Golden Ring

A few weekends ago I went on a bus tour of a region of Russia known as the Golden Ring. The Golden Ring is a group of medieval villages northeast of Moscow, joined in a "ring" by a highway. The towns, of which there are about a dozen, range in size from tiny to the largest, Yaroslavl, which has a population of about 600,000. This region represents an area of political and cultural power during the 12th century and later, before Moscow was even founded. Yaroslavl, which is also the oldest in the region, is 996 years old. In 2010, the city plans to celebrate its 1000 year anniversary, which its tourguides claim will be a huge celebration of the city's beauty and historical treasures.


During our tour, we visited four cities: Pereyaslavl-Zalessky, Rostove Velikii, Yaroslavl, and Kostroma. Although these range in size, they each flaunt a historical Kremlin (a word meaning palace or fortress, which is also the name of the huge Moscow structure near the Red Square that most people associate with Russia) and a cluster of ancient monasteries and churches. Due to the recent return of many Russians to the Orthodox faith, the churches have been brilliantly restored and are quite a site. Although we saw about a half dozen churches on our trip, each one is unique and has it's own individual details.


For me, the most amazing thing were the frescos decorating the interiors of these historical buildings. Every empty space, from the walls to the ceiling is painted in bright colors, showing the illiterate villagers that prayed in these churches different scenes from the bible. Due to the nature of frescos, which had to be painted quickly before the foundation dried, each church was decorated in an amazing 40 days. The frescos we saw on our trip, dating from as early as the 16th century, were original, some of which were so well preserved they had never needed to be renovated.

The trip lasted for two days and one night. Our tour group consisted of 49 people, including two drivers and one guide, all of whom compactly fit into one huge tourbus. We were lucky enough to get a bus with air conditioning (which we didn't use since it was pretty chilly), but no bathroom. The farthest city, Kostroma, was six hours away from Moscow, so the bus was forced to make a number of pitstops in the forests lining our highway. I found it a little annoying that I had to be careful not to squat on a bush of krapiva, a nasty plant that grows pretty much everywhere and leaves an unpleasant rash. Everyone claims getting this rash is good for you, as it brings blood flow to the affected area, but I, personally, am not a huge fan.

Besides seeing a shockingly large number of churches, our trip took us to a number of places which held a great deal of relevance to the history of Russia. One of our stops was a museum of wooden works, which included 150 year old wooden houses and churches taken piece by piece from villages and reconstructed with all the furniture, instruments, and cloth that filled these structures when they were still used by Russian peasants. Having never seen what village life was like in Russia in the past, I was pretty fascinated by the things that could be built without the use of any nails of heavy equipment.

In Kostroma, we saw the place where the Romanov family lived during the Time of Troubles, and where Mikhail Romanov accepted the boyar's plea to become the first Tsar of Russia in 1613. The Romanov dynasty, which is Kostroma proudly claims as its own, ruled in Russia until the Revolution of 1917. There we also became acquainted with the Volga River, the largest river system in Europe into who's cold waters I bravely put my feet.

The cities of the Golden Ring have all maintained a provincial atmosphere that has remained dispite their proximity to the bustle of Moscow. Ancient wooden houses, upaved dirt roads, and livestock are all characteristic of this region, and its clear that life moves a lot slower, even in the relatively developed Yarosalvl. Overall, the trip was very interesting, and I'm glad I had the opportunity to get a feel for the history of Russia before Moscow, urbanization, and Communism.

1000 grams

Recently I've been able to shadow some of our doctors as they go to check on their patients. Because the rules here are more lax than in America, I can actually touch the babies in the hospital and do little parts of the physical exam. Premies in the NICU (Neonatal Intensive Care Unit, or Reanimation in Russian) are so little I worry I might hurt them if I even touch them the wrong way. Their skin feels like thin papyrus, their legs and arms about the size of my thumb and lack the muscle tone of term infants. Because they aren't strong enough to cry loudly like healthy babies, those that can cry make small kitten noises that you can only hear standing next to their cribs. Despite all this, they will still wrap their tiny fingers around yours if you tickle their palm--they like to be touched.

The healthier babies in the intermediate nursery, the ones who are closer to term, look comfortable swaddled in their white sheets. Along with the nurses, the mothers of these infants are actually directly involved in their care, feeding and changing them. My guess is that there just isn't enough staff to care for the 100+ babies in the four units of the neonatal ward of City Hospital No. 13 in Moscow, and so the mom's are enlisted to help.

For the most part I followed Anna Nikolayevna, a neonatologists who specializes in neurology. Much of what she does involves taking neuro-sonographs (ultrasounds of the brain through the open anterior fontenelle) of infants who suffered some kind of neurological injury during birth or as a result of their prematurity. This kind of image can only be captured in small infants, since at 12 months of age the anterior fontenelle closes and the brain can no longer be visualized by an ultrasound machine. In examining the babies, Anna Nikolayevna looks for signs of hemorrhage, cerebral ischemia, and other brain damage. Although all brain damage is serious, some can be reversed if caught early enough, and that is what this physician tries to do with her patients. If nothing can be done to reverse the damage, Anna Nikolayevna at least tries to give the parents a sense of the degree of injury to their child, and the amount of developmental delay they can anticipate.

One of the first patients we saw was a 1000 gram premie (probably 30 weeks gestation). He was a week or two old, still tiny. Not intubated, but on oxygen, and still struggling to breathe. His legs were limp, the muscle tone present in a healthy newborn were almost completely absent. Anna Nikolayevna brought the ultrasound probe up to the tiny head, which was smaller than my fist, and I could hear her take an angry breath in. On the ultrasound, I could see large bright areas, which she explained were ischemic, areas that had died from lack of oxygen. There were big cavities as well, where the brain tissue had already died and dissolved away. The baby had lost more than a third of his white matter, an injury that was serious enough to be fatal. If he survived, it is unlikely that he would ever be able to have higher brain functions--it is difficult to say if he would have a real life.

In Russia, 1000 grams or 27 weeks is considered the limit of resuscitation. An infant born earlier than this will still be worked up, but for the most part these babies are not expected to survive. In America, we resuscitate at 500 grams or 23 weeks. This gap, which represents about 30 years of American and international research, is a huge one. In practice, it is difficult to explain why Russia, a country brimming with oil money and with a strong education system, isn't able to keep up with Europe and the United States in terms of medical development. Partially, this is due to the lack of funding for research in the medical field, which takes second place to clinical practice and isn't considered a profession on its own. Another part has to do with the concentration of all of Russia's money in a tiny fraction of the population, who has access to their own, high quality private medical care. There are many other reasons, and I wonder if Russia itself is able to solve them, or has the desire. For a country that considers itself to be European, to be among the most developed nations, it certainly has a long way to go. Looking at our 1000 gram patient, I couldn't help thinking that this baby, had he been born in America, would have a vastly different outcome.

Quest for the White Coat

As a medical student, I naturally want to follow the neonatologists at my clinic around on their daily duties. It isn't surprising that neonatal wards in Russia are very strict on who they let it, as are the NICU's in America. What I didn't know before I left for my trip was the particular method of security used in our hospital in Moscow. Instead of the ID badges or electronic cards employed by most American medical centers to identify its personnel, Moscow's Children's Hospital No. 13 requires everyone who enters the neonatal ward to wear a white coat. The white coat alone is enough of an ID badge, apparently, to make sure no unauthorized people set foot among the babies. So even if one of the doctors brings you in, and says you're ok to be there, without a white coat you'll promptly get kicked out. Who knew white coats were such great security tools.

Given that I didn't know the white coat rule, I didn't bring mine with me. And, apparently, its not considered appropriate in Russia to share white coats, probably because the hospitals are very hot and everyone wants to keep their coats free of other peoples' sweat. All this meant that I had to go find myself a new white coat among the streets of Moscow.

The quest for a white coat wasn't as simple as that might sound. Keep in mind that Moscow is a huge city and only lunatics and men in BMW's (who everyone avoids in fear of being shot by their 5 closest friends in black) drive. I was first told to go to BDMX, which is a metro stop seemingly close to my house, but due to the somewhat roundabout metro system in Moscow, was actually 40 minutes away. So I decided not to do that.

Sasha then remembered that she saw something that looked like a medical supply store near our house. We walked to this "store." The place had a huge set of windows facing the street, all of which housed only a single manequin, dressed freakishly in green scrubs. We entered the store through some half-open door facing the alley. Inside we saw a lot of boxes, a cat, and a bunch of scattered medical equipment behind glass. A man and a woman were sitting at desks filled with paper work. When we came in they gave us mean, confused looks and briskly asked us what we wanted. I asked for a white coat. The man said to wait and ran into some other room for a moment. Soon, however, he came out without a white coat in hand. He informed us that they are actually closed (did he need to ask someone for this?) and that they will only sell white coats in September. Sasha and I quickly left, fearing we had stepped into some mobster's strange hangout.

Just as I was beginning to mope about the possibility of having to go down to the dreaded BDMX, Sasha brilliantly decided to check the internet for other nearby stores. She found one, about a 30 minutes walk away. Promptly drawing me my "treasure map" so I wouldn't get lost, Sasha told me to try looking there first.

The next day, just as I was about to set out on my quest, I realized that I had somehow managed to lock myself in my house. How could I possibly do such a silly thing? I didn't know either, but I knew that I had to call Sasha to come home and let me out. It turned out, the rug had gotten stuck in the door and kept it from opening. But I digress.

And so I set out to find yet another store with the hopes of finally buying the coveted white coat. After getting a little lost and calling Sasha 3 times for directions, I finally found the building. This was apparently the Dental Institute of Moscow, which is the best place in the country to get anything done with your teeth. Why I was sent here, no one knows.

I asked around a bit and was directed to one of the entrances, where people claimed I could buy a white coat. When I came in, the guard, who was a very strange talkative lady, told me that there used to be a store filled with white coats, but the store couldn't pay their rent and were kicked out. Currently, the guards use the space as a office. Just before I was about to get annoyed at yet another failure, the guard told me that there is a lady who works there who sometimes has white coats to sell. She had just gone home, but since she lives right around the corner, I could wait for a minute and they'd call her. This sounded a little sketchy, but I decided I might as well give it a try.

The guard did finally reach the lady, who asked me some basic questions and said she'd be right over. When she came by, she opened some half-hidden closet near the entrance, out of which she pulled out boxes of snacks, a teapot, and, to my amazement and relief, a stack of white coats. Amazingly, one of them fit me, and when she asked for 650 rubles (about $25), I only complained a little about the price.

And so I got my white coat! Who knew a simple thing could take so long in Moscow. This is possibly why they use them instead of ID badges, but no one has confirmed that yet. I did learn two things, however: I can't live without Sasha, and I shouldn't be afraid of random sketchy guards.

Monasteries

One of the unique things about Moscow is that it has a number of old monasteries, many of which as still functional. These beautiful buildings and complexes date from anywhere between the 16th to 19th century and each one is very different from the others. Due to the recent return to Orthodoxy among many Russians, a significant amount of money has been dedicated to renovation these churches and making them look like they did before the Revolution. When the Communist came to power, their forceful rejection of religion caused the monasteries and churches around Moscow to be closed down. Many were used as storehouses, junk yards, and so on (one particularly unlucky one was torn down to make a public swimming pool). As more and more of Moscow's citizens are falling back into their faith, the monasteries in the city are starting to bloom.


The working monasteries vary in their strictness towards visitors. While some let anyone come in however they choose, others force any women found on their grounds to cover their heads with cloth and wear skirts (supposedly so you don't shock the monks who still live on the grounds). Here's a picture of Nika demonstrating the proper way to enter one of these stricter monasteries. For those tourists who are not smart enough to bring their own coverings, the monasteries usually provide wrap around skirts and scarves, though I doubt anyone can attest to their cleanliness.


Most monasteries don't allow you take pictures inside the grounds (which is quite annoying considering you can only see them well from inside). When visiting a strict monastery you are also expected to keep quite (even outside), and behave in a way that shows respect to the sanctity of the area. If you don't demonstrate reserve, some of the tall men in black suits who seem to wander around the churches might kick you out. How the church can afford such security is another question entirely.


Despite the inconveniences imposed upon tourists visiting these monasteries, they are quite beautiful and certainly worthy of a look. To see more, go to http://www.mumrik.us/photos.mumrik.us/

City Hospital No. 13

Now that I'm not simply pretending to be a medical student working in Russia and have to go to work, I spend most of my time at City Hospital No. 13. This building (which is much bigger than the picture above--that's only the "well" guarded entrance) is mainly an adult hospital which happens to house a large neonatal intermediate nursery and intensive care unit by what effectively was a historical mistake. Way back when, the spread of infection among neonates was much feared in these hospitals, and City Hospital No.13 was one of the only spots with an isolation ward. And so the these tiny newborns found themselves here, in the southeast corner of Moscow, where they have stayed despite the modern ability to prevent infection elsewhere.

The medical system here is vastly different than in the states, and is based largely around hospitalizing patients. If anything care needs to be given to a neonate, including help with feeding and any medication, this, by tradition, is done in the realm of a hospital. As you can imagine, this is a great financial burden on the country, which provides basic, free government health insurance to all its citizens. And so the neonatal ward of City Hospital No. 13 is filled with 40 or so babies, most pink and healthy, and without the debilitating illnesses we usually associate with neonatal ICU's.

My work here is focused on the large number of yellow babies among the pink ones. I'm doing a chart review on the management of neonatal jaundice. Considering that the current protocols used by Russian physicians are older than most of the people who use them, the doctors here feel that something needs to be done to encourage some change, and they wanted my help with this. Lest you think that a chart review is a simple thing, let me show you what the average chart in a Russian hospital looks like. If you think the only reason you can't understand anything is that its written in Cyrillic, let me assure you that this and Cyrillic have little in common. And we say American doctors have bad handwriting.

Despite what many Russians say, the medical system here is quickly falling behind the rest of the modern world. According to many Russian doctors, the quality of health care in Moscow is far behind that of America and Europe. For example, in most American hospitals, a newborn will be resuscitated at 500 grams or 23 weeks (and big medical centers like Stanford will try to push these boundaries even further). In Moscow's maternity wards, the cut off is 1000 grams or 27 weeks. This is about the level of development that America was at 20-30 years ago. For a country with the resources to provide high quality medical care, these numbers a kind of scary.

One of the major reasons Russia is doing so poorly in the medical field is that there is no official government funding (or funding of any sort) for medical research. In a doctor's career, the only time that he or she will be paid any money to do academic work is during their ordinatura (the equivalent of our medical fellowship). Although these doctors are required to write a dissertation in order to finish their ordinatura, they are expected to work on their research only after finishing their patient duties at the hospital. Once they become attendings, doctors here can only do research on their own time. In effect, there is no such thing here as a researcher-physician or the kind of academic doctors that are usually found in most medical school in the States. As a result, Russia produces very little original research publications and is dependent on other countries, mostly America and Europe, for their updated medical knowledge. This kind of system has put Russia far behind most modern countries and is threatening to keep them there.

Dom Otdyxa

This Sunday I visited some of my relatives at one of the few Dom Otdyxy (vacation houses) located in the Moscow suburbs. These huge properties are old estates of Russian royalty who used to populate this area before the Bolsheviks had the bright idea to kill all of them. After the revolution these mansions and the many acres of land that went along with them were passed on to the government, which alternated between using them as vacation houses for the hardworking comrades of the Soviet State, and as private houses given as perks to the members Communist Party who happened to be in favor at the time. In 1991, when the Communist government here dissolved, these houses, as if in tribute to their previous owners, followed suit. The beautiful mansions filled with antique furniture and groomed parks lined artistically with statues began to slowly fade into the surrounding wilderness. Also, they were heavily looted by pretty much anyone with a car, and so are now empty of much of their original interiors (people even stole the decorated hardwood floors). It is only recently that some effort has been made to restore these estates, which have once again become vacation destinations for Moscow's swelling population. Despite the renovation, the work in this dom otdyxa remains largely unfinished, as is the tradition with most projects here that require some kind of money. The result is a strange combination of freshly painted walls with buildings who have almost disappeared into the forest growth.


We came to this vacation house to celebrate the birthday of my grandmother's cousin's husband (who also happens to be, ironically, my grandfather's close childhood friend). The older pair had been living here for a few weeks with their grandson, enjoying the warm weather, forest, and nearby lake.


On our arrival (by metro train followed by a taxi ride), we were greeted by a group of friendly dogs who live on the property. Their sole purpose in life seemed to be to get you to pet them, with the possible addition of getting a snack in the process. Otherwise they seemed happy with their simple life beneath the crumbling walls of this estate. One of the dogs was pregnant, looking like she might explode any minute, if you poked her the wrong way. In real life she's not as unhappy as she might look in this picture, and after smelling me continued to follow me around for the rest of the day.


We spent the whole day at this dom otdyxa, where we were well fed by the local chef, shown the enormous grounds, and even offered a chance to sit in the local banya (sauna) by its live-in keeper. Despite the fifty-odd rooms in this vacation house (which is actually a collection of houses all built around the same period), there were surprisingly few visitors. One of the reasons could be that the price to live in one of these houses rivals a trip to Turkey or a near by sea, unless you happened to be on good terms with the management (which we were). The rooms themselves are pretty small, furnished with thin, worn out mattresses and ancient furniture. In order to get into the main mansion you have to get a set of different keys that opens each of the three floors. Although mostly empty, the mansion does have a set of authentic billiard tables. These are made in the old style, meaning they are much bigger than the American variety and the holes are much smaller. I, needless to say, didn't play that well.

To see more pictures of the dom otdyxa, go to http://www.mumrik.us/photos.mumrik.us/

В Россию можно только верить

Умом Россию не понять,
Аршином общим не измерит:
У ней особенная стать--
В Россию можно только верить.
--Тютчев (1866)

Poem by Tytchev (1866), (very) loose translation:
You can't understand Russia with your brain,
You can't measure it with the standard instruments:
She has a particular status--
In Russia you can only believe.

While this poem was written as an authentic tribute to his country by Tytchev, in modern times it has taken on a different meaning and is often much satirized. In my personal experience with Russia so far, this poem seems to be most appropriate.

Policemen:
Although Katya and Grisha, my hosts here, deny it, I've heard stories of policemen harassing tourists. Warnings to stay away from policemen and to not carry your actual passport around is printed in all the tour books of Russia. Although effectively harmless to authentic tourists with visas and registrations, policemen are known to accost the unwary tourist on the street, probably in hopes that they can frighten the helpless foreigner into some pocket money. Since most policemen, along with pretty much everyone here, gets a very meager salary, they see tourists as their free lunch, or the source of their girlfriend's next present. As is, I try to stay away from them.

So far my encounters with policemen have been mostly amusing. A few days ago I went to one of the many markets around the city that are centered on entrances to metro stations. There are endless booths that sell everything from cherries to ladies underwear. For the most part, the owners of these stands are not Russian (they are Georgian, etc), and I get a little private satisfaction from the fact that their Russian is definitely worse than mine. There isn't much bargaining going on around these markets, but, as Sasha suggested, you could try it if the booth owner is a young man.

Besides the market booths, there are also a number of babushkas (grandmas, or old women) clustered around the metro entrance who sell many of the same products, but for much cheaper rates. Because the babushkas don't have stands, they are technically selling things "illegally." Around them are at least four policemen. The situation generally works like this. Every once in a while a policeman will kick one of the babushkas out of her place. She will obediently run off and, after an appropriate length of time set up shop on the other side of the metro. The policeman goes to this effort not to stop illegal sales, but to encourage the remaining babushkas to give him some money, so that they get to keep their place in the market. As long as they pretend to hide their wares behind the back of the policemen, and keep him stocked with rubles, everyone is happy. When I bought flowers from one of the babushkas, she ushered me behind some walls to actually make the transaction (where the policeman couldn't see), but had her friend wrap the flowers right next to the man. This, apparently, was considered acceptable. For me, this is pretty funny.