CHERNAVSKY, Russia -- It could have been the setting for a horror movie.
In a densely wooded area outside a remote village, a crumbling facade with cracked windows overlooking exposed, rag-wrapped pipes conceals an interior of mold-eaten walls covered with chipping paint. Mice scuttle between rickety beds vacated by patients who have been transferred to other dilapidated hospitals of this poor region where forest meets steppe near the Kazakh border. On the wall of an adjoining building, scrawled letters declare: “Russia’s future is in our hands!!!”
Even before the predawn raid by riot police, the dispute over efforts to close Tuberculosis Treatment Center Number 4 -- the only employer in this tiny provincial town some 1,700 kilometers east of Moscow -- was emblematic of the crisis that medical professionals say is ravaging Russia's health-care system and accelerating the decline of its villages.
Tension began to spike on October 15, when authorities came to remove equipment and shut it down. Officially, the center in Chernavsky, 20 kilometers along potholed roads from the regional capital, Kurgan, was closing for renovations. But as hospitals get the axe across Russia at a pace experts warn is unsustainable, the doctors and nurses of Chernavsky -- many of them women struggling to support families on monthly salaries below $200 -- mounted a desperate campaign to save the clinic and salvage their sole source of income.
Their ally in this fight was the Alliance of Doctors, an independent trade union that has made headlines across Russia since its launch last year with support from opposition leader Aleksei Navalny. Its director, 35-year-old eye specialist Anastasia Vasilyeva, has been traveling around Russia to highlight the often dire state of its hospitals and the problems faced by their staffs, including meager wages and tough work conditions. On October 14, she made the journey from Moscow to Kurgan with her deputy, Anastasia Tarabrina, in a bid to prevent what she deemed the illegal closure of the Chernavsky clinic.
“You failed to inform the trade union, you failed to explain the labor conditions, you failed to provide a decree,” Vasilyeva told regional acting deputy governor Tatyana Menshchikova that evening at a press conference attended by local medical workers and journalists. "This is one violation after another, and now you say the hospital will close. It will not."
Menshchikova responded with what sounded like rote statements about financial constraints and long-term plans for “accelerated modernization.” “The government of the Kurgan region has the situation under control,” she said to jeers from the room, adding: “When our economy starts working, we’ll have money to spend.” In a country where government officials rarely appear at events that are not pre-scripted or stage-managed, Menshchikova was dealt a public humiliation.
The following morning at 7 a.m., an emboldened Vasilyeva drove with Tarabrina and several local opposition activists to Chernavsky, where she joined some 40 staff and three TB patients who had returned to lend support. They were met by plainclothes police officers, state investigators, and, after two nights spent in the rundown wards with the lights and heating cut and the lives of patients in danger, by a raid from riot police and ultimately the arrest of Vasilyeva, Tarabrina and two nurses.
"If you do not cease your illegal activities we will apply force and special measures," they were told at the police station, according to a video the Alliance of Doctors posted online. Shortly afterwards, as Vasilyeva awaited her transfer to court for a hearing, the trade union said she lost consciousness.
Ultimately, she and Tarabrina were charged with disobeying police orders and fined. At a press conference they held late on October 17, they said the fate of the TB center in Chernavsky and the remaining patients was still unclear. Local journalists reported that the windows had been boarded up and the front entrance sealed.
Vasilyeva told RFE/RL she plans to return to Kurgan on October 21 to oversee talks between the regional health department and the doctors and nurses of Chernavsky.
“This situation has arisen because from a legal perspective we were correct, and they couldn’t counter us by any means besides force,” she said. “As tough as it is for us we’ll continue to do what we do because we believe it’s needed, and millions of people are behind us.”
But on October 17, regional health department chief Larisa Kokorina made her views clear. She described the campaign by the Alliance of Doctors as an “orchestrated and absolutely groundless operation to destabilize the health-care system in the region,” echoing a narrative that local authorities had been advancing since the standoff began.
Kremlin critics say the dire situation at many hospitals and other state-run institutions across Russia are a stain on the country and a sign that the government is neglecting its own people even as it builds clout abroad. The standoff at the TB clinic in Chernavsky played out at around the same time as Russian forces surged into northeastern Syria following a U.S. pullback and President Vladimir Putin visited Saudi Arabia and the United Arab Emirates.
“Lord, what is going on in this country?” Navalny wrote in a retweet of a video shot during the standoff, adding with sarcasm: “Superpower. 2019.”
According to a 2017 analysis of government figures by the Center for Economic and Political Reforms, a Moscow think-tank, the number of hospitals in Russia halved between 2000, Putin’s first year as president, and 2015. If the trend continues, the think-tank predicted, numbers could equal those last seen in 1913, in the final years of the Russian Empire, and by 2023, there may be no village hospitals left.
The official justification for many of the closures is a controversial government campaign to consolidate health care into a smaller network of high-tech institutions -- but for Russia’s provinces, where many live in poverty, the disappearance of clinics can spell the end to affordable, accessible care, and employment for thousands who already struggle to make ends meet.
“It turns out we’re not needed. Not by the health department, not by anyone,” said Natalya Lebedeva, the Chernavsky TB center’s 42-year-old head nurse and its employee of 26 years, a single mother who uses her monthly salary of 11,400 rubles ($178) to support her two children and pay off a mortgage.
The violent scenes in Chernavsky also shed light on a broader campaign across Russia against activists who oppose Putin’s government or have protested over economic, environmental, and quality-of-life issues. Rallies for free elections that broke out in Moscow this summer elicited a crackdown that resulted in lengthy prison terms for some activists and fines for many more. Russia’s medical workers, already angry over recent cuts in the health-care budget and five years of falling real wages, publicly denounced the clampdown in an open letter published on September 18.
Arguing that increased scrutiny from law enforcement is contributing to a "suffocating atmosphere of fear and unfreedom" that prevents doctors from making informed decisions about the welfare of patients and leads many to reconsider the utility of remaining at work, they said the clampdown in Moscow had “illuminated the fact that what is happening in health care is merely one aspect of a general crisis in the legal system.”
The TB center in Chernavsky is similar to many provincial hospitals across Russia, the state of which has recently been publicized by online activists seeking to shame regional officials into action. In a basement room where treatment takes place, there’s an empty space after a $1 million X-ray machine provided by the health department in 2016 was removed after several months because the clinic could not stump up the 5,000-ruble ($78) license fee from its budget. Since then, the clinic’s patients have been driven down 20 kilometers of rough road to get their lungs examined in Kurgan.
The facility had around 80 patients before preparations began for its closure. For around 30 percent of them, tuberculosis coexists with HIV, which attacks the immune system and significantly raises the likelihood of infection. According to the World Health Organization (WHO), TB is the world’s most fatal infectious disease and the leading killer of people with HIV.
While Russia has made strides in combating the disease, WHO still ranks it as one of the world’s most affected countries: TB in Russia is becoming increasingly resistant to treatment, and only two-thirds of patients recover. Olga Nechayeva, the head of Russia’s state-run TB Monitoring Center, told RFE/RL that the Kurgan region has particularly high rates of TB compared to neighboring regions. Its three TB clinics are all in bad shape. In Menshikovo, near the regional capital, the walls are propped up with wooden planks and trees grow through the facade. In Shadrinsk, the complex is in need of an urgent repair.
On October 15, three TB patients came back to the Chernavsky clinic from the other treatment centers, returning to their wards as the standoff between staff and law enforcement continued. One of them was Sergei Ivanov, a 55-year-old who, like many other TB patients, caught the disease behind bars, where poor conditions and close quarters with others drive up the risk of infection. He had been a patient in Chernavsky since his release in 2016.
“I feel sorry for these people,” Ivanov said of the staff who looked after him. “Those nurses, janitors, and doctors -- how many people like me have they pulled back out from the netherworld?”
At the press conference on October 14, Ivanov stood up and told Menshchikova, the government official, that he had spent three days wandering around Kurgan after his release from the clinic and had made contact with at least 15 people. He warned of the risks if he’s not placed back into treatment.
Despite its decrepit state, staff and patients in Chernavsky argue the center is fit for further use: Its forested location is ideal for the patients, they say, and the second floor recently underwent a modest renovation.
“They treat us very well here, and the conditions are good,” said Ivan Korobenkov, an HIV-positive TB patient from Kurgan and one of those who returned to lend support. “There’s nature, and you can breathe freely. I can’t handle the city for longer than half an hour.”
Due to a lack of government funding, nurses said they buy their own face masks to ward off infection and had begun renovating the ground floor -- with their own money and help from patients -- in an effort to pass checks to keep the clinic functioning. For many, the prospect of commuting to another hospital after the closure of the Chernavsky center was impractical or outright impossible.
“I don’t have the energy to travel. I just can’t do it,” said Valentina Novosyolova, a 69-year-old nurse who suffers from complications after cancer treatment 11 years ago.
The only store in Chernavsky, population 190, closed permanently last year. The nearest is in Vvedenka, 7 kilometers away. If the TB treatment center closes, its staff say, the only bus service -- which is meant to transport patients for checks in Kurgan -- will stop running. Chernavsky may not survive.
For Nadezhda Konopatskaya, who has worked in Chernavsky for 17 years and who supplements her $178 monthly salary with two other jobs that leave time for three hours of sleep per night, the conditions of her employment -- while it remains -- are representative of a broader crisis.
“This is the situation in Russian health care. You have to make ends meet,” she said.
WATCH: Doctor Anastasia Vasilyeva is detained by Russian police.
After being informed that the Chernavsky clinic would close, the qualified and highly experienced doctor was offered alternative employment in Kurgan. Her choice was between a job washing bedsheets for 4,400 rubles ($68) a month, and a position as a medical assistant at 9,100 rubles ($142). Her decision to defy authorities and stage a protest for the first time in her life stems, she said, from a desperate hope that her long-time employer will stay open.
“I really hope we can save this hospital. It’s the backbone of this community,” she said. “Without it, the village will die.”