Open Left: Moscow Doctors Talk about Their Work-to-Rule Strike

“Two of us covered eight precincts for a week”: Moscow doctors talk about the work-to-rule strike
Alexander Grigoriev
April 22, 2015
Open Left presents a unique set of interviews with the doctors involved in the first protest in the Moscow medical care system since 1993
openleft.ru

Medical workers in Moscow have been on a work-to-rule strike since March 24. The work action has been sparsely supported: around twenty people in seven of the city’s medical centers have been involved. They oppose the downsizing of staff, regular unpaid overtime, and workplace management that is detrimental to standards of good medical care.

The current work-to-rule strike is the first in Moscow since 1993, when ambulance staff protested. Although it cannot be said that there had been no problems in the Moscow and Russian healthcare systems all this time, the situation has deteriorated markedly in recent years, and this is due primarily to ongoing reforms by the government.

Since Soviet times, clinics and hospitals have been funded by the state. This meant that all costs for medical care were covered. In addition, since the 1990s, compulsory health insurance (OMS) funds have been operation in Russia. They are financed by contributions from employers. Currently, the size of each contribution is 5.1 percent of a person’s salary, with the maximum salary capped at 624,000 rubles a year. Higher salaries thus contribute the same amount of money to the OMS funds as salaries of 624,000 rubles. The idea is that the OMS funds allocate money to cover costs incurred by medical facilities in providing care to patients. However, rates for services have been set disproportionately low. For example, a chest X-ray is estimated to cost 275 rubles whereas the real cost is around one thousand rubles. Costs have not been covered by OMS funds, so the entire system has continued to be financed by the state.

2010 saw the passage of the basic law governing compulsory health insurance. The idea was that the money from the funds would “follow” the patient, and medical care facilities would be financed from OMS funds every time they provided care to patients. At the same time, rates for services were not changed, so clinics continued to cover the shortfalls that arose with money from the state budget.

When Putin signed the so-called May decrees on May 7, 2012, it became clear that major changes were coming to the existing system. According to one of the decrees, by 2018, salaries of doctors had to be increased to a level twice the amount of the average salary in each region, but there was no question of correspondingly sharp increases in budgetary allocations. On the contrary, spending on health care has been falling with each passing year. In 2014, the economic crisis further exacerbated the shortage of funds.

The Moscow city government continued to finance municipal medical facilities under the old scheme for quite a long time, but gradually reduced its budgetary allocations. Beginning in late 2013, Moscow authorities researched the municipal health care system in order to identify possible options for redistributing costs. Several options were suggested: casualizing some employees, combining several positions into one and thus preserving the old system of positions and salaries, and increasing the specialization of hospitals.

Queue at a Moscow clinic

Officials settled on the option of reducing the number of facilities in two stages: merging facilities and turning some clinics and hospitals into affiliates of other clinics and hospitals, and subsequently eliminating some of them altogether. Conversion of a clinic or hospital to an affiliate implied the dismissal of specialists who were already officially on staff at the main facility or other affiliates. It was announced that a total of twenty-eight facilities would be closed, including fifteen hospitals.

All this took place amidst protests in the regions, where the situation has been even worse. For example, in 2014, ambulance staff in Ufa twice went on hunger strike. Their demands were generally similar to those being made now by the work-to-rule strikers in Moscow: increased staffing and additional pay for additional shifts. The government of Bashkortostan has repeatedly claimed that it fulfilled all the protesters’ demands, but in March of this year, the hunger strike in Ufa kicked off again and has continued for over a month.

In November and December 2014, there was a series of rallies against healthcare reform in its current form, staff downsizing, and hospital closures. According to organizers, up to ten thousand people attended the largest of these rallies in Moscow. Not only health professionals came to the rallies but also members of various political and grassroots organizations. However, the Moscow authorities chose not to enter into negotiations, claiming it was not medical workers who organized the rallies but outside forces. The demands of the protesters were not met.

The healthcare workers union Action (Deistvie), which originally formed in Izhevsk but is now a nationwide organization with three and a half thousand members in twenty regions, was actively involved in organizing the rallies. It is Action that has now organized the work-to-rule strike by doctors in Moscow.

Open Left has tried to get to the bottom of the situation by speaking with the principal figures in the strike.

 

Andrei Konoval

Andrei Konoval is managing secretary of the trade union Action. Under his leadership, the organization has carried out a number of protest actions. Konoval talked to Open Left about the reasons Moscow doctors went on strike, why this form of strike was chosen, and the goals the protesters are pursuing.

Andrei, what is the state of the trade union Action at the moment?

The trade union has around forty-five locals in twenty-five localities, cities, and regional centers, about three and a half thousand members in total.

Let’s move on to the work-to-rule strike. What caused you to declare it, and why was this form of protest chosen?

Because other ways of highlighting the systemic contradictions in the management of outpatient clinics would have been ineffective. We had to attract public attention. So we chose a form of protest with a flashy name—an “Italian strike” [the usual name for work-to-rule strikes in Russian]. Although the gist of it is simply that, on the spur of the moment, physicians start working in strict accordance with the Labor Code and the standards of medical care.

What are the reasons for the strike?

The reason is that now a medical clinic employee’s actual workday is ten to twelve hours long, sometimes even longer. This overtime is not taken into account and not remunerated properly, as per the Labor Code. Doctors are put into circumstances where they have to speed up the time spent examining patients, which objectively cannot help but affect the quality of care. Less than ten minutes are allotted for receiving and examining patients, which increases the risk of medical error and reduces the quality of work. Under these circumstances, people who work in health care facilities are deprived not only of the possibility of spending time with their families, raising their children, and relaxing after the workday but also of feeling that what they do is important and useful, because when the pace of work is such that is, their ability to perform their professional duties is discredited. Real professionals with a sense of duty cannot put up with this situation and they are opposed to it. So now we are trying to show that the Moscow healthcare system is totally underfunded, there is a real shortage of doctors, and something urgently needs to be changed.

Do you agree with the argument that the strike has failed?

The authorities are no longer saying this. They are silent on this score. This was said during the first week: it was just a PR attack. As we stated from the very beginning, at the press conference, we have around twenty strikers in six medical centers (seven, even). Others had wanted to join the strike, but they abandoned the idea under pressure. This is normal; there is nothing new here. Taking on the system is something that only people with a certain stamina and courage, and who are also well versed in the legal aspects of the issue, can do.

I want to emphasize that the strike’s success depends less on the numbers and more on the fact that we have provided an example of working the right way. Even if only one person in Moscow said that he or she were ready to undertake a work-to-rule strike—and survived the pressure—even then we would consider the protest a success.

But have you managed to achieve anything by striking?

Yes, at specific institutions. On the eve of the protest and especially in the early days, first they promised and then later they really began making changes to the work schedule in keeping with our wishes: to reduce the intake time, increase the time for house calls to patients, and change the standard exam time for a single patient from ten to twelve minutes, for example. Several strikers set individual appointment schedules in keeping with federal requirements and the real time demands for working with each patient. At Diagnostic Center No. 5, they managed to get the head doctor, who was planning to sack five hundred people, fired. And there are the little things, like the provision of stationery supplies, which previously one doctor had to buy at her own expense. In some clinics, they have stopped putting unpaid Sunday shifts on the schedule. Certain processes have been set in motion, but this is only at the local level, while our objective is to bring about changes to the way the medical system is managed. Our main achievement is that we have attracted the attention of the public and certain authorities to the problem.

Are you going to strike in other regions?

Our trade union operates from the grassroots, not from the top down. If our locals are ready to pose this question, then the central leadership supports them. A strike like this took place in April 2013 in Izhevsk and ended successfully: ninety percent of our demands were met. The know-how we are now amassing in Moscow will be summarized and used in teaching materials. In fact, it does not necessarily have to be used in a work-to-rule strike, because, strictly speaking, what is happening now in Moscow is not a strike at all. The goal of the work action is not to cause economic harm to the employer and, much less, to the patients. On the contrary, when our strikers see them, patients receive objectively better medical care. So we might not call it a work-to-rule strike, but simply introduce this know-how as a recommendation for protecting the rights of medical workers, resorting to the term “strike” only when we need to draw the public’s attention.

How do you see the future of the trade union Action?

Unions have to be massive. This allows them to have a serious impact on social and labor relations with employers. This is not an easy task, but there is no other way.

Open Left also contacted the strikers themselves and asked them about the reasons, goals, and outcomes of the protest.

 Yekaterina Chatskaya

Yekaterina Chatskaya is an OG/GYN at Branch Clinic No. 4 of City Clinic No. 180. She had struggled on her own to improve her working conditions, but had failed to change anything. After her little son tearfully begged her not to go to work, because he never saw her at home, she realized it was time for decisive action.

Tell us about the conditions in which doctors are now forced to work in the clinics.

Our situation is like this. Our workload had already been quite large. I work in Mitino, a young, growing district, at a women’s health clinic. We have a lot of pregnant women and, accordingly, women who have given birth, and female cancer patients.

We had always had a shortage of doctors, and yet management periodically took on new doctors, and the staff gradually expanded. This, of course, provided some relief. But when this optimization kicked in, the number of doctors at our clinic was dramatically reduced, and the service precincts were disbanded, but no one really counted how many women there were in the service precinct. The residential buildings were simply divvied up (it is not clear on what basis) and the patient load, of course, has increased significantly.

Even before this, UMIAS2 (Unified Medical Information Analysis System 2) had been installed. This was in 2013. By order of the Ministry of Health, an initial consultation with a pregnant woman should last thirty minutes, and a follow-up visit, twenty minutes, but UMIAS set the new time it should take to see one patient—fifteen minutes. That is, they deliberately reduced the time we have to see patients and made it impossible to really help a woman during this time. However, the numbers of high-tech care techniques, such as in vitro fertilization, grows, and so I end up in a situation where a woman comes to see me and, say, she has been infertile for many years or has suffered many miscarriages (some women have ten miscarriages, twelve miscarriages), and now she has finally become pregnant, as she wanted. How can I consult her in fifteen minutes? It turns out that doctors should just engage in a sham, roughly speaking. It is all just for show, for ticking off a box on a form: the patient came in, showed her face, and left. Everything else is outside the time limit. Or the second option is that the doctor does real clinical work, the whole appointment grid shifts, and the doctor does not have time to do anything during the time allotted for seeing other patients, and she starts seeing the remaining patients on her own time.

I cannot deal with a woman like this in only fifteen minutes. In the end, my working day lasts ten to twelve hours, sometimes even longer. Because I have to do paperwork for all the patients I see, and there are also a lot of reports, whose numbers grow constantly. And it turned out that no one had been taking this time into account, it was of no interest to anyone, and basically everyone got paid the standard salary.

The situation was already critical, and I had repeatedly appealed to management to clear up and resolve this situation somehow. They told me that we had to try and make do somehow, everything had been decided, they were powerless to do anything, and we had to meet the norms. Then we were set a norm of twelve minutes per person, which was even shorter, and were told there would also be layoffs. The time for seeing patients was increased, that is, the number of people we had to see increased. However, this standard is not written down anywhere: it is all a matter of verbal instructions.

So things have deteriorated even further since the reforms to the healthcare system began?

The situation has deteriorated dramatically.

I see. And you got no response at all from management?

Absolutely none. They tried to smother “in house” all our attempts to change anything so they would not go any further. I myself personally repeatedly offered to management to write about this to the higher authorities. I even drew up a document, but I got no support from management.

What was your point of no return? What finally convinced you of the need to protest?

For me personally, as a mother, it was when I would go to work in the morning, and my son would still be asleep, and when I would come home from work, he would already be asleep again. I simply did not see him. At some point, he woke up when I was heading off to work yet again. He grabbed my arm and started crying, “Mom, don’t go!” I just realized that was it, I had to change something. When I got home that day, he was already asleep, naturally, and I was very tired. I had had a very rough day. I came home and sat down. I was crying my eyes out. I simply did not know what to do. I plucked up my courage and wrote it all down. I described the whole situation, as it had come to be at our clinic, and sent it to the labor inspectorate. So far, there has been no response, though it has been almost two months.

In the end, I waited a couple of weeks, and then I realized that the matter would remain there, it would go no further. I started looking for like-minded people, because fighting alone, of course, is quite difficult. And so I found colleagues who also wanted to change something. I met with them and talked, and we came up with the idea of a work-to-rule strike.

Why do you think this strike has not yet evoked such a response within the medical community? Why have other doctors decided not to join you?

It’s all a mess. Doctors probably have a well-developed sense of passivity. Very many of my colleagues support me; I would say that almost all of them do. And no one has ever told me that I was wrong. On the contrary, everyone says more power to you, they are on my side, but very many of them are afraid of taking active steps. In our clinic, however, several colleagues have supported me; I am not the only one involved in this. And yet many people fear activism. We have a lot of retirees who just want to make it to retirement. We have a lot of people who have sized up this whole situation and begun to seek work elsewhere. They are planning to leave. When they leave, it is unclear what will happen.

At our clinic, for example, an ultrasound doctor was laid off. The load on the other doctors dramatically increased, and one doctor left: she could not stand the stress. We were left with one doctor who could do ultrasound tests on pregnant women in a huge district. In my opinion, it is simply absurd that, in the twenty-first century, a pregnant patient of mine should wait two or three weeks for an ultrasound. And it turns out that either I should “gently” hint that it would be nice if she paid to have it done (because it is urgent) or she has to wait, and I worry we will let something slip.

Twenty-four appointments for a pelvic ultrasound were issued for next week at our clinic. Only twenty-four appointments for an ultrasound and gynecology exam! This is an outrage. Ideally, every woman should have an ultrasound at least once a year, and those who have had problems, sometimes once a quarter, sometimes once a month. But we have no such possibility.

I have another question for you. These are not just your problems, after all, but the problems of your patients, of the populace. Does management not react to this in any way, either?

Absolutely not. We have instructions from the health department to increase the availability of appointments. Not the availability of health care, but the availability of appointments. In our clinic, it turns out that the overall time each doctor should receive patients has increased, while the time each patient can be seen has decreased. In addition, all repeat appointments have been abolished at our clinic, meaning that as a doctor I cannot make an appointment for someone to see me again; the woman has to make the appointment herself. But the earliest appointment is generally within two weeks. For example, a woman has come to see me to get a signed sick leave form. I give her five days of sick leave, but I cannot take her off sick leave in five days, because I have no room on my schedule. And I am forced to see her on a first-come-first-served basis, as it were, over and above my scheduled appointments.

In order to further increase the availability of appointments, so that they light up in green on the computer monitor at the health department, they do another really interesting thing. Registrars are given verbal instructions to randomly cancel three or four appointments for receiving physicians. While we are given orders, again verbally, to see both those patients who had appointments and those who had to get new appointments.

This increases your workload even more?

Of course. We are also required to see emergency patients, but that is not even up for debate. Rendering emergency aid is a doctor’s direct duty, and if a woman comes in with pain or bleeding, she has to be seen, too. The patient load is truly enormous.

Our service precincts had not been calculated, and when we began our protest, they finally counted the number of people attached to our clinic. By order of the Ministry of Health, the gynecological norm is 2,200 women per doctor. But after the calculations were done in Moscow, it turned out that there were service precincts with 2,900 women per doctor, and precincts with 7,000 women per doctor. So they just divided all the service precincts in half, and now we all have 5,500 women per doctor in each precinct. But each doctor gets only the standard salary.

And the last question. How do you see the future of your movement and the trade union Action in general?

Our trade union is gaining momentum. More and more people are joining it, because they see the real outcomes of our fight. I think the scenario looks positive.

As for our protest, I am still hoping for dialogue with the authorities. We have already had one meeting at the Ministry of Health’s Public Chamber. They took the proposals that we drew up for them, in which all the problems had been laid out. They took all this and promised to get in touch with us. So far, however, they have been silent, but they promised they would call, so we are waiting.

So there have been no breakthroughs so far?

Sundays had also been made working days at our clinic, though officially we have a five-day workweek. This was done without additional agreements or even oral instructions. They would just make appointments for a doctor on Sundays, and that was that. It was assumed the doctor was obliged to go in to work that day. After my written request to management (I asked them to clarify on what basis appointments had been made for me), such shifts were abolished at our clinic and declared illegal. This is one of our victories

 Elena Konte

During the course of a week, Elena Konte had to cover eight service precincts along with another doctor, after which she decided to start fighting for her rights. So far, Konte has seen no major positive changes, but she remains optimistic.

Could you tell us about the conditions in which doctors are now working in the clinics.

Well, there is a lack of personnel. In our department, four doctors are covering eight service precincts.

This was a major problem for you?

Yes, and the instability of wages. A lot depends in this instance on incentive payments, but now they are here, then they are gone, and it is unclear what percentage of extra pay they will give you, and so on.

What impact have the recent reforms had on the situation?

The most direct impact.

It was right after them that the firings began?

Yes. Our GPs were not dismissed, but our specialists were. The physiotherapist, the opticians, and some others were dismissed. Lab technicians.

I see. And how did management behave?

You mean—

The clinic’s management. You probably complained to them about the shortage of specialists. Did they react somehow?

Of course. But these were not written complaints. They were oral complaints at the general clinical conference that is held once a week. They said the same thing in response to all our recommendations: it was a done deal, no one is going to change anything, so that is why we switched to this scheme of working, work as you like, but be patient and keep working, because nothing is going to change, everything was decided long ago. It is standard practice.

I see. But when exactly was your point of no return, the point at which you decided you needed to go on a work-to-rule strike?

Ha! It was after another doctor and I covered eight care precincts alone for a week!

Why do you think many doctors are hesitant to join your movement?

I think it is this “great Russian patience,” passivity.

Last question. How do you see the future of the trade union Action and the strike itself?

That is a great question. I think the trade union Action has a bright future. More and more people are beginning to understand that it is a trade union that is worth joining and that can really solve our problems. For example, many of our doctors are now quitting the state-sponsored trade union.

As for the work-to-rule strike, to be honest, I have the sense that for now we are looking at an indefinite action, because it still has not solved anything at all.

Anna Zemlyanukhina

Anna Zemlyanukhina is one of the strike’s coordinators. She presented a broader picture of what is happening now at the leadership level. She made the decision to strike after facing the total incomprehension of her clinic’s management. She is confident in the trade union’s successful future.

Could you say a few words about the conditions in which doctors work today.

The main difficulty is that there are not enough doctors. They are laying off not so much pediatricians as narrow specialists. So the flow of patients to the remaining doctors is quite large, and often it is a problem getting an appointment to see a particular doctor.

In addition, the Moscow City Health Department has announced a campaign for improving access to healthcare, but given the shortage of doctors this is implemented by lengthening a doctor’s workday and reducing the time an individual patient can be seen. But since it is impossible to examine a patient humanely in that amount of time, we have to go beyond the time limits, and in fact the physician’s workday is increased.

How have the recent reforms in the health sector affected this situation?

Frankly, until January of this year, things were more or less normal. Of course, they were hard, but they have gotten worse. Most importantly, the reforms have led to the closure of inpatient facilities, and now it is much harder for a patient to be admitted to an inpatient facility. There are verbal orders from above not to admit patients to hospital, and when a doctor refers a person to an inpatient facility, the ambulance service refuses to hospitalize him or her. A patient might be refused admission three or four times. Patients are admitted only when they are already quite ill.

What role is played in all this by clinic management? What is their stance?

They are subject to their superiors, who send them their orders.

Meaning that they do not try and meet you halfway?

It depends a lot on the individual. Some try. Typically, the lower-level bosses—the department heads—are mostly competent people, and try and meet you halfway, but at the higher levels… No, there are competent people there, too, but they are hamstrung. They get these orders from the top brass and are forced to follow them.

What was your point of no return, when you realized that protest was the only solution?

My point of no return was the increase in mortality rates among patients. And the top brass’s reaction to our protests. At a meeting with them, we raised all these questions—that it was impossible to see a patient in that amount time, that it was impossible to do our work—and the response was the same: “The decision has been made.” People are trying to get across that this is wrong, and they are told it was decided at the top and nothing can be done about it.

That is clear. Why, in your opinion, has your movement not yet engendered a broad response among other doctors? Why have they not joined?

In fact, some have decided to join. Why is this not happening en masse? Because our system “works” well. In many institutions, as soon as doctors show the desire to join up, the top brass immediately gets involved. They coerce them. They promise to get them put in jail, I don’t know, or fired or something else. And god forbid there should be any leafleting. After that, as a rule, the desire to join up diminishes.

And the last question. How do you see the future of your trade union and your protest action?

I see the future of the union as something quite positive. Many doctors are now exiting the official trade union as they no longer trust it, while our organization is gaining in popularity.

Have there been any concessions on the part of the authorities and top management?

For now, the main and only concession is that they have increased the time for seeing each patient. It is fifteen minutes again. Previously, it had been twelve minutes, and they were thinking about reducing it even more.

Maria Gubareva

The last person with whom we were able to speak was Maria Gubareva. Before the strike, she had had to see thirty-six patients in seven hours or so, which is quite a lot for a gynecologist. She tried to appeal to the Ministry of Health, but received no reply. In her opinion, the protesters have managed to achieve some success, but they have not yet achieved any major changes in the healthcare system.

Could you tell us about the conditions in which doctors are forced to work today in clinics.

Specifically, in our clinic, the length of time we see patients and the number of patients we see during this time have increased. In other words, the grid interval in UMIAS has been reduced. In particular, after all these changes, the daily intake for gynecologists (I am a gynecologist) is seven hours and twelve minutes, and thirty-six patients. This exceeds all conceivable norms. It is physically impossible, agonizing both for patients and doctors. Plus, it is impossible to refer patients for tests (at our clinic, these are usually ultrasounds, blood tests, and such) because some ultrasound doctors have also been sacked, the workload has increased, and when it went critical, they started quitting, because it is also impossible to work in this way. Well, as for tests, you have to sign up for a blood test ten days in advance. Many other tests are just not done at all anymore, quotas on blood clotting test were introduced, and so on.

In addition, some of our midwives were fired. (We work with midwives, not with nurses.) The doctors work alone: there are one or two midwives for several doctors. The midwife is planted in a separate room and “services” patients there. In other words, the women first go see the doctor. He or she makes recommendations. Then the women sit in the queue to the midwife for another hour or two, go berserk, and go ballistic on each other and the midwives. The midwives are supposed to assign them tests and write out prescriptions, make appointments for them to see specialists through UMIAS, and so on. Basically, it is torture for everybody, for doctors and patients.

All these changes occurred as part of the reforms to the healthcare system? The reforms have had such an impact on the situation?

Yes, the changes have been very serious.

And how does clinic management act given the shortage of specialists and the increased load on doctors? Have you appealed to the authorities about this?

Before the start of the work-to-rule strike, we tried, but no one listened to us. When it was first announced, three months ago, that the workload would increase, I personally asked the deputy chief physician, “How is this possible? It is a violation of labor laws and basically just cannot be done.” To which I was told, “Anyone who does not like it can quit. The country is in a crisis: everyone has to tighten their belts.” It is like. “Everyone off to work. Work, while the sun is still high!”

I see. And what exactly made your cup of patience run over and forced you to go on strike?

It was when I was seeing patients in this crazy way for a week. Even before all the layoffs. I had written about all of it to the Ministry of Health and the labor inspectorate, but had gotten no replies from them. Then a week passed, the week when we had this crazy intake, and it became clear that working this way was just impossible. Either I had to do something or I had to leave.

Why have others not dared to follow your example? Why has the strike not taken on a broader scope?

Because people do not believe you can change anything in this country. The general opinion is that fighting the system is useless. Because the changes are implemented from the top down, they are government policy, Ministry of Health policy, everyone thinks the system cannot be moved. It will just crush its tiny functionaries—that is, those of us who do not agree with it. Plus, those who at first had almost decided to go on strike with me (they, as I have said, were in a really difficult situation) immediately came under pressure with the aim of putting the whole thing to a stop. Management acted against us with all possible means, mainly verbal. They accused us of sabotage and treason. They told us that the state had given us a job, and now we had gone against the state. And so on. Many people simply abandoned the idea. They decided to spare themselves the trouble.

How do you see the future of the union and the work-to-rule strike?

I haven’t especially thought about the future of the union. I guess if its membership grows, it will gain strength and might be able to start solving some of our workplace management issues, to do what a trade union is supposed to do: protect the legal rights of its members.

As for the strike, I cannot give you a clear answer, because the statement by the authorities that the strike failed is ambiguous. When viewed from the perspective of the twenty people who have taken part in the strike, all of our demands have been satisfied, because they were legitimate. It turned out that management has had nothing to counter us with: everything had been done strictly according to the law, in keeping with all the norms. And we have observed all the requirements, so now I see a humane number of patients, I have a humane amount of time to see them. Basically, everything is as it should be.

But this does not solve the overarching problem of healthcare, which would have happened had a significant number of people joined the strike. In our department now, where I am the only one on strike, the patients who do not get in to see me are simply fobbed off onto the other doctors. So they are seeing their own patients and that other guy’s patients, and that other guy is me. But if we had all said we would see patients as they should be seen, then half the patients would have been unable to make an appointment to see a doctor. They would have attacked the head physician and the health department, and ultimately management would have had to hire staff, which, in fact, would have solved the problem.

Alexander Grigoriev is a student in the history faculty at Moscow State University.

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Photos courtesy of Open Left. Translated by The Russian Reader