Can the Ukrainian population reach 52 million again?

Over the 20 years of independence none of the prime mi-nisters or presidents managed to accomplish the single most important feat for the nation: to stop (and reverse) Ukraine’s demographic collapse. We were 52 million when we regained our independence. Now we are only 45 million and 770 thousand! These ca-tastrophic statistics confirm that the nation’s health is not a priority for the authorities. Viktor Yanukovych, whose electoral promises included bringing the population back to 52 million, has now embarked upon a complex medical reform. What must be done for the reform to be successful? What is needed for births to finally exceed deaths? We asked these questions to the famed neurosurgeon, former public health minister, and head of the National Council for Public Health, the Stroke Control Association, and the NGO Coalition “For a Tobacco Smoke-Free Ukraine” Mykola POLISHCHUK.

“PUBLIC HEALTH REFORM IS BEING DISCUSSED TOO MUCH”

In November 2010 President Viktor Yanukovych ordered you to reform public healthcare — improving the quality and accessibility of medical services for Ukrainians. A year has passed. How would you assess the progress made with this medical reform?

“The president did an important thing when he announced the public healthcare reform. He charged the Committee for Economic Reforms, headed by Iryna Akimova, and not the Ministry of Public Health to develop the program. In my opinion, the economic committee worked quite efficiently. Its members didn’t start from scratch, they used the existing groundwork. The healthcare reform has been discussed since 2000, when the Council Cabinet developed its concept, which was later signed by Leonid Kuchma in 2001. By the way, the concept is good. In 2003, the Council Cabinet adopted the decrees concerning the reform. In 2005 the Ministry of Public Health [headed by Mykola Polishchuk at the time – Ed.] tried to reform this sector, but the following minister cancelled everything that had been done. Actually, from the end of 2005 to 2010 the ministers have talked a lot but done virtually nothing.

“Doctors are unable to reform the public healthcare system, this can only be done by economists — after all, one cannot expect people to objectively reform themselves. Thus, the president’s team did the right thing when they made the economic committee responsible for the reform. They have created quite a good program based on the previous work. The only thing is that it should be done in the whole country and not in three regions. I think that they chose three regions to avoid sparking up the social tensions that exist because of the pension, tax and medical reforms. The latter will be more complicated as compared to the pension reform or other reforms.

“Thus, the committee has developed the program, which has to be realized by the executive structures. They don’t need the Parliament to approve it; the Council Cabinet can launch it in those three pilot regions simply with its decree. Putting it off, waiting for public debate, and avoiding a decisive decision (that should have been made promptly and be initiated by the Ministry of Public Health as the Council Cabinet executive structure) is blocking the reform process. Any reform has to be realized quickly. In January and February the reform was discussed on the radio and television, as well as during the roundtables initiated by the economic committee. So, the specialists have already discussed it, now it’s being discussed too much.”

Obviously the reform aims to improve the nation’s health. What does the government have to take into account when realizing it?

“The reform aims to optimize medical help. According to Mykola Amosov, the Ministry of Public Health is the ministry of diseases as today it deals with diseases and not public health protection, except in what regards sanitary-hygienic and prevention issues. The rest deals with treating illnesses. I believe that the program developed by the economic committee will make the medical services more accessible, and it will have a preventive effect if we introduce family doctors as legal persons — the holders and managers of personal funds. Then they will do the preventive work. The only drawback of this program is that it provides for the creation of outpatient clinics, [which are] consultative clinics for family doctors. It doesn’t have to be done by administrative means. When working, family doctors have to define themselves and what they need to optimize their work, otherwise the clinics will work to fulfill the plan, which won’t make the situation better.

“The government has to keep in mind that it is not the people but doctors who will resist the most. The so-called elite, the ‘medical top,’ will be against public health reform, as the sub-specialists don’t need it. They work in public hospitals in Kyiv, Kharkiv, Dnipropetrovsk, Donetsk, and Odesa and feel fine with it. There are even official fees for their medical help, which are only 30 to 40 percent lower as compared to the private cli-nics in Kyiv.”

UKRAINIANS DIE BECAUSE OF BAD HABITS

The World Bank has presented its fourth study, called “What Underlies Ukraine’s Mortality Crisis?” The main conclusion is: Ukrainians are dying out, especially working-age men. Most Ukrainians, 82 percent, die because of noninfectious chronic diseases: heart attacks (40 percent of deaths), strokes (12 percent) and cancer. This rate is two to three times higher than European ones. What are the reasons for this situation and what do you think has to be done to significantly decrease this deplorable rate?

“We have to specify that noninfectious diseases account for 82 percent of deaths and the remaining 12 percent are caused by traumas. The latter can be mechanical, thermal and chemical injuries, asphyxia, drowning, etc. Between 60,000 and 70,000 people die every year because of injuries and poisonings, much more than the number of heart attacks. Some 10 to 17 percent of heart attacks result in fatal outcomes. Last year 106,000 strokes were registered and over 30 percent of them had lethal results. This means that strokes kill three times more people than heart attacks. Cardiovascular disease is responsible for 62 percent of deaths.”

What are the reasons for this?

“First of all these are social, economic and medical problems. Traffic accidents, burns, domestic traumas, and suicides kill eight to ten times more people in Ukraine than in Europe. Smoking is the primary cause and the information from the World Bank proves it. 100,000 to 110,000 people, according to some statistics up to 115,000, die because of smoking and reasons related to it: heart attacks, strokes, cancer and various allergic diseases; passive smoking accounts for 10 percent of death rate. It’s very good that we adopted the law that prohibits smoking in public places. Alcohol comes in at second place. Nine to ten thousand people die every year from alcohol poisoning. If we take into account that alcohol is the reason for mechanical injuries such as falls from heights, industrial injuries and suicides we can say that alcohol kills not less people than smoking. 70 percent of working-age men die from alcohol [-related causes]. If we look at the Ukrainian statistics from 2009, we’ll see that men prevail in the age category up to 30 years old, but there are more women aged between 40 and 60 — 147 women for 100 men!

“They say that the death rate started increasing during the years of independence. It’s not true. Mortality in Ukraine started growing back in 1958, it leapt dramatically in 1966 and this pace remained stable after independence. Between 1958 and 1991 Ukraine had the highest mortality rate among the Soviet republics. The main reasons for this were social and economic. I saw the information of the State Statistics Committee in Kyiv for 2008 and I found out that they didn’t register a single death from alcohol poisoning. I had a question: why? I work in the ambulance [service of a] hospital, once a week I give consultations and examine patients, and I know that the rate of alcohol poisonings is high in Kyiv. However, there’s no information about it. We should ask this question to doctors as well.”

In fact, people died…

“Lots of them, but they attributed it to other reasons. The statistics are often wrong. I’d like to emphasize that the president made the regional authorities responsible for the regions. They have to be responsible not only for the GDP but for public health as well, since the GDP doesn’t work for the public health. The president clearly declared healthy lifestyle propaganda to be a priority, which is extremely important. However, the healthy lifestyle promotion and corresponding programs are not the responsibility of the Ministry of Public Health. The ministry treating the diseases can’t develop a program called ‘The Healthy Nation.’ Such a program has to be developed by the Ministry of Social Policy, the Ministry of Family and Youth, the Ministry of Finance and Economy, where they can involve the representatives of the Ministry of Public Health as it was in 2007. Charging those who are interested in spending money on medical treatment instead of health improvement to develop this program is absurd.”

Why haven’t any of the presidents or governments managed to reduced the mortality rate, which is growing. The UN predicts that in 2050 there will be 25 million Ukrainians left...

“If we compare the statistics of 2003-05 with the last years, we can notice that the mortality rate has decreased. In 2007 mortality was at 16.4 per 1,000, in 2008 it was 16.2 per 1,000. In 2009 the mortality paradoxically decreased by 2,400 people though 2,000 people were killed in traffic accidents. Before the law on the fines for traffic accidents was adopted 24 people died in Ukraine every day. In 2007 10,000 people died on the roads because of traffic accidents and other reasons. In 2010 nearly 6,000 people died, which means that the number of people killed in traffic accidents decreased. This positive tendency is due to the adoption of the law. Today 12 to 14 people die every day; previously the rate was 20 to 24 people. From 2007 on the number of heart attacks and strokes has been significantly decreasing. It’s related to the complex measures that resulted in the decrease of the number of smokers by 4.5 million people. The number of diseases and mortality have gone down with the adoption of the law on smoking and the implementation of stricter measures with corresponding forms of treatment. The number of poisonings fell after alcohol prices augmented by 20 percent. The complex social measures, the limitation of access to poisons and the explanatory work will make it possible to decrease the mortality rate by 30 to 40 percent. However, we have to use strict and unpopular measures.”

In his election program Ukraine for People Yanukovych promised to work on bringing Ukraine’s population back up to 52 million. Demographers say that even if each family has three children it will be impossible to stop the demographic crisis because of the high mortality rate...

“There will never be 52 million Ukrainians. Unless we accept them from Libya and other Arab countries and grant them citizenship; however, we’ll have to accept several millions people including women and pay them the same money when they have babies that we pay to the Ukrainians…”

Will it be impossible in the nearest future, or in 10 to 20 years?

“Not in 20 or even in 30 years! Now people don’t have babies but work on their careers. There are a lot of negative trends in society, for example the initiatives to allow people with alternative sexual preferences to adopt children. Of course, they will bring up a child similar to them and unable to have babies. First of all we have to create the conditions to encourage young families to have babies which implies adequate salaries, housing and a range of legislative and administrative initiatives. It’s necessary to adopt strict laws on the factors that increase mortality: traffic, behavioral responses and diseases, including AIDS. People have to be responsible, since 60,000 to 70,000 die because of the behavioral diseases or traffic accidents. Of course, strict limits on alcohol consumption and smoking have to be implemented through banning publicity [for alcohol and tobacco products], increasing prices, and limiting distribution and consumption. State structures have to react quickly if a law is violated.”