• Pulmonary Rehabilitation in Other Countries

  • Drs. Olga Baranova, Audhild Hjalmarsen and Elmira Zilber at the CSPR Conference
  • A few weeks ago, we had the privilege of hosting some wonderful guests from Norway and Russia at our annual CSPR (California Society for Pulmonary Rehabilitation) meeting in Long Beach, CA. Dr. Audhild Hjalmarsen of Tromso, Norway is a longtime friend who has visited here before. She asked if she could bring some colleagues from Russia to help them learn more about pulmonary rehab. Joining her for a 10 day visit were Drs. Elmira Zilber of Karelia, Russia (600 kilometers north of St. Petersburg) and Olga Baranova of St. Petersburg. They were accompanied by the very charming Vladimir Kozlov, who helped with the translations.

  • Vladimir Kozlov
  • During their stay, they visited various hospitals including Harbor-UCLA, Long Beach Memorial Medical Center and Citrus Valley Medical Center. We'd like to thank the administrations and pulmonary rehab staff and patients at these hospitals. We'd also like to thank Dr. Tom Storer of El Camino Community College and the patients in his wonderful maintenance program. They all gave so graciously of their time. We can assure you that it was appreciated! Dr. David Sachs of the Smoking Cessation Research Institute in Palo Alto spent a whole day giving them the latest information on handling the chronic disease of smoking. To have an internationally renowned busy physician like Dr. Sachs give them a day of his valuable time was truly remarkable and much appreciated. He gave them some new insights into the smoking problem and how to control it. While smoking is a major problem in Norway, it is much worse in Russia, where 80% of the men still smoke.

  • Visit with Dr. Richard Casaburi in Torrance, California
  • Participation of our guests in our CSPR seminar was one of the highlights of the trip for these physicians as well as for the other attendees. In two sessions, each participant first told us a little about pulmonary medicine and rehab in their respective countries and later answered questions from the curious audience.
  • Dr. Hjalmarsen impressed us with slides of her pulmonary rehab and maintenance programs in Norway. Tromso is a lovely University town 600 miles above the Artic Circle. Because of the Gulf Stream, she describes the climate of Tromso as "mild". A relative term, my dear readers! You are more apt to find polar bears than palm trees should you have the pleasure of visiting. We can't find our picture of a patient herding reindeer with his portable O2, but here is a picture of one of their rehab oxygen patients riding his snowmobile.
  • Another minor problem, she told us, is that for 2 months every year they never see the sun above the horizon. However, Tromso makes up for it in the summer when the sun is visible 24 hours a day for two months! Would you like to have her tell us more details about life in the far North some day?

  • Patient using portable oxygen on his Snowmobile in Norway
  • Dr. Hjalmarsen's programs can successfully compete with the best of any program in the States. There is even a swimming pool; indoors and heated, spoiling our vision of hardy Norwegians breaking the ice for a daily dip. Maintenance programs are part of rehab and, without cost, include 3 sessions a week in well-appointed gyms. All patients meeting standard guidelines of desaturation, and need for exercise, are put on portable liquid oxygen. National health care pays for all of this, plus medications, without any charge to the patient. Just recently, however, the Norwegian government has cut back on liquid oxygen payment so hospitals have to assume the cost. Even so, do you wish we also had such high quality health care, free to everyone? The Norwegian health care system ranks as one of the best in the world but there is a small catch. Income taxes are at least 50% of income. I don't know about Norway, but in Sweden, this rate can go up to 90% for high-income people. Do the rock stars and baseball players complain? No, they move someplace where they don't pay such high taxes. I've got a feeling that would also happen here in the States should we increase our taxes this much.
  • Our two Russian physicians fascinated us with a glimpse of their country during the first session on pulmonary rehab and later when answering questions from the audience. Dr. Elmira Zilber started by telling us that it is winter 6 months of the year in Karelia. Long Beach was in the middle of a 96° heat wave so that instantly caught everyone's attention. Her hospital in Karelia is starting the first rehab of pulmonary patients in Russia with the help of Dr. Hjalmarsen and the Norwegian government. They have begun with breathing exercises, lectures, and proper use of inhalers and inspiratory muscle trainers. Life in Russia is in stark contrast to that of neighboring Norway. For many, many years, most of the wealth and the efforts of this vast country seem to have been devoted to the military. Infrastructure, and things like public health and hospitals, received scant attention and even less financing. Do you complain about the food you get when in the hospital? There is nothing to complain about in Russia since no food is provided to patients. Families are responsible for bringing in meals. No family? That presents a problem, though they assured me that something was worked out. All medications are purchased at the pharmacy without a prescription, but there is sometimes a problem with quality control or watering down, of medications. As is typical in most countries there are no respiratory therapists. Physical therapists, as we know them, do not work in hospitals either. There are very few nurses and no nurses' aides.

  • Heated pool for patients in pulmonary rehabilitation in Tromso, Norway
  • Our two Russian physicians fascinated us with a glimpse of their country during the first session on pulmonary rehab and later when answering questions from the audience. Dr. Elmira Zilber started by telling us that it is winter 6 months of the year in Karelia. Long Beach was in the middle of a 96° heat wave so that instantly caught everyone's attention. Her hospital in Karelia is starting the first rehab of pulmonary patients in Russia with the help of Dr. Hjalmarsen and the Norwegian government. They have begun with breathing exercises, lectures, and proper use of inhalers and inspiratory muscle trainers. Life in Russia is in stark contrast to that of neighboring Norway. For many, many years, most of the wealth and the efforts of this vast country seem to have been devoted to the military. Infrastructure, and things like public health and hospitals, received scant attention and even less financing. Do you complain about the food you get when in the hospital? There is nothing to complain about in Russia since no food is provided to patients. Families are responsible for bringing in meals. No family? That presents a problem, though they assured me that something was worked out. All medications are purchased at the pharmacy without a prescription, but there is sometimes a problem with quality control or watering down, of medications. As is typical in most countries there are no respiratory therapists. Physical therapists, as we know them, do not work in hospitals either. There are very few nurses and no nurses' aides.
  • Dr. Baranova told us that in one 640 bed building in her huge hospital there were only 34 nurses. That got the attention of her medical audience! Their nurses apparently don't seem to have the educational background that we have in the states, and definitely have different job descriptions. So, who takes care of the patients? The physicians-in-training do most of the other work! These doctors are mostly women. Very few men go into medicine these days and it is easy to see why. Do you grumble about having to use oxygen when you go out in public? Russian patients don't have that problem. As in most Eastern Europe, there is no portable oxygen. In fact, there is no oxygen at all, even in the hospitals. If you are put on a ventilator, you will still be on room air, because even then oxygen is not available. The number one cause of death in Russia is pneumonia. The average age of death for a man is 57 years. Dr. Baranova is the leading Russian expert on restrictive diseases. Russia seems to have many more patients and problems than we do because of air pollution and poor working conditions in factories and mines. Smoking doesn't help the situation. Dr. Baranova is hoping to start some form of rehab in St. Petersburg. She told us that one of their professors had been giving lectures to respiratory patients. How large was their class? Their class in St. Petersburg was an auditorium of 500 people......who were allowed to smoke in class. This shows how eager these COPD patients must be for help. I'm sure many of you can empathize. Hospital care in Russia is paid for by the government, as are hospital workers. Physicians make $200 a month. Nurses make $100. (Gasps from the audience.) This is apparently no more than a factory worker makes and is difficult to subsist on. The problem is that the government just doesn't have any money to pay for this care. You may think that the good news is that these poorly paid hospital workers don't pay taxes. But the bad news is neither do the billionaires! No one in Russia pays taxes! The problems our Russian colleagues face are mind-boggling. And so is their dedication to the sick, and their determination to improve things, in spite of difficult working conditions and low wages. So, what can be done to help these people? After years of war, fear and hostility toward their large neighbor, the Norwegian government decided it was time to move on and wiser to assist them. Audhild Hjalmarsen and her fellow physicians in Tromso hold training programs for Russian physicians in Tromso, and are also going to Russia to teach. The Norwegian government sponsored our Russian physicians for this visit to America. Audhild Hjalmarsen goes even beyond that, and is becoming the physician equivalent of Florence Nightingale in Russia. She personally has delivered 40 oxygen concentrators, plus IPPB machines and other used equipment to the hospitals in Karelia and St. Petersburg. This is not an easy task. When border guards check her van, she has to be careful that they don't confiscate some of her supplies to sell on the black market. That is how they supplement their meager salaries.

  • Visit with Dr. David Sachs in Palo Alto, California
  • Vladimir Kozlov told us what it was like to live in a closed society, without access to the outside world for so many years. He has relatives who were able to get out of Russia many years ago; they are now living somewhere in South America or perhaps in the States. Because contact was forbidden for so many years, they are lost to each other. In 1985, when Dr. Jan Zielinski of Warsaw, Poland visited us, we were able to help him with donated, refurbished equipment because the Polish-American Societies did the shipping. Russia has been isolated from the rest of the world for so long that they are cut off from the old friends and relatives who escaped Communism. It is not ex-party members that we are trying to help. They, apparently, are doing quite well. What we learned was that the average Russian was trapped in the system, just as Eastern Europeans were. If any person or organization is feeling a little philanthropic, and wants to donate used equipment, or an oximeter, we personally know 2 very dedicated physicians who would be most appreciative. However, since there is sometimes a problem with having donations "liberated" we will have to research the best way of delivering things so they get where you want them to go. Let us know if you are interested in having us work further on this problem. While we have spent most of this newsletter on our guests from Russia and Norway, we don't want to neglect two other members of our panel at CSPR on rehabilitation in other countries .
  • One was our very good friend and Webmaster, Dr. Janos Porszasz, who told us about pulmonary rehab and medicine in Hungary. We dedicated an issue to this after our return from Hungary last September so we won't repeat ourselves. However, we would like to tell you about the big laugh he got during his presentation. He showed a slide of Deszk hospital in Hungary, the luxurious ex-residence of a Count, surrounded by lush grounds, fountains, lakes, statues and, well.... you get the picture. He dryly announced, "This is where Dr. Attila Somfay has his rehabilitation program. I have come up in the world and this is where I am now Technical Director of the Rehabilitation Clinical Trials Center." The picture flashed on the screen to a view of our beloved but rather dingy Harbor-UCLA Research and Education Institute temporary building with the dirt parking lot next to it. It is definitely not someone's former palatial estate. The audience hooted in appreciative laughter.
  • Last but most certainly not least, Dr. Hideki Tsurugaya told us about pulmonary rehab and medicine in Japan, apologetically explaining that he is a cardiologist, just now learning about pulmonary rehab. That produced an appreciative round of applause and lots of good-natured comments about how unique it was to have a cardiologist interested in pulmonary rehab. Dr. Tsurugaya is at Harbor-UCLA for 2 years doing research on breathing, but is interested in visiting rehab programs, especially those that combine cardiac and pulmonary rehab. He hopes to start such a program in his hospital when he returns to Japan. We were told that there are more than 5 million patients in Japan with COPD probably because of the problems with smoking as well as the aging of the population. He felt they needed more rehab programs plus doctors, nurses and physiotherapists trained in this specialty. Japan also has problems with insurance coverage from the government. When HOT (Home oxygen therapy) was first covered in 1985, 100,000 patients signed up for it! He felt the same expansion would occur once rehab was covered. In Japan, he told us, many patients become house-bound or even bed-bound because it is so difficult to remain active. Of course, this same problem occurs in this country. The Japanese Respiratory Society recently published a pulmonary rehabilitation manual that physicians are beginning to use. In some of the large cities like Tokyo, pulmonary rehab is at the same level as it is in the United States. They also have an active patient support group and are part of an international effort to encourage recognition of the problems of COPD. Our cardiologist got a big round of applause for contributing to our meeting, plus several invitations to visit pulmonary rehab programs.