Azerbaijan, like all post-communist states, has struggled to maintain a functioning health-care system since becoming independent. But financial pressures and the conflict with neighboring Armenia have overstrained the medical system. Maternal mortality is rising, life expectancy is falling, and diseases once nearly eradicated, such as tuberculosis, are making a comeback. RFE/RL spoke this week with Dr. Stephen Ayres, a U.S. cardiologist who is leading an effort to train Azerbaijani doctors and nurses to provide more efficient health care while helping them obtain the medicine and equipment they need.
Prague, 3 August 2000 (RFE/RL) -- Cardiologist Stephen Ayres is the former dean of a respected medical college in the U.S. state of Virginia. Since retiring from that post, he has traveled throughout the former Soviet Union with a small team of American colleagues trying to help where there is a medical need.
Ayres's current project focuses on Azerbaijan. Thanks to a new grant from the United States Agency for International Development, USAID, Ayres has been able to bring Azerbaijani doctors and nurses to the United States for training, and to travel himself to the country to offer needed medical equipment and often, a little advice.
Ayres recently returned from such a trip. He says Azerbaijan, with its huge refugee population faces a daunting health challenge.
"Because of major political problems between Armenia and Azerbaijan, there are large numbers of displaced persons. They are both refugees and internally displaced persons. In fact, probably one out of eight of anyone living in Azerbaijan is now displaced. One could imagine what would happen to a country like ours or anywhere in Europe, that had that large a number of displaced persons. And I'll just mention that of course, with all those displacements -- with all those internally displaced persons, health needs are immense, and the system which was fragile to begin with is now just overpowered."
Ayres told RFE/RL his next task will be to send a team of medical experts to Azerbaijan later this month, to assess needs and see how local doctors can best be helped. His goal will be to emphasize what medical professionals call "primary care." Ayres explains:
"We think that where we can work the most, is by helping them develop an approach to health care that's called primary care -- where everyone really has a family doctor and the family doctor takes care of 70 percent of the problems. The way it used to be in the U.S. and the way it is today in most of the former Soviet Union, is it's just all specialty medicine. If you come in with a sore throat, you'll be referred to an expert in sore throats, and that's very inefficient. And so we've pushed very hard on the concept of primary care."
Ayres emphasizes that from his experience so far, he has been impressed with the quality of Azerbaijani doctors. The problem is the lack of medicine and equipment.
"I'd like to say right up front that we've really found that the physicians we've worked with are practicing at a very high level. They're very good at the diagnosis of illness. They know a fair amount of prevention. But where they fall down is in the ability to use modern technology. And I don't mean high tech. They don't have real access to antibiotics and other pharmaceuticals. They don't have things like mammography or ultra-sound, and they have a whole series of organizational issues that they need help with."
Ayres enumerates the main health problems facing doctors in Azerbaijan:
"We'll take the problems that are of most importance; tuberculosis is one. They have some malaria, they have dysentery and then they have all the other diseases -- sore throats, pneumonias, that one could imagine. And so we have to work with them and basically, since we obviously can't make much of a dent ourselves, we have to really search out those doctors who are change agents and who are open to new ideas and try to make them the trainers. So in a sense, on this next visit, we'll be identifying people who can become the trainers and then we'll train the trainers. And we hope that that will become the primary care population of doctors. We know now that they already have what they call 'area physicians.' The area physicians make house calls and go out into the community and so we'll be training those area physicians and helping them become more modern primary care doctors."
Ayres says the Soviet medical system trained its doctors relatively well, but kept them in isolation, preventing them from exchanging knowledge with colleagues in other parts of the world. Now, the borders are open, but a lack of funds prevents communication.
"The Soviet system was such that physicians were not encouraged to talk to the outside world. They just weren't supposed to talk to enemies of the people and so as a result, during these last 30 years, which were so influential in the development of health care, there was no contact to speak of, with the outside world. Now, with the fall of the [Soviet Union] and all the changes that occurred under perestroika, they were free to talk to the outside world. But they didn't have the money to get medical journals and various kinds of teaching aids. So we're trying to fill in that very important educational deficiency."
Ayres says his team will also be bringing equipment:
"You know, in the United States, if a piece of equipment is, let's say, five years old, somebody will throw it out. So we're there with our hands wide open and we can look at them. We have a biomedical engineer on our team. We can analyze whether they're in good shape or not. If there are some things we have to purchase, then we just make outright purchases. And there are other organizations. There's one called Care Lift that works widely in the newly independent states. And their whole reason for existing is to help countries like Azerbaijan acquire needed equipment. It's very important -- this is kind of the next paragraph, to get just the right equipment. People who have traveled widely in the former Soviet Union can relate tales of seeing all kinds of equipment not being used or used improperly. Many times they're just missing a [component] or they're missing some set of batteries and so we have to, in addition to getting the equipment, we have to teach them how to use it, then help them interpret the results, and then make certain that there's an engineer around that can help fix it, if it falls apart."
One obstacle to bringing over more aid and equipment, says Ayres, are laws that prevent U.S. assistance to the country. But he notes that his group, by focusing on refugee care, has been careful to stick to the letter of the law.
"The major issue for us has been the United States government, because of specific injunctions against helping Azerbaijan. It's actually legislatively mandated. However, the U.S. government allows us to deal with the refugees directly, as long as we don't do anything that is seen to help the country itself. So we focus basically on the refugees. Now it's obvious that we work very closely with the local doctors so part of it is a little bit a sleight of hand. But as long as we don't directly support the government with all kinds of things, then it seems to be OK." Ultimately, Ayres notes, Azerbaijan's health care system will not recover until the country emerges from its general economic crisis. But when that happens, he says, the country's leaders will have to commit a much greater percentage of their resources to health, if they are to reach acceptable levels.
"You can look at the health care systems and see what percentage of GDP they invest in health care. Of course, in the United States, it's been as high as 16 percent but in Azerbaijan, it's only about 1 percent. So one can see that for whatever reason, we need to encourage them -- the Azerbaijani doctors -- to work with their leaders to invest more into health care."