制裁影響俄羅斯的醫療保健系統
資料來源：亞歷山德拉.鮑里索娃 / 2022 年 4 月 7 日 / Medscape / 財團法人台灣紅絲帶基金會編譯
為應對俄羅斯入侵烏克蘭，包括醫藥領域在內的國際公司和專業協會已採取各種措施停止與俄羅斯開展業務。儘管這些措施的目的可能是對俄羅斯總統弗拉基米爾.普京的政權施加壓力，但它們也對醫生對患者的照護上產生了重大影響。
排除在全球科學界之外
目前的氣氛與一個月前的情況相去有如光年般遙遠，當時俄羅斯醫生仍在參與國際研究和臨床試驗。他們參與了國際合作，並認為自己是全球醫學界的正常成員。
Luch Clinic 的醫學腫瘤學家和俄羅斯聖彼得堡高等腫瘤學院的計畫主任 Polina Shilo 醫學博士說：「看到專業協會如何擱置與俄羅斯醫生的合作非常痛苦」。「我們，這些深思熟慮的醫生，多年來所建立的這些合作關係。讓國際間的同事們了解我們，我們是會說英語的普通人；俄羅斯有適切的醫療和適切的醫學科學。我們覺得我們終於成為社區的一部分，但現在結束了」。
「合作停止了，即使是那些已獲得資助並已開始臨床工作的合作，但我們也無能為力。在國際同行評審之期刊上發表我們的作品更加困難。他們之中許多收取非常高的費用而新匯率對我們來說也很高，且我們仍必須弄清楚如何支付，因為我們的銀行卡停止運作。透過外國來源之訂閱也是如此」。
「恐怕參與會議、活動、參加聯合科學研究肯定會有問題」，一位來自私人診所的匿名醫生說道。 「國際醫學界說英語，我們才剛剛開始『接觸』這個世界，引入循證醫學。信息的封鎖只會降低新興的醫療保健標準。沒有國際信用卡，我們就無法支付國際數據庫比如像UpToDate之費用」。
「我們的醫生可能無法獲得實習、助學金和[和]交流。而這一切只會導致『老學究』以其專家意見取得勝利，而其在現代醫學科學的證據水準最低」。
診斷和牙科
基於影像的現代診斷方法是第一個面臨風險的項目，因為電腦斷層(Computed tomography，CT) 、 核磁共振(Magnetic Resonance Imaging，MRI) 、正子斷層掃描(Positron Emission Tomography，PET).和其他復雜檢查方法所需的機器和用品依賴於國際供應，而且難以採購，尤其是快速採購。
「舉一個例子，我們用於乳房哥攝影檢查的 X 射線膠片僅在比利時生產」，一位來自大城市大學診所的匿名醫生說。 「現在我們科室只剩下三盒了。這對 100 名女性來說足夠了，但我們需要成千上萬的量。這意味著今年將沒有乳癌篩檢。我們的斷層掃描儀是俄羅斯生產的，但就像用來自美國或日本半拆卸零件來組裝的汽車。且現在保固期結束了。一年前一個X射線管的成本約為1000萬盧布，這對醫院來說已經是難以承受的數額。我們需要第二個CT室來進行中風檢查，並希望在夏天之前做到這一點，這將不會發生」。
他繼續說，「俄羅斯的公共醫療保健透過強制醫療保險運作。它的價格是根據藥品和其他供應品的一定價格計算的。過去有優惠和不太優惠的關稅。每個人都試圖對待病人以其疾病之『最有利的』方式。現在不會再有這樣的了」。
「至於設備，我希望它不會完全消失」，莫斯科一家大型私立醫院放射科主任說。「我們將開始透過第三方國家購買二手貨，或者使用中國的類似產品。也許是一些黑市。但另一個問題是技術支持和服務。目前看來，之前簽訂的合同似乎沒有取消，但遲早或以後，這個市場也會崩潰」。
幾乎所有類型的現代高科技牙科和齒科矯正學都存在同樣的擔憂。 「目前，我們沒有感覺到劇烈的變化，但它們會在倉庫用完醫療設備、藥品和組件的庫存那一刻出現（儘管對宣布制裁的供應商已決定禁止其產品出口到國外，但它們也會用完）」，一位來自莫斯科的匿名牙醫說。
「高科技設備供應商已經提高了醫療設備的銷售價格。因此，我們為患者提供的高品質、高科技之治療和診斷方法將急劇下降。因此，國家將經歷慢性病、惡化期癌症，以及其他可在早期階段即可診斷和治療的問題之增加，而治療品質的下降將導致對醫生的投訴和訴訟數量增加，增加所有醫務人員的負擔，這將不可避免地使大量高素質的專家離職」。
他繼續說：「實際上，這是雙重打擊：藥品、產品和服務的盧布價格上漲，加上斷層掃描儀、牙科設備等逐漸退役。更聰明的人創造了消耗品庫存（麻醉、牙科植入物、填充材料、矯正元件等），這將足夠大約 6 個月左右，然後我們亦會看到問題」。
即使是戰前與俄羅斯客戶的安排，外國供應商似乎也很不情願。一位來自聖彼得堡的匿名牙醫說：「我們的行業無法生產現代高級牙科所需的產品，這已經不是什麼秘密了」。「現在發生的事情太可怕了。例如，隱視美(Invisalign) 事後告訴我們它沒有將其產品運送到俄羅斯。他們責怪他們的運送者 UPS，但這是他們的責任。保持器已經被訂購、生產、計費和付款，現在他們說還沒發貨的東西都會留在他們在墨西哥的倉庫裡。我們無能為力。病人問我們問題，我們不知道該回答什麼。它損害了無辜者的健康，損害了我們的聲譽，這一切都是糟糕的」。
藥品價格飆升
出於人道主義原因，藥品和醫療器械和設備被認為是必要的，不受制裁。儘管如此，仍有幾家公司在不顧制裁的情況下採取了行動。
美國製藥商禮來公司表示，它將為癌症和糖尿病等緊急醫療狀況提供藥物。它正在暫停「非基本藥物」的銷售以及所有投資和促銷活動。它也不會在俄羅斯開始任何新的臨床試驗。
「俄羅斯的國際臨床試驗現在暫停」，希洛說。「這是我們的患者免費獲得使用實驗性或最佳可用療法之診斷和治療的方法之一，也是醫生從他們微薄的薪水中獲得一些額外收入的方法之一。大多數公司現在引用後勤和運輸問題為由在俄羅斯交付服務停止運作，但事實上，目前並沒有新患者被接受入院。對一些患者來說，參加臨床試驗是最後的手段。對另一些人來說，這是一種大大減輕財務負擔的方式」。
限制他們在俄羅斯業務的其他公司包括諾華、艾伯維、強生、輝瑞和拜耳。他們中的許多人宣布，他從俄羅斯市場獲得的利潤將用於支持烏克蘭。
「儘管製藥公司尚未宣布縮減其在俄羅斯的活動（儘管在各個層面和平台上都呼籲這樣做，不幸的是，也包括 Medscape），但有幾個原因，儘管是暫時的，可能導致某些藥物短缺」莫斯科醫生兼《俄羅斯藥學》雜誌主編、醫學博士阿列克謝·沃多沃佐夫說。
「第一，後勤困難。所有的主鏈都被打斷了，需要時間才能找到可以接受的變通辦法。第二，盧布匯率波動導致相互結算、價格表修訂和價格上漲的問題。 不一定是製造商——分銷商首先採取行動，然後藥店被迫改變價格標籤。第三，恐慌性謠言在社交媒體上散佈，我們的公民對任何困難的通常反應是購買藥品。目前，在當地藥房很難找到 Nurofen 或 Norvasc、Depakin 或胰島素，儘管它們的供應似乎並未停止。現在，類似物和學名藥會有所幫助。很明顯，最終情況會有所改善並穩定在某個新的水準，但醫生和患者都會非常擔心」。
「目前，用於腫瘤患者的進口療法仍有庫存，以每歐元約 60 盧布的價格購買」，聖彼得堡癌症預防基金會的腫瘤學家兼執行董事 Ilya Fomintsev 醫學博士說。 「但它們很快就會用完，大約一個月。接下來的購買將以每歐元約 160 盧布的速度進行，這意味著原本已經昂貴的治療成本增加了三倍。這將使患者完全無法使用治療，除了那些可以自己買單者」。
他繼續說：「昨天，我和一位病理學家交談。免疫組織化學的試劑和載玻片已經消失，所以我們可能會回到組織學上的蘇木精-伊紅染色。但不是所有的年輕人都知道怎麼做，而且他們是對的——這就像在使用電腦斷層(CT) 和核磁共振(MRI) 的時代仍使用敲擊以及聽診器一般」。
「看起來國際公司將離開我們的市場」，Shilo 說。「這是非常可悲的，儘管我預計腫瘤藥物市場不會完全崩潰。俄羅斯的類似藥物並沒有人們想像的那麼糟糕」。
人道主義危機
「我失去了有用的感覺」，一位匿名的莫斯科放射科醫生說。 「醫學不僅僅是藥物和儀器。它是一種正確地去完成工作、發展和成長的意志。這種成長的意志受到理解人們需要你的作為的支持。但這些天來這種感覺已經完全消失了。想像一下，一家非常好的餐廳的主廚，由於某種他無法掌控的原因，讓他的生意受到了影響。人們告訴他，「來吧，不要難過，人們還是會想吃」。「當然，你可以用熱狗餵人，用橡樹皮治病。但這會非常令人沮喪。去年，我的四個員工移民了，這很難忍受」。
「傳達一個簡單的想法對我來說非常重要：製藥業應更著重於製藥並超過只是商業」，Shilo 說。「如果每個人都離開俄羅斯，那我們的病人真的有麻煩了。我們缺乏一個可以涵蓋腫瘤學需求的行業。即使有些什麼，受到專利的限制我們仍然無法去生產我們所需要的東西」。
「這一切到頭來只會增加悲傷和痛苦，這與人道主義完全背道而馳」。
Sanctions Affect Russia’s Healthcare System
Alexandra Borissova / April 07, 2022
In response to the Russian invasion of Ukraine, international companies and professional associations, including those in the field of medicine, have taken various measures to stop doing business with Russia. Although the intent of these measures may be to pressure the regime of Russian President Vladimir Putin, they also are having significant effects on doctors’ care for their patients.
Excluded From Global Science
The current atmosphere is light years away from what it was a month ago, when Russian doctors still took part in international research and clinical trials. They participated in international collaborations and felt themselves to be a normal part of the global medical community.
“It’s very painful to see how professional societies put on hold collaborations with Russian doctors,” said Polina Shilo, MD, medical oncologist at Luch Clinic and program director of the Higher School of Oncology in Saint Petersburg, Russia. “It took us, thoughtful doctors, years and years to build these collaborations. International colleagues learned about us, that we are normal people who speak English, that there is proper medicine and proper medical science in Russia. We felt like we were finally a part of the community, but now it’s over.
“Collaborations are stopped, even those where grants were won and clinical work started, and there’s nothing we can do about it. It’s more difficult for us to publish our work in international peer-reviewed journals. Many of them charge a fee that is very high for us with a new exchange rate, and we still have to figure out how to pay it because our bank cards stopped working. Same thing with foreign sources by subscription.”
“I’m afraid that there will definitely be problems with attending conferences, events, with joint scientific research,” said an anonymous doctor from a private clinic. “International medicine speaks English, and we have only just begun to ‘touch’ this world, to introduce evidence-based medicine. Blocking access to information will only lower the emerging standards of healthcare. Without international credit cards, we cannot pay for international databases such as UpToDate.
“Internships, grants, [and] exchanges may become unavailable to our doctors. And all this will only lead to the ‘old school’ triumph with its expert opinion, which for modern medical science has the lowest level of evidence.”
Diagnostics and Dentistry
Modern imaging-based diagnostic methods are the first items at risk, as the machinery and supplies needed for CT, MRI, PET and other sophisticated methods of examination depend on international supplies and are difficult to source, especially quickly.
“To name one example, the x-ray film that we use for mammography is produced only in Belgium,” said an anonymous doctor from a university clinic in a major city. “Now we have just three boxes left in the department. This is enough for 100 women, and we need thousands and thousands. This means no breast cancer screening this year. Our tomograph is of Russian production, but it’s like cars: semi knocked-down assembly with the components from America or Japan. Now the warranty period is over. An x-ray tube cost about 10 million rubles a year ago, which was already an unbearable amount for the hospital. We needed the second CT room for stroke duty, and hoped to do it by the summer. This is not happening.”
He continued, “Russian public healthcare operates through compulsory medical insurance. Its prices were calculated on the basis of certain prices for medicines and other supplies. There used to be favorable and not-very-favorable tariffs. Everyone tried to take patients with ‘beneficial’ diseases. Now there will be no such ones.”
“As for the equipment, I hope it will not disappear completely,” said the head of the radiology department at a large private hospital in Moscow. “We will start to buy something secondhand through third-party countries or use Chinese analogues. Maybe some black market. But another problem is the technical support and service. For now, it looks like the previously signed contracts are not canceled, but sooner or later, this market will collapse too.”
The same concerns apply to virtually all kinds of modern high-tech dentistry and orthodontics. “Right now, we do not feel drastic changes, but they will come at the moment when warehouses run out of medical devices, medicines, and components (and they will run out, despite the decision to ban their export abroad by suppliers who have announced sanctions),” said an anonymous dentist from Moscow.
“Suppliers of high-tech equipment have already raised selling prices for medical devices. As a result, the availability of high-quality, high-tech methods of treatment and diagnostics for our patients will drop sharply. As a result, the country will experience an increase in chronic diseases, advanced stages of cancer, and other issues that could be diagnosed and treated at an early stage. This deterioration in the quality of treatment will result in an increase in the number of complaints and lawsuits against doctors, and an increase in the burden on all the medical workers, which will inevitably make plenty of highly qualified specialists leave their jobs.”
He continued, “Effectively, here is a double blow, so to speak: an increase in the ruble price of drugs, products, and services, plus the gradual decommissioning of tomographs, dental units, etc. Those who are smarter created stocks of consumables (anesthesia, dental implants, filling material, orthopedic elements, etc.). This will be enough for some 6 months or so, and then we will see.”
Foreign suppliers seem quite reluctant even about their pre-war arrangements with Russian clients. “It is not a secret that our industry does not produce what is needed for modern, high-class dentistry,” said an anonymous dentist from Saint Petersburg. “And it’s awful what is happening now. For example, Invisalign informed us post-factum that it is not shipping its products to Russia. They blame their shipper UPS, but it’s their responsibility. Retainers were already ordered, produced, billed, and paid, and now they say that everything that was not yet shipped will remain in their warehouses in Mexico. We are clueless. Patients ask questions, and we do not know what to answer. It harms innocent people’s health, it harms our reputation. It’s all terrible.”
Drug Prices Soar
Medicine and medical devices and equipment are considered necessary for humanitarian reasons and are excluded from sanctions. Still, several companies took action without respect to the sanctions.
US drugmaker Eli Lilly and Company said it will send medicines for urgent medical conditions such as cancer and diabetes. It is suspending sales of “nonessential medicines” as well as all investments and promotions. It will also will not start any new clinical trials in Russia.
“International clinical trials in Russia are now on hold,” said Shilo. “This was one of the ways for our patients to get diagnostics and treatment using experimental or best available therapy for free, and for the doctors to gain some additional money to their modest salaries. Most companies now cite issues with logistics and shipment, as delivery services stopped working with Russia, but as a matter of fact, for the time being, no new patients are being admitted. For some patients, being part of a clinical trial is a last resort. For others, it’s a way of seriously lightening the financial burden.”
Among other companies limiting their operations in Russia are Novartis, AbbVie, Johnson & Johnson, Pfizer, and Bayer. Many of them announced that the profit they gain from the Russian market will be dedicated to supporting Ukraine.
“Despite pharmaceutical companies having not yet announced the curtailment of their activities in Russia (although there are calls for this on various levels and platforms, including, unfortunately, Medscape), there are several reasons for the possible, albeit temporary, shortage of certain drugs,” said Alexey Vodovozov, MD, a physician in Moscow and editor in chief of the magazine Russian Pharmacies.
“First, logistical difficulties. All of the main chains have been disrupted, and it will take time to find acceptable work-arounds. Second, fluctuations in the ruble exchange rate lead to problems with mutual settlements, revision of price lists, and price increases. And not necessarily by manufacturers — distributors were the first to act, and then pharmacies were forced to change their price tags.
Third, panic rumors were dispersed on social media networks and the usual reaction of our citizens to any difficulties is to buy up drugs. Right now, it is very difficult to find Nurofen or Norvasc, Depakin or insulin in local pharmacies, although it seems that their supply has not been stopped. Analogues and generics help out, for now. It’s clear that eventually the situation will improve and stabilize at some new level, but both doctors and patients will be thoroughly worried.”
“Right now, imported therapies for oncologic patients are still in stock, purchased at a rate of about 60 rubles per euro,” said Ilya Fomintsev, MD, oncologist and executive director of the Cancer Prevention Foundation in Saint Petersburg. “But they will run out very quickly, in about a month. The following purchases will go at a rate of approximately 160 rubles per euro, which means tripling the cost of an already expensive therapy. This will make therapy completely unavailable to patients except those who pay for it themselves.”
He continued, “Yesterday, I spoke with a pathologist. Reagents and slides for immunohistochemistry have disappeared, so we will probably go back to hematoxylin-eosin. Not all young people know how to do it, and they are right — it’s like using percussion and a stethoscope in the age of CT and MRI.”
“It looks like international companies are going to leave our market,” said Shilo. “It is very sad, though I do not expect a complete collapse of the market of oncological drugs. There are Russian analogues that are not as bad as one might think.”
Humanitarian Crisis
“I lost the sense of being useful,” said an anonymous Moscow radiologist. “Medicine is not just medicines and instruments. It is a will to do your job properly, to develop, to grow. This will to grow is supported by the understanding that people are in need of what you do. This very feeling has totally disappeared these days. Imagine a chef in a very good restaurant whose business suffers for some reason beyond his control. People tell him, ‘Come on, don’t be sad, people will still want to eat.’ Of course, you can feed people with hot dogs and cure them with oak bark. But this demotivates terribly. In the last year, four employees of mine emigrated. It’s difficult to stand.”
“It is very important for me to convey a simple thought: the pharma business is more pharma than business,” said Shilo. “That if everyone leaves Russia, our patients are really in trouble. We do not have an industry that could cover the needs of, say, oncology. And even if there is something, we will still not be able to produce what we need due to patent restrictions.
“All this in the end multiplies sorrow and suffering, which is completely contrary to humanism.”