Interviewed by Oleh Feya
You are doing a lot to raise awareness, including by debunking healthcare myths. Which ones are the most dangerous in Ukraine?
— Most myths have to do with vaccination. Ukraine has an outbreak of measles with over 100,000 sick and 37 dead. Some pseudoscientists in academia and the medic community say that getting sick is better than getting vaccinated. They simply forgot the consequences of terrible diseases. Polio epidemic used to break out in the past and people were kept in iron lungs. We no longer have any of this thanks to vaccine against this disease. There are some small breakouts amongst unvaccinated people, but we have generally managed to defeat the disease. Measles epidemic in Ukraine broke out as a result of low level of vaccination. These diseases have dangerous consequences; saying that it’s better to have them is irresponsible. We have 100% of the necessary vaccines. But people refuse to vaccinate themselves and their children.
Are there many such people?
— As of today, 90% of the children that need vaccination as scheduled have been vaccinated. When we came to the Healthcare Ministry, less than 60% were. A small percentage of people cannot be vaccinated for medical reasons. But the problem is different: quite a few people buy fake vaccination certificates. Parents buy them and doctors sell them – they don’t understand that this is dangerous for the child and for those around it. We have recently had a special operation in Lviv Oblast. We came to vaccinate unvaccinated children. Before going there, we checked data from schools and hospitals.
Hospitals told us that 25,000 children needed vaccination. In fact, it turned out that 50,000 needed it. Something didn’t match! Half of the certificates in schools were fake. Many children were not vaccinated before they turned 18. We had conference meetings with every oblast. For example, Kyiv says that 99% of babies have been vaccinated. We know how many children were born and how many vaccines were used. The figures don’t match. It all looks good on paper. In reality, we have problems. We have certainly vaccinated 1.5mn adults and children ever since the measles epidemic broke out. Zero people have died of vaccines, but measles has killed 37 people in the past six months. It’s more dangerous to get measles than to get vaccinated. It is a myth that vaccination is dangerous. Another popular superstition is about side effects of vaccines. They don’t have any. These two myths stand in the way of vaccination.
What can be done with vaccine opponents? Some countries impose sanctions. For example, Australia withdraws benefits from those who don’t vaccinate their children.
— Germany has a fine of EUR 2,500 for refusal to vaccinate children. Ukraine has a rule of not letting such children into schools. But parents can buy fake certificates. And not every school sticks to this rule. We don’t have mechanisms to control this. Some countries restrict access to social programs and impose fines. We do not want to use such tools. Instead, we encourage people to get vaccination. We have enough vaccines procured via UNICEF and other international organizations. The next step is to make sure that people trust the quality of vaccines. And to make sure that doctors, immunologists and academics stop hampering the process and encourage people to get vaccination instead. It is important to avoid politicizing this issue. Valeriy Suchkevych accused the Healthcare Ministry of a poor vaccination campaign at a recent Cabinet of Ministers meeting. He had polio as a kid and has a category of disability now. According to him, the Ministry does nothing to prevent the disease and fails to provide enough vaccines. This is not true. We do have more vaccines than what is used.
The American Journal of Public Health once ran an article about Russian bots trying to stoke controversial attitudes towards vaccination to undermine the confidence of parents about the need of vaccination. We have asked the political elite and the Church in Ukraine to make statements on vaccination. The clergy did not want to get involved. They said that this was up to the parents. But this is not up to the parents, this is a matter of national security! We’ve already had small outbreaks of measles in the National Guard. We’ve spoken to the Ministry of Defense and they said that “We cannot demand the military to get vaccinated.” Yet, this is the only entity that can actually demand this. I asked Americans and Canadians about whether they vaccinate the military. They do not ask for consent: the military must be vaccinated. Diseases can undermine the capacity to defend the entire country!
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What other popular and dangerous myths exist?
— One is that rehabilitation can be done with magnet therapy or electrophoresis. What does weak electric charge do when connected to the body? It does not reach the muscles, it does not even reach deep into the skin. When I ask academics about how exactly they use this method and how it works, they say they don’t know. They wrote their dissertations 30 years ago and have since been replicating these outdated techniques. In many cases treatment has no underlying research basis. They are popular in sanatoria where directors say: “Patients keep coming here, eat well, rest, get electrophoresis treatment and feel better.” I would feel better too after two weeks of rest, even if it wasn’t in a sanatorium. This is not evidence-based treatment. As a doctor, I look at scientific literature in my work and follow the rules of evidence based medicine. So I find it difficult to speak to people who claim to be scientists but give no clear answers to my questions.
I once saw data from the Healthcare Ministry saying that nearly third of what Ukrainians spend on medicines is for homeopathy and other similar “treatments”. Do you have statistics about how dangerous it is to use such placebo?
— It’s difficult to collect statistics. Because it’s hard to rewind everything and see how the person was treated until he or she gets into a hospital. If we look at 10 medicines with proven effect most used in the EU and compare them with 10 most used medicines in Ukraine, the lists will be completely different. Not a single identical item! Ukrainians buy hepatoprotectors, neurological vitamins and the like. There are several reasons for this. People are afraid to visit doctors and do self-treatment instead. They watch warnings in advertising on TV against self-treatment in big leters, and still use it. That treatment doesn’t work, but people still believe ads. We have submitted amendments to the law on advertising to decrease the promotion of unproven treatments and to represent medicines more accurately.
The packaging for homeopathic medicines in the US has a disclaimer saying that they don’t treat or work.
— These substances are not even called medicines in the US. In Ukraine, anything is called medicines. The State Expert Center registers them as medicines. The Healthcare Ministry regularly signs an instruction whereby medicines with proven effect have to be sold with a prescription. All the other stuff that’s called medicines, including bioactive supplements, vitamins and the things that deal with symptoms, does not treat a disease. The Ukrainian language is beautiful and rich but it lacks words to distinguish between these things. We work with the State Service for Medicines and Drug Control, the regulator, to increase fines for selling medicines without prescription. People must understand that the medicine is real if it’s sold with prescription. Canada and US have the concepts of over-the-counter when an item can be purchased from a drug store, and behind-the-counter where medicines are sold with prescription only. These medicines are physically separated in drug stores. People see this and realize that anything sold over-the-counter is not medicines. We want to accomplish this in Ukraine. Unfortunately, disclaimers on the packaging don’t help. Another thing is that patients do not think critically, they don’t ask themselves why they need this. If a doctor prescribes 15 items without giving prescription, this is a signal of something wrong. Each of us has a smartphone and Internet, we can check any medicine. We are working to physically separate real medicines from supplements and vitamins, so that the patients could easily distinguish between them.
What should I do as a patient if a doctor prescribes homeopathic treatment?
— I would switch to a different doctor. We are now introducing licensing for doctors. Whenever you want to drive a car, you should get a driver’s license. It is taken away if you break a rule. We will do the same thing with licenses for doctors. A medic in the EU, US, Canada or Australia must have a medical degree and complete internship with respective exams. The license requires that a doctor sticks to clinical protocols. If your specialist does not stick to the protocol and prescribes homeopathic treatment, you can complain to the licensing council. It will fine the doctor or withdraw their license. We will give doctors five years to get the licenses. After five years, licenses will be mandatory, establishing another instrument of control over the quality of medical services.
The second thing is the National Health Service of Ukraine. It is currently paying for services in primary care. It will cover a clear list of services in secondary and tertiary care, for hospital and inpatient treatment. There will be a requirement to stick to clinical protocols. Medicines for specific diseases will be included in the covered service. If a doctor prescribes something extra, this will go beyond the protocols and the hospital’s agreement with the National Health Service. The hospital may lose funding as a result. This will be our financial way to control the quality of services.
We as doctors should comply with ethical conduct. We as patients should have common sense.
In terms of common sense – you have a popular blog on healthcare. How does it work? Is it effective?
— Let’s start from the end. We have recently looked at the weekly reach of our posts. It’s 2 million views, and that statistics is from Facebook alone. Many of our texts are published as articles or reports on TV. Healthcare is finally on the agenda of our society! We are getting many ideas from the readers. Can we eat salo, they ask? We write answers. What about onions? We reply.
How do we do this? First, we look for an expert in Ukraine, a doctor or a researcher dealing with the given issue. Then we look for sources of accurate information to make sure that every point can be referenced to scientific literature. We write in a language people can understand, while research articles are hard to read. We’ve tested this on the Ministry staff to make sure they understand what we write. Then we tested this on people from other professions. We did not learn to write facts simply from day one.
I had a Facebook account when I came to the Ministry. I wrote about transformation of the healthcare system and about my meetings. I was not interested in reading it myself! At some point, my colleagues suggested that I write about getting the Mantoux test wet (a popular cliche in Ukraine and other post-Soviet countries is that it’s forbidden to get the area of the Mantoux test wet for a certain period of time after it is done – Ed.). I was surprised. Why would you write about it when everybody knows that you can wet the spot! No, they told me, we were said not to wet it. Who said it? Doctors did. “We used to take baths sticking our hands out to make sure the water doesn’t get on it.” This is the common sense issue – the vaccine is under the skin, it cannot get wet there! Public response to that post was very visible. We then sat down to discuss other issues, some things from their childhood – I kept laughing about the things that were myths. And we wrote about all this.
Also, we are promoting the idea that we are not the ministry of treatment, but the ministry of healthcare! We should help people be healthy. That’s when we began to write about public health as support for the health of all people, not the treatment of the sick. We are now writing about healthy eating, working out and prevention of diseases. This is our second major topic.
MP Ihor Shurma complained at the very beginning that I was writing on Facebook instead of doing my job as minister. But raising awareness is out great responsibility. We cannot transform the healthcare system and improve medical literacy without this massive awareness campaign. We teach people to think critically. And I see some interesting things! For example, I have recently written news about my lawsuit for libel against Oleksandr Dubynsky (blogger and journalist with 1+1 channel – Ed.). We started getting comments about “bad doctors and reform not working”. I no longer have to respond to this – average users come and respond with different comments: “Do you realize that it’s primary care that has been reformed so far? Hospitals as secondary care will be reformed next year.” People begin to understand, react and think. Because it is not the state that’s responsible for our health. Each of us is responsible for our health; we must read and understand things.
Your work often triggers criticism and lawsuits. Who opposes the reform? How do you work with them?
— We have three major groups of opponents. Some are afraid of change. I worked in the US when Obamacare was introduced. Many doctors opposed it, they did not know the future. It took time for them to understand why the system was being changed and how things would work. If people don’t see themselves in the new system, they fear becoming redundant. In our transformation, everyone is needed – doctors, nurses. Nobody will toss them out. Because we need to treat people and the workers of the healthcare system are its most important element. They are told that they would lose their jobs, hospitals would close down, and people don’t know what will happen to them. They are manipulated.
You can speak to them, can’t you?
— We actually speak to them more than anyone! Now to the second group of opponents. In the Ministry’s system of communication, we send information down to oblasts, oblasts send it to rayonsor counties, then it goes to chief doctors, then to average doctors. All these segments do not want change because they will no longer be as important in the new system of healthcare. The payment will go directly from the National Health Service to the hospitals, and intermediaries will lose control of the funding. Those who mismanaged and stole the funds will lose their positions. Those who did things honestly will find a spot in the new system.
The third group was definitely making a lot of money by using misleading schemes in the healthcare system. One example is the chief doctors from the Heart Institute with their hundreds of thousands of dollars which they did not earn through honest work. This group is shrinking. We have gotten rid of many, they’ve lost access to the distribution of funds. This group sees the end and is becoming more dangerous. They are launching a massive attack because all funding, other than for military hospitals, will go through the National Health Service after January 1, 2020. They will lose control over billions of hryvnias. So they desperately need to postpone or abolish the 2017 law. They have accumulated billions after decades of using these schemes. And they have access to oligarch-controlled television. People don’t see us on TV often, but they see them.
You speak about the future with confidence. Will the reform last under the new President?
— In fact, a president does not have huge influence on the healthcare system, it’s not his jurisdiction. It’s the portfolio of the Government which stays until parliamentary election at least. We have full support from Prime Minister Hroysman and Government and will continue our work. The important thing is that we have done many irreversible things. We have created the National Health Service, an institution for transparent payment for services. Their website shows how much every doctor receives for their patients. 27 million Ukrainians have signed contracts with their family doctors. 35 million prescriptions have been issued under the Affordable Medicines program. We have the Public Health Center. Hospitals become more autonomous, freed from the chains of the state budget. We have created many positive things. Doctors tell us “Don’t stop, we want the same thing for hospitals as what you’ve done for primary care.” That will only happen when the transformation is completed.
It is important that the Ministry has changed. We have five directors and 71 employees, all working full time. These are professional civil servants who do not depend on the political situation. It’s like in Europe: prime ministers and presidents change, civil servants continue working on the state policy. A change of president does not mean a change of everything, the rejection of past accomplishments. We have our vector towards the EU and NATO. Transformation of the healthcare system. All this does not have to change when one person leaves their position. We will spend the next six months explaining what we do if the team of the new President is interested, so that they understand what is happening. We hope to get their support, including for better funding of healthcare. We are the only country in Europe that spends more on education than on healthcare, because our people cover half of all medical expenses. This is wrong. We have to do this through state insurance. We will develop state education with time; we have established the unified qualification exam and licensing for doctors. Many things have been done this year and we cannot return to what we had before.
Volodymyr Zelenskyi mentioned Dr. Komarovsky as his healthcare advisor. What do you think of him?
— He says all the right things about vaccination because he used to work as pediatrician. I hope this will trigger more public discussion on vaccination. He has expressed support to the transformation of healthcare. Representatives of Zelenskyi’s team have said that they want to see how things are happening. We are ready to talk to them about it. But an advisor is one thing, and the first person in the country is another thing. The President has not yet said anything specific. Healthcare is an important political topic. One of the most debated issues in the US Congress election was about healthcare. Presidential candidates and parties speak about it a lot before elections in other countries. In Ukraine, it’s often different. One of the biggest accomplishments is that healthcare is on the agenda of politicians and citizens. It is trendy now!
What was the focus of your research in the US? Do you have time for it now?
— A minister has very little time for anything beyond their job. I have four deputies for every section, and I deal with all sections. But I still read academic journals on my specialization. I’m a radiologist, I worked with women’s diseases as a doctor and as a researcher. I also read the Journal of the American Medical Association on medicine generally. I often send articles from those journals to my deputies and colleagues so that they see what’s going on.
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Is the Ministry planning to develop medical research?
— We have funded research institutes throughout all years of independence. But 90% of the funds was spent on salaries. We are changing the approach. Just like money will follow patients in hospitals, it will follow good research. The National Research Council will consider research projects and provide recommendations on the funding of specific research works, not entire institutions. There will be an allocation for the National Research Fund. The Ministry, too, has funds for research, albeit not much. Ukraine produces very little world-class research. Even the little funding we have is spent ineffectively. We should channel it into innovation and state priorities.
We inherited a horde of institutes that don’t do any research from the Soviet Union. They publish something once a year for reports and the money is dispersed between them. I was following scientific discoveries when I worked in the US. It’s very important for professional growth. Here we have a problem with English. Doctors read journals in Ukrainian or Russian, but they often do not cover the most up-to-date research. Doctors seem to stop developing after they graduate from the university. Medicine changes on a daily basis and we should always keep track of the new, learn and read journals. We are introducing requirements for professional growth, and doctors are not very happy because it’s easier for them not to learn. We will create all the necessary conditions for the doctors and researchers publishing in the top journals, so that they don’t compete with a crowd of pseudo-researchers for grants. So that they receive money for science, not yet another institute of fooleology.
Bio
Ulana Suprun was born in 1963 in Detroit. She has been Acting Minister of Healthcare in Ukraine since August 1, 2016. She got her medical degree at the College of Human Medicine, Michigan State University, and worked at the Women’s Imaging Center, Medical Imaging of Manhattan in New York, and as Acting Director of Women’s Imaging at the Henry Ford Hospital in Detroit. She has lived in Ukraine since 2013. She worked at the EuroMaidan’s medical service as activist and doctor, then headed the humanitarian program of the Ukrainian World Congress.
