[Editor's note: Merrill Goozner has spent the last two weeks reporting on the state of Russian health care. See his previous posts from the field: "It's all about the oil: Russia's resurgence rests on slippery foundation" and "Russia boosts healthcare in Siberia"] MOSCOW – On my last morning in Russia, I dined with Vasiliy Vlassov, professor of research methodology at the Moscow Medical Academy and head of a small but feisty group of Russian physicians called the Society of Specialists in Evidence-Based Medicine. “We’re trying to get the government to cancel ineffective care,” he said. Give me an example, I said as I bit into an inch-thick lox sandwich. “The salt rooms,” he replied without hesitation. A quick check online later found that halotherapy, or speleotherapy as it is sometimes called because aerosolized salt dust is administered in cave-like rooms, has been widely practiced in Eastern Europe for over 200 years. There are dozens of spas, including some in government-run hospitals and health clinics, offering the salt cure for almost every lung disorder, ranging from chronic pulmonary obstructive disease to seasonal asthma. However, the practice, which has almost no following in the U.S., has never been systematically studied. The National Library of Medicine’s PubMed database contains just 14 citations for halotherapy – all written by Russian physicians and none involving a test on more than 138 patients. Most were on just a few dozen. “It is from the middle ages. It is nonsense,” Vlassov said. It’s been nearly four decades since the Scottish epidemiologist Archie Cochrane introduced the concept of evidence-based medicine in the west. It spawned a worldwide movement among physicians called the Cochrane Collaboration. Committees were established to evaluate all the clinical trials in a given area of medicine and issue objective clinical practice guidelines. Many reformers in the U.S. believe getting physicians to use evidence-based “best practices” generated by independent groups like the Cochrane Collaboration as key to holding down health care costs, since it could eliminate many useless medical practices. But whereas American physicians often must be persuaded to ignore powerful financial incentives and pay close attention to the evidence, their Russian counterparts face an entirely different problem. They don’t have the intellectual tools necessary to evaluate the evidence. The Cochrane Collaboration’s local chapter, which Vlassov headed, fell apart a few years ago. The problem begins in the medical schools, he said, where young doctors receive almost no instruction on biostatistics, epidemiology and methods of decoding the evidence generated by clinical trials. Specialists do not receive their training until they are on the job, where they are apprenticed to senior physicians who pass along the practical knowledge they have accumulated over their own careers. Some teachers publish in Russia’s medical literature, but its quality leaves a lot to be desired, Vlassov said. With the fall of Communism, there are no longer political barriers to gaining access to the western medical literature. But the financial and linguistic barriers are just as daunting. In a country where the average physician’s salary is about $800 a month, “the cost of books, whether over the Internet or on paper, is big money,” he said. And while some prestigious journals like the New England Journal of Medicine have been made available free of charge, “who can read it? It’s in English.” In the 1990s, the Journal of the American Medical Association attempted to launch a Russian language edition, but it failed. Vlassov was hired as a consultant by the Italian firm that ran the project. “I had to stop after five issues because the quality of the translation was so low that it made the volumes of my work overwhelming,” he said. So where do Russian doctors get the latest information about medical advances? Over the past two decades, physicians here have been exposed to the same commercial pressures that influence U.S. and European physicians. The global drug and device industries hire young Russian doctors go to go into hospitals and clinics (that are the main delivery points for primary care) bearing small gifts and free samples. “They are even more effective than U.S. drug reps because this is doctor-to-doctor marketing,” he said. Leading Russian physicians in the universities can also earn as much as $2,000 extra per month by giving lectures on behalf of drug companies to their colleagues. Vlassov has given lectures on behalf of Novartis, Pfizer and GlaxoSmithKline. But he hasn’t given up trying to broaden the base for more objective, evidence-based medicine in Russia. He recently helped organize an evidence-based medicine training project funded by the Eli Lilly and Ford foundations and run through the Russian Academy of Medical Sciences, which is a 250-year-old government-run medical society roughly analogous to the U.S. Institute of Medicine. Earlier this month, it conducted a week-long session for 30 young Russian physicians, training them in the basic tools of interpreting medical evidence. There will be a number of such programs throughout the year. “Our goal is to train them so they can interpret and understand evidence, and conduct clinical trials,” he said. “We need people who can train the next generation of medical students in these techniques.” -- Edited by Merrill Goozner at 06/16/2008 12:19 PM