MOSCOW — In the intensive-care unit at Hospital No. 1, there are 12 beds for the near-dead. One morning 10 unfortunates lay there, mostly unconscious and virtually naked beneath tobacco-colored sheets.
The first had ignored an earache, which grew into a raging bacterial infection of the brain. The second, third and fourth shattered their bodies in auto accidents. The fifth, sixth and seventh bloodied their brains in mostly drunken falls.
The eighth had his skull fractured in a beating. The ninth had been run down by a car.
The 10th is Yuri Ivanov. He was felled by a 20-pound cat, a fat black Persian with which he was playing. "I was walking backward and stumbled on the stairs and fell," the 46-year-old import-export businessman said through his oxygen mask. "That night I went to sleep. When I woke up at 6 the next day, my body was all swollen — my neck, my shoulders, my hands, my belly — everything."
Still more harrowing, his skin crackled like bubble wrap whenever he pressed it.
So he drove 50 miles to a doctor, who instantly sent him by ambulance to the emergency room here. The diagnosis: two broken ribs and a punctured lung. The escaping air had inflated Ivanov like a beach toy.
Almost anywhere, a trip to the hospital is an unsettling experience. But Ivanov had cause to be nervous: In Russia, in the year 2000, it can be a life-threatening one.
Russian hospitals — like almost all of Russian health care — are in a perilous state. Drugs are in short supply; if available, they are often too costly for the average citizen to afford. By one 1999 estimate, every year at least 20,000 cancer patients die because they cannot afford medicine. By another, some 200,000 diabetics are unable to get insulin, even though the government guarantees a free supply, because local and regional governments cannot afford to buy it.
Doctors and nurses are astonishingly underpaid, as much as a third below the national average. The best ones leave for better jobs or move abroad. Those who remain are constantly battling the lack of money, medicine and equipment.
The problem is not just that Russia's health-care system is ancient (one in 10 hospitals was built before 1914) or ill-equipped (two in five hospitals have no running hot water; one in five have no running water at all). Nor is it that the system is huge and inefficient (12,000 hospitals and 20,000 clinics).
Those things were true when Russia was under Soviet rule. But the new problem is that there is no health-care system — not as there was before.
It is a hybrid beast — no longer communist, but certainly not capitalist.
In theory, doctors have more technology and training than ever, and yet they yearn for the days when basic drugs were always in stock and when equipment, however outmoded, at least worked. Patients detest bribing doctors and buying medicines that hospitals no longer stock, yet they say they cherish the freedom to choose better, if costlier, treatments.
The system seems destined to linger in this economic purgatory unless Russia's leaders give it more money and attention.
Historically, that has never happened. Soviet health spending was between 3 percent and 3.5 percent of the gross domestic product for decades, barely a third of the rate in Europe generally. Independent Russia spends perhaps 5 percent of a gross domestic product vastly shrunken from Soviet days. In 1995, that amounted to $148 a person. The amount spent on the average American was 25 times as much as this.
In N.I. Pirogov Municipal Hospital No. 1, a rambling 1,500-bed institution on the edge of downtown Moscow, Dr. Alexander Ivanovich Turchev said, "Sure, in the past we didn't have big possibilities — we had less equipment, and lower standards," he said. "But if something happened in intensive care when someone was on duty — a light was out, or one of the systems broke down — it was an emergency. You could call the main headquarters of the party, and immediately they would fix everything."
And now? "Two weeks ago, the central vacuum system in the unit was down," he said, referring to the electric pumps and hoses used to suction fluid and mucus from unconscious patients. "It took 10 days to fix it." Meanwhile, doctors used an ancient manual pump.
"In the Soviet Union, everything was simpler," said Angela Zabrodnaya, the trauma department's willfully cheerful head nurse. "There was enough for everybody — enough to use, enough to steal. But now, we haven't received a single disposable syringe all year." Indeed, she said, the hospital's chief doctor taps his office account to buy them.
One reason Russian health care is in desperate shape is that the average patient's stay approaches 17 days, compared with five in the United States. In Des Moines, Iowa, doctors would have treated Ivanov's lung puncture and bade him farewell in under a week; here, he remained for 15 days.
It is not unheard of for children to commit elderly parents to hospitals because they cannot support them. Nor is it particularly unusual for ordinary people to check in for long stays — stays that after all, include free meals, laundry, a bed and lots of companionship.
Someone has to bear the added cost. And in part, the burden falls on genuinely ill patients, who pay more than they would have in Soviet times, or endure more Spartan conditions to subsidize roommates.
In room 518 at Hospital No. 1 is 30-year-old Aleksei Belov, who ran his motorcycle full speed into an illegally turning car. His broken pelvis is held together with a brace that spans his abdomen like a suspension bridge.
It is $2,000 worth of secondhand steel, bequeathed from patient to patient. On doctor's advice, his mother, Valentina Belov, also scoured local stores for a $130 knee brace and $47 of pain-killing injections.
On an ingenious doctor's advice, she also bought him a $2.30 Looney Tunes beach ball covered with bright yellow Tweety Birds.
Bedridden Westerners puff into special breathing devices to exercise their lungs and ward off pneumonia. Belov inflates his beach ball, to much the same effect.