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Foreign Affairs Flushing Out the Shlaki

Illustration by Joe Ciardiello

The surprising consolation of formerly Soviet medical care

by Jeffrey Tayler

I FIRST felt something was wrong in the evening. As my taxi whisked me across the spreading black expanses of the Crimean steppe, under a purpling, starry canopy of winter sky, I began to sense a pressure behind the ears, an ache behind the eyes. When, around midnight, we pulled into the halogen-lit warrens of Odessa, my destination, I felt worse, ragged and exhausted, unsteady on my feet; I knew I had to see a doctor.

But what sort of doctor was I going to find in Odessa? In Moscow, where I live, European and American clinics provide effective, if exorbitantly priced, medical care. In Odessa, a provincial Ukrainian city much poorer than the Russian capital in everything, perhaps, save culture and monuments to Chekhov and Pushkin, there were no such Western-style amenities. Just the thought of checking into an unreconstructed formerly Soviet clinic and subjecting myself to the dirty sheets, bloody floors, shortages of medicines, and rancorous, ill-trained staff I had seen during visits to sick friends in Russian hospitals brought on something akin to vertigo, and I felt suddenly vulnerable and queasy with fear.

Discuss this article in the Foreign Affairs conference of Post & Riposte.

More on foreign affairs in The Atlantic Monthly and Atlantic Unbound.

From the archives:

"Dead Souls," by Murray Feshbach (January 1999)
A prominent demographer warns that the spread of tuberculosis and AIDS in Russia will soon make Western hand-wringing over the pace of Russian "economic reform" seem quaint.

From Atlantic Unbound:

Interviews: "Russia's Other World" (March 1999)
Jeffrey Tayler talks about his new book, Siberian Dawn, which tells the story of his 8,000-mile odyssey through lands rarely visited.



Elsewhere on the Web
Links to related material on other Web sites.

"Family Practice: A For-Profit Model for the Provision of Primary Health Care Services," by Dean Millslagle
A case study of health-care-reform efforts in an industrial city in Ukraine. Posted by socialsector.net, a site that offers information about USAID-sponsored initiatives in Central and Eastern Europe.

"Concepts of Health Care Reform in Ukraine" (December 7, 1999)
A report by the American International Health Alliance that outlines "strategic directions to reform the [Ukrainian] health care system."

After settling in to my hotel room, I called my wife, in Moscow. She is Russian, and after expressing concern about my health, she said, "Well, tell the hotel receptionist that you need a doctor and you'll pay for it. Just stay away from the free state clinics. Odessans are very educated. You'll find a good doctor if you pay."

"But ... a Ukrainian clinic? Whether I have to pay or not, I don't know. Maybe I should just wait until I get back to Moscow."

"That's not necessary," she answered. "Our Soviet doctors are some of the best in the world. Really, the problem isn't that they're unskilled; it's that most are paid so little they don't care if their patients live or die. But if you pay them, they care."

After hanging up, I told the hotel receptionist I wanted a pay doctor. She advised me to try the recently privatized clinic off Primorsky Boulevard. It was, she said, one of the best in the city.

IN the morning the bare black branches of ancient mulberry trees stood stark against a frigid blue sky, and the feeble February sun washed the nineteenth-century buildings of the center in slanting gold light. Rusty old taxis rattled and tooted down potholed avenues. The clinic off Primorsky Boulevard rose before me, an architectural relic of the Stalin decades. It was two-story and lopsided, flat-roofed and covered in peeling orange stucco, recalling, with its careless design and inwrought decrepitude, every wretched building ever erected by every wretched slave-labor gang in every wretched gulag city. This is the best Odessa has, I thought. Looking at the clinic, I felt a renewed onrush of dizziness that seemed at once to prompt me to enter and incite me to flee. I dithered, but finally the ache behind my eyes persuaded me to take the risk. I darted through the door.

"Muzhchina!" ("Mister!") a grandmotherly woman in a conical white paper hat called out from a tiny barred window near the entrance. "Halt! You have to register with me first!" Above her hung a menu of medical procedures in eye-strainingly minute script: EKGs, x-rays, ultrasound probes, blood and urine tests, VD screenings, massages, MRIs, all listed with their prices. One could take one's pick, suffer a jab or give a sample, learn the results, and walk out; consultation with a doctor was optional.

I told her my symptoms and asked for a consultation with a doctor.

"Muzhchina, we're legally obliged to do tests before anything else," she answered, her hat wobbling with an imperious wag of her head. "Why not try an EKG and have your blood pressure checked? We have a good cardiologist here."

"Well, if it's the law, okay." I figured that a cardiologist would at least have had serious training -- a good person to start with.

"That will be twenty-one hryvnia" -- about four dollars.

She took my money and told me to go to Room 25. Carrying a limp brown piece of paper showing that I had paid, I joined the crowd hustling down ramshackle green halls, mindful of undulating warps in the cracked linoleum floor and paint flaking off the walls. Treatment here was apparently a cause for some merriment: middle-aged men and women sat beneath ceiling-high windows, enjoying the bath of light, bantering in lively tones about symptoms and cures, their drooping eyes fixed on one another, their eyebrows dancing with the enthusiasm they felt for their common subject -- their health. Only the young, who were mainly women, looked sullen, perhaps because they were for the most part queuing outside offices whose block-letter signs indicated the humiliating analyses performed within: VD TESTS, STOOL SAMPLES, URINE TAKEN HERE. I thought of the epidemics of syphilis and gonorrhea now afflicting the former Soviet Union, and of the shaming stares and abusive remarks ("Shlyukha! [Slut!] You should whore around less! What would your parents think if they found out about your dirty disease?") to which I had heard that doctors and nurses still subjected their young female patients, in the most pitiless and perdurable traditions of Soviet moral upbringing.

Room 25 was a great blue room furnished with clean but aged cots and wheeled chairs, along with a Soviet-era contraption of iron and glass bristling with wires and meters -- an electrocardiograph. A pert young man introduced himself as the assistant and then attached the wires -- electrodes -- to my chest, pushed a button, and read the yards of ticker tape that spurted out of the machine's nether end. In came the doctor -- a green-smocked, red-faced, and jovial middle-aged fellow with a big belly and a shock of white hair. There was something avuncular in his sad blue eyes, and the breath in his lungs rattled with what I took to be asthma or a smoker's cough. He examined my EKG, frowned, and took my blood pressure.

His eyebrows jiggled with concern. Wheezing, he took the stethoscope plugs out of his ears and asked, "Drink any cognac recently?"

"Why, yes, in fact. The other day I had a couple of snifters with a friend."

"What was the brand name?"

"I don't know. What does that have to do with my EKG?"

"How much did the bottle cost?"

"About five dollars" -- a standard price.

"Oho! That's what did it. It raised your blood pressure. It's a bit high."

I objected to his analysis: I had not drunk enough to feel inebriated, and that was three days earlier, and in any case what had the price of cognac to do with anything?

He shook his head. "Listen, real cognac -- the Armenian kind that in Soviet days used to be sold everywhere -- costs a hundred dollars a bottle now and lowers the blood pressure; in fact, my father treated his hypertension with a good strong hundred grams of the juice a night. But what you drank was bootleg. Swill. Gasoline. Nothing like the real Armenian article!" His tongue ran over his dry lips, his voice in its sudden hoarseness suggesting an intimate familiarity with all sorts of liquor. "I ask you: can real cognac cost five dollars a bottle? Think about it."

"You're probably right. But what's wrong with me?"

He appeared not to have heard my question. "I see cases of cognac poisoning here almost every day. You'll live, but we need to go to the military hospital and do a u-z [ultrasound exam]. Always good to have a u-z done."

"The military hospital?"

"Yes. Since 1996 they've been accepting paying customers. Quite a good deal. It was our number-two hospital in Soviet days, and now they've got German equipment and everything. I'll take you there myself."

I said okay. His offer to accompany me did not surprise me. I was a Western foreigner whose passport suggested financial solidity. It would have been foolish to treat me as he did his local patients, who were unlikely to be either as remunerative or a cause for who knew what foreign repercussions should they give up the ghost under his care. And why should I not undergo the test he was proposing? He seemed to have my best interests at heart, and I knew he must have gone through the standard six years of medical school plus three years of ordinatura (a combination of internship and classroom instruction in cardiology) that would have taught him what in the West would be considered the acceptable basics of his profession.

He put on a red felt hat with a pheasant feather rakishly stuck in the side, slipped into a stylish leather jacket, and lit a Marlboro. On the street we stopped a cab and got in.

"There's a lot in our country for a writer to see," he said, exhaling smoke and turning to look at me from the front seat. "Ukraine's going to hell. All our leaders steal, and there's no hope of change. No hope, not a ray of hope, we're finished ..." He wheezed and shook his head, beads of sweat forming in the folds of skin under his eyes. The cloud of smoke in the cab grew impenetrable: both he and the driver had lit up, and the windows were closed. "No hope in Ukraine" -- he coughed -- "nyet, no hope."

THE military hospital was a five-story brownstone building. The doctor took me past the guards at the gate, up several flights of stairs, and down several halls peopled by old men wearing medals on their gowns -- veterans. In a small yellow room he introduced me to a technician and a spiffy-looking machine with a German name stamped over a luminous sea-green screen. The technician told me to take off my shirt. He smeared grease on my chest and asked me to lie on my side; then he began running a bulbous ultrasound probe in circles over my heart. The volume was set at full blast -- heartbeat-paced gurgles and sputters and squeegee sounds filled the room.

"He drinks cheap cognac -- the five-dollar kind," my doctor shouted over the amplified gurgling.

The technician shook his head. "All the young do. They don't know the Armenian brands."

He finished, and my doctor asked me to wait in the hall while they conferred, but not before I gave the technician his fee -- two dollars' worth of hryvnia. I paid and walked out and joined the old men who were standing around staring at the floor, saying nothing and waiting for the results of their own analyses and tests.

On the street my doctor lit another cigarette. The amplified gurgles and squeegee sounds had me worried. I asked him to give it to me straight.

"You mean tell you my diagnosis?" he asked, snorting smoke. "I'd rather not say just yet. To check your kidneys and other organs we should go to the hospital of Ukrainian border guards to do a more general set of u-zs. They've got a new German machine there, too."

"But what exactly is it you're looking for? Can't you give me a clue?"

"Well, as I said, your blood pressure could be lower. Why not have your kidneys checked out at the border-guard hospital? Often a kidney infection can raise the blood pressure."

"And the hospital for border guards is the place for such a test?"

"It costs some money, but they do good kidney u-zs. Anyway, in Moscow you'd pay a pretty kopeck for such service -- a lot more than here."

AFTER another taxi ride of smoke, coughing, potholes, and commentary ("City's falling apart." Bump. "But who cares? No hope here in Ukraine." Cough, bumpety-bump. "Nyet, no hope at all"), we turned right behind the Yantar Café and pulled up to a concrete shack. Border guards in blue -- with the same vaguely hostile faces I had seen at passport control on landing in Kiev -- loitered in the parking lot. The doctor took me past them and up three flights of stairs. As we walked into the ward, a husky nurse came charging out of the receptionist's office, her arms raised, her huge bosom bouncing, her flip-flops scuffing the dusty linoleum. She shouted at the top of her smoke-clogged lungs, "Why are you using this entrance! You'll disturb our patients by walking down the hall like this! Always use the side entrance!"

All male and mainly young, the patients on stretchers scattered up and down the ward raised themselves in alarm, or peered at us from rooms where they were bunked in groups of five or six without the privacy of screens or hanging sheets. My doctor tried to apologize, but the nurse followed us and persisted in her shrill attacks. "You're creating an uproar traipsing through here like this! You should be ashamed! What kind of peace and quiet can my patients get with you making such a ruckus!"

My doctor hustled me into a small, immaculate white room and shut the door, cutting the shrew off in mid-diatribe. "Whew!" he said, and winked at me.

Two young women were cleaning utensils in a sink. One of them wore a nametag that read Yelena. I removed my shirt. Yelena greased my stomach and began the exam, keeping her eyes on the screen as her hand guided the probe hither and yon.

"He drinks five-dollar cognac, not the Armenian kind," my doctor said. "But you, Yelena, might be too young to know Armenian cognac. This country's going to hell. Young people are drinking all this bootleg swill ..."

Yelena paid him no attention, addressing me as she studied the screen. "You have ... yes, it's clear now ... aha ... you've had sausage and black bread for breakfast ... You had an infection in your gall bladder at some point. I think we should examine your gall bladder more carefully. Eat coal tablets [a common Soviet-era remedy for diarrhea, which I did not have] and abstain from sausages for twenty-four hours. Then come and see me in the morning. We'll do another test."

I had never had an infection in my gall bladder, but her sincerity and soft manner prompted me not to object. "Well, what could be wrong?"

"All I can say now is you'll live as long as you're supposed to live."

Her words reminded me of an aphorism I had heard quoted by a Soviet doctor friend years ago in Tashkent, an aphorism that might well serve as a Soviet version of the Hippocratic oath: "He who is fated to hang will not drown." That I was going to live as long as I was supposed to live sounded like basically good news, and not wanting to tempt fate, I decided to refrain from asking any more questions. I paid her a couple of dollars and promised to return. She wrote out an elaborate recommendation concerning what other organs I should have checked at what other defense-related hospitals, smiled, and handed me a packet of coal.

My doctor led me out onto the street. He grabbed the packet, crumpled it, and tossed it in the gutter. "There's nothing wrong with your gall bladder -- I saw the screen. Let's just go back to our clinic."

My fears about my condition revisited me. "Well, what's your diagnosis?"

"We'll talk at the clinic."

AT the clinic we returned to Room 25 and sat down at his desk. The assistant entered, grinning. "A fat lady's coming. Big as a boat!"

"Oho!" the doctor said.

A large woman in her late fifties waddled in and asked in a loud voice if she should strip. "Strip!" the assistant said. Older people here, raised in the abnegating spirit of Soviet collectivism, are unaccustomed to the privacy we would demand in a doctor's office in the West, but I felt ashamed for her nonetheless. She reclined on the cot in front of the desk, and I turned away from her.

She complained to the assistant in practiced tones. She was, it seemed, a professional patient. The doctor ignored her. Patting the perspiration from under his eyes with his handkerchief and breathing loudly through his nose, he began writing and writing, covering an entire sheet with elegant, looping script. From the amount of it, I gathered I had much to be cured of. I felt nervous once again.

"Well, have you reached a diagnosis?"

"You seem to have a bit of high blood pressure," he said, fingering a cigarette as though aching to light up. "It's not the chronic kind, but you've got to watch it. What I'd really like is for you to stay here in Odessa and let me treat you. In a couple of months I could whip you into fine shape."

"How?"

"I'd flush all the shlaki [junk] out of your organizm [system]. You see, our ecological conditions are killing us. Our organizm can get all clogged up with shlaki."

I glanced down at the notes he had just finished writing. A couple of medicines were listed (Ukrainian-made tablets that lowered blood pressure), but mostly he had detailed a two-month regimen that included powdered birch buds, thrice-daily injections of broth of boiled dog rose, and regular dashes of polpola grass, followed by copious servings of figs, pomegranates, dried apricots, plums, and curds. All this was to be finished off with a nightcap composed of tincture of valerian -- an herbal tranquilizer. Judging by the frequency of feeding and pricking, and the complexity of the cooking methods prescribed, if I chose to take his advice I would be spending the better part of the day running to the market and back, boiling and mincing, chewing and stabbing.

I recognized all this as part Russian folk cure, part Soviet medicine -- the sort of odd mixture of things commonly prescribed here to relieve malaise rooted in stress and grief and hardship, the eternal elements of Soviet and post-Soviet life. The paternalistic Soviet state used to give free health care to all; for many in a society that did not reward hard work, the chiding of doctors was nourishing attention, the boiling of herbs a comforting ritual.

The doctor smiled. "People like you and me live hard and burn out young. We've got to watch it."

As I started to ponder this grave yet matey pronouncement, a chorus of creaky springs resounded from the cot behind me: the large woman, now clad in only her reinforced bra and broadsheet panties, had sat up. She said, "Take the doctor's advice! I clean the shlaki out of my system with those grasses -- they really help!"

The doctor noticed the skepticism about his cure that had crept over my face. He hurried to tell me that Odessans were very unhealthy, that life expectancy was dropping, and that they did not have access to Western medicines, which were rare and far too expensive for the majority of people, who earned the hryvnia equivalent of $10 or $20 a month. Ukrainians did not trust medicines anyway, he said -- they preferred familiar folk cures. Hence the herbs and fruits, which were, he insisted, just as effective as pills, and more natural. They would clean out my shlaki.

In his compassionate blue eyes I saw a doctor who truly wanted to heal me, in the way he judged most effective. Issuing frank diagnoses and chemical prescriptions was, I now gathered, not really what he was used to doing or what he thought I wanted. Experience with elderly and dying people in my wife's family had taught me that doctors here often withhold the truth from their patients, telling it only to their relatives, and usually ensconcing it in copious verbiage, including admonitions of the not-to-worry variety. He must have assumed that I needed the consolation offered by homebred cures -- as did the large woman on the cot, as did so many others in the former Soviet Union who live tough and tragic lives that leave them ready for the grave at fifty. But I had no faith in such cures, and didn't want to try them.

I DIDN'T tell him that, however, ill though I still felt. There was no point in dragging out my visit, since it was clear that what I was suffering from was a bout of high blood pressure -- a symptom of the mundane process of aging. But the doctor and the woman on the cot, to say nothing of the resigned expressions on the faces of the patients in the halls, appeared to be telling me that everything -- illness, debility, and death -- would happen to me in its own time, and I had better just accept that and take comfort when and where I could find it: in boiled broth of dog rose and powdered birch buds, for example, and in the notion of shlaki being salubriously flushed out of my organizm by cures approved by papa and mama, grandpa and grandma, by the neighbors and the village healer. Anyway, if I was not fated to drown, I would hang.

I asked him what his fee was, thinking about the five hours he had taken out of his day to spend with me. Three dollars. I paid him this and added a tip and said good-bye, thanking him for his compassion and efforts. In the closet-size pharmacy near the lobby I bought the medicines he had prescribed, but I forwent the long search in local markets that would have been necessary to find the dog rose, herbs, buds, and fruits.

The next evening I felt fine (as a result of the doctor's pills, I believe) and, much relieved, went for a walk along the promenade above the port. The sun was slipping into the Black Sea, bronzing the slate-gray waters and bouncing off the dock cranes and trawlers and rusted African freighters clogging the harbor. Couples, laughing and snuggling, were strolling arm in arm beneath the ancient mulberry trees, their collars raised against the stiffening breeze. I watched them for a while and then turned back toward my hotel, to call my wife and tell her I had been cured.


Jeffrey Tayler is the author of Siberian Dawn (1999) and Facing the Congo (2000). Two of his articles for The Atlantic have been included in Houghton Mifflin's Best American Travel Writing (2000).

Illustration by Joe Ciardiello.

Copyright © 2001 by The Atlantic Monthly Company. All rights reserved.
The Atlantic Monthly; January 2001; Flushing Out the Shlaki - 01.01; Volume 287, No. 1; page 23-26.