When East meets West
For much of the 20th century, Russian medicine was cut off from the international scientific community by the isolation of the Cold War. As it begins in earnest to reconnect, a Yale collaboration in Tatarstan is helping to break down old bariers. A letter from Kazan.
To appreciate the sea change under way at Kazan State Medical University, one needs a swift history lesson, a tour of the 189-year-old school that shows what this seat of learning once was and what it hopes to be. A good place to start is inside the wood-paneled anatomy theater, where 19th-century instructors dissected cadavers before audiences of medical students (and the occasional Russian aristocrat permitted to watch from the balcony above). Around the room, glass display cases hold dozens of jars containing organs, limbs and fetuses, a collection of odd specimens that once belonged to Peter the Great.
Down the hall in a classroom, students wearing white caps and lab coats study under a mural depicting great healers from antiquity alongside esteemed medical professors from 19th-century Kazan. The painting shows men standing around a cadaver, those on the left side wearing ancient robes and turbans. Among them are Ibn Sina, the 11th-century Iranian philosopher who wrote The Canon of Medicine, and Galen, the ancient Greek who first diagnosed a patient by taking a pulse. There’s Nikolai Ivanovich Pirogov, the Russian scientist famous for developments in battlefield medicine during the Crimean War, and next to him are three former chiefs of the Kazan anatomy faculty: Aristov, Tankov and Lesgaft.
These pieces of art and artifact testify to a long and substantial history and an era when the medical school was internationally renowned. “In 1880, Russian science was at the level of all Europe,” says Valerii Albitski, M.D., Ph.D., chief of the university’s department of medical ethics, history and law. He is standing across campus in the school’s museum, which also pays homage to this chapter in Russian history. The walls are lined with the portraits of scientists and physicians from a prerevolutionary epoch when Russian doctors led many of their fields. Ivan Petrovich Pavlov won the Nobel Prize in 1904 for his research on the effects of the nervous system on the gastrointestinal tract, and Ilya Illyich Mechnikov’s work on the immune system earned him the Nobel four years later. The hero claimed by the city of Kazan, a metropolis of 1.1 million inhabitants 450 miles east of Moscow, is Alexandr Vasilyevich Vishnevski, who in the 1920s played a major role in advancing techniques for administering local anesthesia. He eventually became the Kazan medical school’s rector, or dean, and his statue—along with those of Lenin and the writer Pushkin—stands on the sprawling city campus of large, Soviet-era buildings.
Russian medicine changed after the fall of the czars and the sealing off of the Soviet Union that began under Stalin and continued through most of the 20th century. Like other institutions, Kazan’s medical school became isolated from international dialogue, and nearly a century after social and political revolution began fermenting in the old Russia, Russian medicine is still recovering from its aftereffects. “It’s something of a Russian curse,” says historian Albitski, “that we have to remake ourselves every 100 years.”
While the paranoia of the Cold War did much to drive scientific achievement in fields crucial to the arms and space races, it also had the effect of curtailing inquiry that depended on scientific exchange with the West. The enormous social changes—the abolition of class-driven wealth and status, the equalizing of professions—meant less funding for established Russian institutions, including those that had supported medical research. Today, the physical environment of Kazan’s medical university wears the scars of those years of deprivation. The dignified buildings of the rambling campus are dim and grimy from lack of maintenance. Students wear thick sweaters under their white lab coats. The heat is not on, even though it is early October and snowing. But step inside the classroom of surgery professor Arsen Kourbangaleev, M.D., and you’ll see part of the latest “remaking” the historian is talking about.
Kourbangaleev, a lanky, soft-spoken man with a bushy moustache, hits the play button on a VCR, then appears on the screen dressed in green scrubs, sitting behind a desk and speaking in Russian. Soon, the image changes to the tiny blades of a laparoscopic instrument snipping away at fatty tissue. The procedure is the nephrectomy portion of a kidney transplant, and the video—a routine teaching tool for doctors in the United States—provides the first glimpse of laparoscopic surgery for many students in the classroom. Kourbangaleev learned laparoscopic technique after spending several months as an observer in New Haven three years ago, and made his own video on his return home with footage shot at Yale. The tape lasts only 30 minutes but it represents several decades of technological catching up with Western colleagues and a big step forward in the institution’s efforts to rejoin the international medical community at full speed.
Kazan State Medical University was founded in 1814, the same year Yale conferred its first medical degrees. It has a student body of 5,000, encompassing medicine, nursing, pharmacy, dentistry and social work, and a faculty of 650. (By comparison, Yale has 507 medical students and 1,330 full-time medical faculty members, many of whom are engaged primarily in basic research or clinical care, rather than teaching.) Medical education in Russia begins after secondary school and lasts six years.
Eager since the fall of communism to regain its previous status, Kazan’s medical university has been active in seeking connections with the West. Kazan faculty have research affiliations with several European institutions, in particular the Catholic University of Leuven, in Belgium, and the medical school is working on setting up a program with East Carolina University, in Greenville, N.C. But Kazan’s exchange with Yale is the main one, because it has continued for so long and is open-ended. For the past five years, Yale faculty and residents have gone to Kazan every year, and Kazan professors have come to New Haven and nearby Waterbury, Conn.
So far 30 Russians have come here, and 20 faculty members, residents and students from Yale, along with several administrators from St. Mary’s Hospital in Waterbury, have gone to Kazan. The most recent visitors from Russia included a neurologist, an infectious disease specialist and two obstetrician-gynecologists, each of whom spent several months last fall following mentors at St. Mary’s and Yale-New Haven hospitals and meeting with Yale faculty and house staff. Also this year, the School of Public Health became involved in the Kazan exchange and sponsored a faculty member from Kazan who is spending a year in New Haven.
Among those traveling from Yale to Kazan last fall was Jeffrey G. Wong, M.D., an associate clinical professor of medicine, who gave seminars designed to turn good physicians into good teachers. His trip in September was his third in two years. He was joined by two Yale residents in internal medicine, Michael Z. David, M.D., a resident physician and doctoral candidate researching the history of tuberculosis and its treatment in Russia, and Diana Nurutdinova, M.D., a native of Kazan who came to Yale on the exchange in 1998 and returned to New Haven two years later to continue her training in internal medicine and infectious diseases. David and Nurutdinova conducted research into the social history of patients at a tuberculosis hospital, poring over files to determine, for example, if they were smokers or HIV-positive.
They also taught a class in evidence-based medicine, an emerging field based in part on concepts developed at Yale by the late Alvan R. Feinstein, M.D. In the course, residents from Kazan learn how to formulate a clinical question, find relevant data by searching the medical literature, evaluate the data and make clinical decisions based on the best available evidence. Although the scarcity of medical journals in Kazan has been a major obstacle to the project, Yale’s help in providing a small reference library and 11 computers with Internet access has made a large difference. Another focus of the exchange has been to establish team-based teaching on the wards for students and residents in Kazan, where clinical instruction is mostly classroom-based with little input from practicing physicians.
The program’s success reflects a warmth among the participants that has grown over the past decade, says Asghar Rastegar, M.D., one of its main architects and Yale’s associate chair of medicine. A visitor to Kazan is wined and dined, whisked to the ballet and museums and taken on outings down the Volga River or to the 17th-century monastery at Raifa. On this end, Russians spend considerable time with the Yale professors in New Haven and Waterbury and sometimes live with a faculty member during their stay. The socializing that goes on helps foster a trust that eases communication between members of two very different cultures.
“It’s very important that our program with Yale is ongoing, because that means it works,” says Nail Amirov, M.D., the Kazan medical school’s rector. “Isolated visits of just one month wouldn’t work, but over time, this has showed the advantage of what can be taken from the American system.”
What can be taken, says Amirov, are strategies for better medical training. By seeing the American medical system firsthand, Kazan’s faculty members fully grasp developments the Russian medical system missed during the Communist era. Further fueling the need to make up for lost time is the pace of social change in Russia. A growing consumer culture, the spread of information via the Internet and rising standards of living mean that Russian people want, and demand, more from their doctors—though there remains a sizable gap in expectations (See sidebar). Private insurance is on the horizon, and people with money can go abroad for operations. Kazan, the capital of Tatarstan and a center of Russian culture and history—where the dramatist Maxim Gorky came of age, where Tolstoy and Lenin studied, where Nureyev danced—is relying on Yale and other international contacts to speed its development in medicine. “Fifteen years ago, this would have been impossible to imagine,” the rector adds. “Back then, there was total isolation.”
A cultural crossroads
The seeds of the Yale-Kazan program were planted in 1992, when Yale residents and faculty in internal medicine began participating in a program, funded by the U.S. Agency for International Development, to help modernize the former Soviet medical system. The grant, managed by the University of Rochester School of Medicine, enabled visits by American academics to 13 schools in Russia, Ukraine and Belarus. Representing Yale was Asghar Rastegar.
Rastegar, a nephrologist who joined the Yale faculty in 1985, had long wanted to visit the country that produced the literature of Dostoevsky and Tolstoy. In Kazan, he found a city rich in history and a culture shaped by a melding of European and Asian influences. Located near the confluence of the Volga and Kama rivers 600 miles north of the Caspian Sea, Kazan marks a crossroads of East and West. Its prehistoric settlements date back 100,000 years; modern habitation began in the eighth century when members of the ancient Bulgar tribes began to populate the Volga valley. Islam became the state religion in the 10th century and remained dominant until the invasion by Ivan the Terrible in 1552. But unlike the situation in the Caucasus 900 miles to the south, where Chechen rebels and Russia’s military are fighting a brutal and protracted war, Tatarstan’s ethnic groups have enjoyed a mostly harmonious coexistence for centuries. Forty-nine percent of the population of the Federal Republic of Tatarstan—one of 21 republics in the Russian Federation—is ethnic Tatar, a predominantly Muslim people who migrated to the region from the east. Most of the remainder, 43 percent, is Russian, with a tradition that is mainly Slavic and Christian. The tight interweaving of these two groups is apparent throughout the city, in a skyline punctuated by the crescent moon of Islam atop minarets, in the onion domes of Russian Orthodox churches and the city’s Kremlin (a sprawling, walled government complex that soon will be 1,000 years old) and in the faces of its people. All this, along with the city’s role as an active river port, creates a cosmopolitan setting that extends to the medical school.
“Out of all my contacts in Russia, Kazan was the only place where I sensed a clear desire for change,” Rastegar recalls during an interview in his office in New Haven. “It wasn’t expressed openly, but I sensed their desire to become what they were in the last part of the 19th century. They are very proud of what they were. I got that feeling in my meeting with the rector. All the other rectors in the other medical schools tended to be very formal, and they never moved on to the more personal questioning of ‘Why are you doing this and what are you interested in?’ These questions opened up the conversation to a different level.”
A native of the ancient city of Shíraz in southwestern Iran, Rastegar has an easy charm and a gift for diplomacy. And his own history has given him empathy for people who have experienced political upheaval. After getting his medical degree at the University of Wisconsin and training at Penn in medicine and nephrology, Rastegar returned to Iran in 1973 and taught at Shíraz’s medical school. He spent a sabbatical year at Yale in 1976-77 and returned home just in time for the start of the Islamic revolution that toppled the Shah and laid the foundation for the country’s current political climate. Rastegar was expelled from his teaching job and briefly imprisoned for his activism for democracy. He left the country in 1983, settling at Yale two years later.
Lessons from the East
While a professor in Iran, Rastegar participated in several faculty and resident exchanges with Western institutions, including Yale. He saw how such projects could founder on cultural misunderstandings if the Western partner tried to impose its values or methods without consideration for the country it was trying to help. “One needs to make sure that advice is filtered through the reality of life,” he says. “In my contacts with Kazan, I was very conscious that they are the ones who are going to solve their problems. But having contact with the best institutions abroad can energize the process of change.”
So Rastegar began thinking about how an exchange could work. In 1997, he asked his Yale colleague Majid Sadigh, M.D., to go to Kazan. Sadigh, an associate professor of medicine, had been Rastegar’s student and resident in Iran and experienced similar repression before coming to the United States. “Dr. Sadigh went [to Kazan] out of curiosity, with no expectations,” says Rastegar. “He was captured by the phenomenal energy of the young people in Kazan and said, ‘Let’s do it.’ ”
Together, the two men hashed out the beginnings of the exchange proposal. The program grew with help from St. Mary’s Hospital in Waterbury, which chipped in room, board and funding for travel for the Russians; Yale has provided books, journals and computer expertise to the medical university. Financial support for the exchange has come from individuals and organizations including the Waterbury Medical Society and the Jewish Federation of Waterbury. Yale’s International Health Program has helped support Yale residents who choose to spend time in Kazan as part of their training. Rastegar will make his fifth trip to Kazan in June with Yale colleague Fredric O. Finkelstein, M.D., to lead the city’s first international nephrology conference.
The direction in which much of the knowledge has been flowing during the initial years has been from west to east. But Rastegar sees many opportunities for American doctors to learn from their Russian and Tatar colleagues. The time-capsule effect of the Soviet era left intact systems of alternative medicine as well as a network of sanitoria used for rehabilitative medicine. Sick people in Russia often travel to the countryside to convalesce for weeks at a time, a therapeutic approach unthinkable under American managed care. “Their rehabilitation is much more holistic than ours,” says Rastegar. “This area is fascinating to me, and there’s no data on this yet to show.” All it takes is for someone to get interested, he says, and the exchange program will adapt. With a core goal of “change through education,” as Rastegar defines it, the Yale-Kazan project is wide open for whatever participants want to do, on either side.
Kourbangaleev, the surgeon who came over in 2000 as an observer, is a good example. “He really used his time here,” says Rastegar. “We brought him here to learn how surgery is taught” on a basic level, but Kourbangaleev expanded the scope of his training to include laparoscopic procedures, and he now teaches those advanced methods at home with the help of the videos he made. “This was not the objective of the program,” Rastegar says. “But that’s what happens.”
A different mentality
For now, the changes in Kazan are at a grass-roots level. Everyone, from the rector to the hospital residents, says the medical system needs to change, but the system is still centralized and any significant change would require support on the federal level. Hence, the Yale influence in Kazan has much to do with changes in attitude. That involves encouraging doctors and students to trust their judgment, think for themselves and not rely only on tradition and business-as-usual. Resident Michael David describes the goal of evidence-based medicine this way: “As a doctor, you “should always be curious, you should always be skeptical. You should always be conscious of what you’re reading, where the source is. Never accept things blindly, which is the way many are taught to practice medicine. What we’re teaching is a new mentality, a new approach to medical epistemology.”
Another facet is expressing that independence of thought. This is rather radical in Russia, where medical education is largely based on a 19th-century German model in which the teacher is the ultimate authority. That history, plus the legacy of the Soviet era, means Russian medical students tend to keep their heads down. Even getting professors to speak up is a major hurdle, says Wong, the Yale faculty member whose course on teaching techniques relies on class participation and role-playing. But once they start participating, the professors seem to love it. “I’ve never experienced such teaching,” says Yudina Guzel, M.D., Ph.D., a lecturer in dentistry. “He talks to us like we’re his equals. This is the way all teaching should be.”
At one of the many dinners Wong attended during his stay, he raised his glass to the Kazan professors. “It’s fairly difficult to imagine how to change what you’ve always been told to do,” he told his Tatar and Russian hosts. “So I think it’s very exciting that Kazan has started to make this step to be very progressive.” Still, there remain differences between the American and Russian medical systems that no amount of cross-cultural goodwill can overcome.
Start with money. The medical system in Russia has little of it, and Russian doctors’ salaries are a pittance compared with what U.S. doctors make. At a little under $100 a month, they provide barely enough to live on, much less buy a car or a house. The equipment at Kazan hospitals varies wildly. The No. 1 Republican Hospital, which serves all of Tatarstan, population 3.7 million, has only one MRI machine and one CT scanner. Meanwhile, across town, the Interregional Diagnostic Center has the latest state-of-the-art equipment, including a room for telemedicine conferences, but part of the building is still under construction.
And in a climate where entrepreneurs seem to have all the cash, some Russian doctors are abandoning medicine. Adelia Maxudova, M.D., assistant professor, has a car because her brother bought it for her. He left medicine to open a laser eye surgery clinic. Once he achieved financial security, he became the administrator of an ophthalmology clinic. But he does not practice medicine. Maxudova was in the first wave of Russians coming to Yale, and because of her time in New Haven she decided to specialize in nephrology. She is a passionate doctor and a passionate booster of the Yale exchange, yet she is frustrated with teaching. Some students at the Kazan medical school, she says, have no intention of actually becoming doctors. Because medical school starts after high school here, a medical degree in Russia can be like a U.S. undergraduate degree—a ticket to a profession that has nothing to do with your major.
“I get very upset about this sometimes,” says Maxudova, sipping coffee in a Kazan café. “Often I talk to someone who says, ‘My daughter wants to be a doctor.’ I say: ‘Do you realize what your child is going to make on a doctor’s salary?’ Under Soviet times, nobody was rich. Everybody was the same. Now the salary is so small. But the profession is still very prestigious.”
So being a doctor in Russia is a labor of love: there’s respect, but not much money. And it raises the touchy problem of whether Russian doctors who come to the United States via Yale will want to return to Russia. Rastegar says the program takes care to pick Russians who have compelling ties to home—young people in the middle of fellowships, faculty members with prestigious positions or strong family connections. Participants have an unspoken contract with Yale not to exploit the exchange and a written contract with the university to return to Russia and work for at least three years. No one has broken that pledge to date, perhaps in part because of the way many of the physicians in Kazan regard a life in medicine in the United States. As one of the residents visiting Yale from Russia this winter put it, she would gladly live without a higher salary and access to modern medical technology in order to retain the strong family and community ties she has in Kazan.
Bringing it home
Yale resident Nurutdinova plans to bring some of the best of American medicine back to Kazan when she returns after completing a fellowship in infectious diseases. After graduating from medical school there in 1996, she started a residency in internal medicine (infectious diseases). Two years later, she visited Yale as part of the exchange program. Back in Kazan, she realized she wanted the more general medical training available in the United States. (In Russia, she says, medical students specialize quickly. “And my specialty is so broad-based, I need to know medicine really well.”) “A residency in the United States is a really good opportunity to become a better physician,” she says. So Nurutdinova took steps 1 and 2 of the United States Medical Licensing Examination at great expense and effort, applied to Yale’s internal medicine residency program and got in. She’ll complete the program in June at age 29.
After more than two years in New Haven, her trip back to Kazan in September for tuberculosis research was a welcome chance to see her family. Her next goal is to secure a fellowship at an American hospital where she can learn to write grants. But she plans to return to Kazan to do research on HIV/AIDS, a growing problem in Tatarstan. “You have to go to the United States and stay there for some time to realize the place you belong to is home,” she said during her visit to Kazan. “I had this first surge of thinking that maybe I should stay in the United States. But I’m not going to be useful by staying there. That’s not going to make sense with what I want to do with my life. Besides, I miss my family so much.”
Another Yale exchange alumnus, urologist Dmitri Tarassevitch, M.D., wants to follow a similar path, at least the part that takes him back to the United States for a residency. But he is less tied to home. Reflecting on his goals in an e-mail, Tarassevitch described his frustration with Russia’s lack of funding, good medical equipment and up-to-date research. His goals are wide-ranging. He hopes to participate in international programs, like those of Doctors Without Borders. And he, too, wants to settle in Russia—eventually. “I love my country, my people, teachers, friends, colleagues,” he wrote. “The problems and needs of Russia are too familiar to ignore them. I would love to serve people and to know that people need me. But I would also like to be a man of the globe, not to confine myself to a narrow region with borderlines. Doctors must be like that, I believe.”
Sitting at his desk in Kazan, deputy rector Alexei Sozinov, M.D., an associate professor of infectious diseases, is well aware of the potential for brain drain. He says he understands and accepts that students will be attracted to opportunities abroad. “It’s life,” he says. “Everyone wants to have a good life. And the residencies in the United States are the best in the world.” More troubling is the potential loss of faculty. In the physiology department, for example, about 10 professors have left for the United States and Europe. But despite the risk of losing other faculty members, his commitment to international programs is strong, evidenced by his animated tone—not to mention the large collection of mugs from around the world that decorates his office. For one thing, the exchange of ideas and people will make Kazan State Medical University a stronger institution and a more desirable place to teach, study and do research.
Sozinov told a story: “Several months ago, President Putin met in St. Petersburg with students. Russian students asked him this very question about the problem of young, talented Russians wanting to get out. Putin says, ‘Of course, we’re concerned that young people with good educations are going to leave the country. It’s a real loss, and it’s even an economic loss. But we’ll never use old measures to stop this process. We’ll never close the country. Our goal is to make life in Russia much better so that doctors and teachers will want to stay here.’ And I share these ideas 100 percent. I have the same point of view.” YM