Doctors Hit the Rails to Plug Medical Gaps

For MTA doctor talking to a prospective patient from the Nikolai Pirogov, which is giving people access to diagnostic equipment not available where they live.
There is a line to board the train at Yemtsa, an isolated village in the far north, and a crowd of people stand in the thick mud below the door.

Once inside, instead of putting on slippers they pull on blue plastic footwear covers that medical institutes make visitors wear. Instead of the aroma that a train packed with people exudes, there is that familiar hospital smell of antiseptic.

The Nikolai Pirogov, a medical train run by Russian Railways, or RZD, was only in Yemtsa, a 19-hour train ride from Moscow, for 24 hours in October, but for many of the villagers it is a lifeline to a different medical world.

The train provides free treatment to all railway workers, their families and railway pensioners. Residents with no connection to the railway are treated on a commercial basis. Prices, patients said, are reasonable if not cheap.

"When we opened at eight this morning there were already four people standing outside on the street," said Yevgeny Pyatakov, the chief doctor of the train.


Kevin O'Flynn / MT
At some stops, a ladder has to be put out for people to enter the reception car.
By the end of the day, 80 people had come to have various ailments and illnesses checked out by a cardiologist, a gynecologist and the nine other doctors on board.

"It's great, it should come more often," said Yevgenia Karlina, a cheery septuagenarian now retired after working for the railways for more than 30 years.

The medical train is there to fill a gap in villages and remote train stations that once had their own medical infrastructure.

"There were doctors [in the village] before," said Karlina, "but they have all died."

It has become a regular sight in Yemtsa since it began running in 2005. Named after Nikolai Pirogov, one of the greatest surgeons of Russia and Europe and considered the founder of field surgery for his work during the Crimean War, the train travels two weeks out of every month all year.

The Pirogov was on the tail end of its journey up the northern railway route, which goes from Yaroslavl to the port of Arkhangelsk on the Barents Sea.


Kevin O'Flynn / MT
The Nikolai Pirogov is a step up from earlier examples of mobile medical care.
Last time the train was in Yemtsa, half a year before, the doctors arranged for Karlina to be admitted to hospital because of blood pressure problems. Now she is one of many who are having checkups and treatment. "They want to live long, and they readily crawl to the hospital for their health," she said of her fellow pensioners with a giggle.

Overseeing the project is Oleg Atkov, a vice president of RZD, a cardiologist and former cosmonaut who spent more than 200 consecutive days on the Mir space station in the 1980s as part of the Soviet space program.

"The medical train is the only kind like it in the world," said Atkov in an interview at the RZD office. It has patented the idea and has interest from a number of countries in exporting the concept, he said.

The railway worker shares some qualities with the cosmonaut, Atkov said. None of them will spend 236 days, 22 hours and 49 minutes on a journey as Atkov did -- Russia isn't that big, or rather, the trains aren't that slow -- but the "people who worked on Russian railroads have a tiny amount of space. They are traveling and they are away from home for many days."

"This is very stressful. More or less the same situation," he said. "As with astronauts, they are working also in isolation and in stressful conditions."

With more than a million employees, the RZD is known as "a state within a state." Like a state, it has its own health service, its own doctors and its own clinics. Rail travel in Russia began 170 years ago, and the railway began its own medical service 10 years later.


For MT
A medical technician showing off one of the train's compartments, which have the feel of a strange hybrid, with contemporary X-ray equipment finding a place along with traditional Russian Railways carpeting, windows, doors and other fixtures.
The RZD, Atkov said, needs to ensure that it's workers are healthy before they get behind the wheel, and the health service aims to diagnose problems before they happen. In Soviet times, the RZD had 300 clinics across the country. Now there are about 200, and the train is partly designed to fill in the gap.

Medical trains first appeared in Russia during World War II and were used to provide first aid and evacuate injured soldiers from the battlefield. They were revived in the 1970s and 1980s in a simpler form, used primarily for collecting blood and providing simple medical procedures such as X-rays.

It was only in the 1990s that they became traveling diagnostic centers where basic medical tests could be completed. A patient who climbs up the high steps of the train -- it is about as handicapped-friendly as any ordinary Russian train -- and into the eight wagons can see an optician, a gynecologist, a cardiologist, a psychiatrist and a dentist in the space of a day.

The RZD's three trains stop at more than 170 different stations in 20 different regions. The stations are often very different, but all of them are in need of the advanced medical treatment that the train can provide.

The other two trains travel in western Siberia, the Far East and the Baikal area. Next year, a fourth train will come on line with a different philosophy. Funded by the Krasnoyarsk regional government, it will travel to similar remote villages but will provide free treatment to all those within the region.


For MT
The hospital in Obozersk, the next station the train visits a little over half an hour up from Yemtsa, is a small one-story wooden house that looks ready to collapse and has little of the bustle, energy or the equipment of even one wagon of the medical train. It is typical of the medical facilities at such a station. The chief doctor of the hospital refused the staff permission to speak to reporters.

Most of those who visit the train are pensioners, many of whom have never visited a modern medical facility -- a noticeable difference for the doctors, most of whom have worked in cities before.

"In big cities where medicine is accessible, people take it for granted," said Pyatakov. "But here you can feel this insane gratitude, the babushkas bring you pastries and apples to last the whole year. ... You get the sense that if it wasn't for you no one would help these people."


For MT
"The patients are old and neglected," said ophthalmologist Svetlana Shatskaya, "but it's much more satisfying than a city clinic. ... The crowd there is spoiled by medicine, but here they are helpless. We help people live longer and get pleasure from life."

The strangeness of the train can be too much at times.

"They confuse the doctors. They confuse the names. They go to a dentist as if it's a gynecologist," Pyatakov said. "Or they go to a gynecologist to get their teeth done."

One old woman sat down in a dentist's chair and started showing the doctor her legs. "She said her veins hurt, and we explained to her for a long time that she was at the wrong doctor," he said.

Each train costs around 100 million rubles ($4 million) to get on the track. The medical trains help save RZD more than 3 billion rubles per year, Atkov said, as it doesn't need to send railroad workers for treatment and tests to a faraway clinic.

"If they wanted to access the clinics, they would have to go about 200 kilometers one way," said Atkov.

The next step for the train is to add another wagon that will allow doctors to conduct noninvasive surgery, including treatments such as laser therapy and endoscopy. Atkov hopes that a prototype of the wagon will be ready for use next year.

The equipment used is chosen for its capacity to take stress. The train does not move when treating passengers, Atkov said.

"We use Russian X-ray machines, which are very reliable," said Atkov, "You can throw them from the fourth floor ... nothing happens."


For MT
The train is equipped with telemedicine capabilities so it can connect via satellite with doctors in the country's top hospitals to discuss and diagnose patients and decide whether to hospitalize a patient.

The last consultation on the Pirogov via telemonitoring was a discussion in August about a child with a serious heart problem, who was sent to Moscow for an operation. (Normally the train does not deal with children under 14.)

Four trains are not enough to cover the whole of the railway network though. Another train will come on line next year to work on the Sverdlovsk railway line in western Siberia, and another four trains would be optimal to cover the country, Atkov said.

If the RZD expansion goes ahead as planned, more than 20,000 kilometers of new railroad will be built in eastern Siberia and the Far East, in some of the country's most inhospitable parts. "We will need more of these kind of trains in the near and distant future, maybe even an extra four or five," he said.

Future railway workers will have their own distinct health problems. Shatskaya says many of her patients in the north suffer from cataracts and glaucoma much earlier than is usual.

"In the south if they start to get it at 70, here they start from 45 years old," she said. "The north does not provide hospitable conditions. There are less vitamins here, and it's hard to get fruit and vegetables."

A few days before arriving in Obozersk, the train had been in Plesetsk, a town more famous for its Cosmodrome. A Topol rocket was fired from the Plesetsk Cosmodrome to Kamchatka last month during President Vladimir Putin's annual phone-in question-and-answer session.

The effects of radiation are visible in the eyes of those seen in Plesetsk, Shatskaya said.

The doctors, on a train two weeks at a time, are as much railway workers as those they treat, said Atkov. They face the same stress of being away and confined as they travel to places where modern medicine is often a futuristic concept.

Shatskaya, 36, recalled how she treated a woman with very bad eyesight. "I put glasses on the woman, and she exploded, saying, 'I can see you. Is it really possible?'"