. [15] Noticeably, a Yudin’s work from the 1940s, recommending gastrectomy for the treatment of duodenal and gastric ulcers was reprinted by the main journal of Russian surgeons “Khirurgiia” in 1991 without any criticism and with approving words in the introduction. [12]

The so-called “administrative factor” certainly played its role, [8] i.e., endorsement of certain methods by the health care authorities, who sometimes favored that less individualized modalities be applied en masse to large contingents of patients. This factor obviously contributed also to the high negative appendectomy rate in the former Soviet Union and persistence of some outdated practices in other fields of medicine, such asþroutinely performed diathermocoagulation or cryotherapy of cervical pseudo-erosions, known sometimesþto beþquite unpleasant because of insufficient anesthesia. Administrative decisions were efficiently introduced into practice thanks to the authoritative management style ingrained in Russia. Meanwhile, another related mechanism has become apparent: the semi-official propaganda of “manliness,” [16] one of the purposes of which is the stigmatization of intelligentsia. The image of a “true man,” propagandized by the Russian mass media today, is manly indeed, but somewhat gregarious and not independent. The men of this kind know who are above them and who are below them, forming a hierarchy like in a flange of baboons. They have difficulties with independent thinking, and this is one of the reasons why scientific misconduct and plagiarism are tolerated; some leading men practice it and others, maintaining their loyalty, are trying to emulate it. Some kinds of work are considered unworthy of a true man, [17,18] while illegal activities, corruption, and plagiarism “are manly” all right. Therefore, evidence-based medicine, health care, and public assistance often remain out of the forefront. It is no surprise that apart from some beggars, there are almost no people in wheelchairs on Moscow’s streets. [19]

Conclusion

The limited availability of foreign professional literature and the partial isolation of Russian medicine from the rest of the world have contributed to the persistence of outdated methods and approaches in the everyday practice of medicine. [20] At the same time, limited access to international literature has been replaced by the issuing of Russian editions of books, for example, a handbook of immunohistochemistry, [21] which contains references to questionable [22,23] and potentially misleading [24-26] publications, as well as those requiring reevaluation and new interpretation, [27] some of which have been discussed previously. [28-31] Editions of this kind are poorly illustrated, if at all, and can contain outdated information or mistranslations, which have lead to the loss or distortion of the original meaning. [2,3] (An internationally recognized handbook of diagnostic immunohistochemistry [32] would be indispensible in Russia.) The same can be said of the new Russian-language atlases of diagnostic cytology, which are less extensive and are apparently compiled from foreign sources, [33,34] partly plagiarized handbooks of pathology, [2] radiology, [3] and others. Moreover, it would be advantageous for specialists to understand English instead of the Russian medical terminology, which is freshly invented for new fields of science and is associated with risks of mistranslations and misunderstandings. A concluding point is that production of domestic surrogates of international handbooks is harmful for health care in Russia.

Summary

Barriers to the importation of foreign medical products to Russia contribute to higher prices on the internal market, and this process is harmful to the care patients. Particularly harmful for health care is the limited access to international literature, which has resulted in the persistence of outdated concepts and methods in medicine. The shortage of modern professional literature is compensated for by the issuing of domestic editions, which are partly compiled from foreign sources and sometimes contain extensive plagiarism without reference to the source material. The quality of translation in such editions is often poor, and overt mistranslations can be found. Therefore, compiled and plagiarized editions can be misleading for practitioners.

Sergei Jargin, M.D., is a pathologist from Moscow, Russia. This article was reviewed by Almut Böer-Auer, M.D. Contact author via e-mail: sjargin2000@yahoo.com .

References

1. Jargin SV. Barriers to importation of medical products in Russia. Lancet. 2008; 372(9651):1732.

2. Jargin SV. Examples of plagiarism from the former Soviet Union. Dermatopathol: Pract & Conc. 2008;14(2):19.

3. Jargin SV. Plagiarism: Rough and ready—How to write a handbook from the Internet. Dermatopathol: Pract & Conc. 2008;15(4):14.

4. Kovanov VV, Perelman MI. Operatsii na grudnoi kletke i organakh grudnoi polosti [Operations on the chest and thoracic organs]. In: Kovanov VV. (Editor) Operativnaia khirurgiia I topofraficheskaia anatomia [Operative surgery and topographic anatomy]. Moscow: Meditsina, 2001:297-321.

5. Semiglazov VV, Topuzov EE. Rak molochnoi zhelezy [Breast cancer]. Moscow: Medpress-inform, 2009:93-104.

6. Frank GA, Volchenko NN. Morphological diagnosis and prognosis in early ductal breast cancer (in Russian with English summary) Vopr Onkol. 1992;38(3):299-310.

7. Jargin SV. Unnecessary operations: a letter from Russian pathologist. Int J Surg. 2010 Jun 7. [Epub ahead of print] PMID: 20538081

8. Balalykin DA. Introduction of pathogenic principles of surgical treatment of ulcer disease in Russian surgery (in Russian). Khirurgiia (Mosk) 2004;(10):73-8.

9. Balalykin DA. History of surgical treatment of gastric and duodenal ulcers in Russia (in Russian). Khirurgiia (Mosk) 2001;(3):64-6.

10. Lobankov VM. Surgery of ulcer disease on the boundary of XXI century (in Russian). Khirurgiia (Mosk) 2005;(1):58-64.

11. Petrovsky BV. About Sergei Sergeiievich Yudin. In: Yudin SS. Selected works (in Russian). Moscow: Meditsina, 1991:356-75.

12. Iudin SS. Essays on gastric surgery (in Russian). Khirurgiia (Mosk). 1991(7):159-66 continued in (9):152-61.(Note: the name spelling as in PubMed).

13. Makarenko TP. Is it necessary to improve the classical method of gastric resection in peptic ulcer? (in Russian) Sov Med. 1973;36(6):46-50.

14. Korolev MP. The surgical treatment of duodenal peptic ulcer. Materials from the discussion of the problem at the 8th All-Russian Congress of Surgeons, Krasnodar, 21-23 September 1995 (in Russian). Vestn Khir Im I I Grek 1996;(1):96-100.

15. Kuzin MI, Chistova MA. The stomach and duodenum. In: Kuzin MA (Editor) Surgical diseases (in Russian). Moscow: Meditsina, 1991:337-407.

16. Jargin SV. Manliness propaganda and contact lens complications: a view from Russia. BMJ Rapid Responses; published online 13 March 2010. http://www.bmj.com/cgi/eletters/339/dec09_2/b5336#232668.

17. Jargin SV. Modern methods in histo- and cytopathology: a view from Russia. FASEB J. 2010; 24: 954.4.

18. Jargin SV. On the causes of insufficient restroom environmental hygiene in the former Soviet Union. Rev Inst Med Trop Sao Paulo. 2009; 51(6):353.

19. Jargin SV. Radiotherapy in Russia: a redundant method. Lancet Oncol 2009;10(1):8-9.

20. Jargin SV. The practice of pathology in Russia: On the eve of modernization. Basic Appl Pathol. 2010;3(2):70-3.

21. Petrov SV, Raikhlin NT (Editors). Manual on immunohistochemical diagnosis of human tumors. 3rd edition (in Russian). Kazan: Titul, 2004

22. Kogan EA, Ugriumov DA. Correlation between proliferative processes and cell death in non-small cell lung cancer with glandular differentiation at different stages of tumor progression (in Russian). Arkh Patol. 2002;64(1):33-6.

23. Kogan EA, Mazurenko NN, Iushkov PV, Trishkina NV, Kiselev FL. The immunohistochemistry of cellular oncogenes in precancer and cancer of the lung (in Russian). Arkh Patol. 1990;52(8):3-11.

24. Paltsev MA, Kogan EA, Tuntsova OI.Immunohistochemistry of biomolecular markers of early thyroid cancer (in Russian). Arkh Patol. 1997;59(6):18-23.

25. Pal’tsev MA, Kogan EA, Tuntsova OI, Severin ES, Silaeva SA, Golenchenko VA. Morphologic and molecular-genetic characteristics of carcinoma, adenoma and surrounding tissue of the thyroid gland (in Russian). Arkh Patol. 1998;60(3):5-10.

26. Kogan EA, Sagindikova GS, Sekamova SM, Jack G. Morphological, cytogenetic and molecular biological characteristics of lung cancer in persons exposed for a long time to radionuclide radiation pollution in the Semipalatinsk region of Kazakhstan {in Russian). Arkh Patol. 2002;64(5):13-8.

27. Vozianov AF, Romanenko AM, Saidakova NA, Morell-Quadreni L, Nepomniashchi VN, Llombart-Bosch A. Ecological pathomorphosis of renal cell carcinoma in the inhabitatants of radiocontaminated regions of Ukraine. J Acad of Med Sciences of Ukraine. 2002;8(1):120-31.

28. Jargin SV. Over-estimation of radiation-induced malignancy after the Chernobyl accident. Virchows Arch. 2007;451(1):105-6.

29. Jargin SV. Overestimation of medical consequences of nuclear testing in Semipalatinsk area: an example. BMJ Rapid Responses; published online 10 June 2008. http://www.bmj.com/cgi/eletters/314/7073/82#196850

30. Jargin S. Chernobyl-related Cancer: re-evaluation needed. Turkish Journal of Pathology 2010;26(2):177-81. http://www.turkjpath.org/pdf/pdf_TPD_1440.pdf

31. Jargin SV. Overestimation of Chernobyl consequences: biophysical aspects. Radiat Environ Biophys. 2009;48(3):341-4.

32. Dabbs DJ. Diagnostic immunohistochemistry, 3rd edition. Philadelphia: Saunders-Elsevier, 2010.

33. Shabalova IP, Kasoyan KT. Cytological Atlas. Cytological diagnosis of cervix uteri. Moscow: Kafedra KAD, 2006.

34. Shabalova IP, Dzhangirova TV, Volchenko NN, Pugatchev KI. Cytological Atlas. Cytological diagnosis of breast diseases. Moscow: Kafedra KAD, 2005.