President of the Russian Academy of Medical Sciences – about the present and future of Russian medicine
The cage opens
President of the Russian Academy of Medical Sciences Ivan Dedov: The greatest hopes of medical scientists
it is associated with the development of cellular technologies and personalized medicineRossiyskaya Gazeta, 01.02.2013
Where did the iodized salt go? In which areas is Russian medical science at the level of world standards, and in which areas is it lagging behind? What is the average age of RAMS members? This and many other things were discussed at the "Business Breakfast" in the "RG" with the President of the Russian Academy of Medical Sciences, Academician of the Russian Academy of Sciences and RAMS Ivan Dedov.
Where are you, Russian Gates?Ivan Ivanovich, the Gates Foundation recently allocated a lot of money to a center that is specifically engaged in genomic technologies in oncology.
Are such donations made in Russia?Ivan Dedov: Gates' experience and example is unique.
It is not enough that a person has created his own ingenious information system. The size of his donations is amazing: tens of billions of dollars invested in the fight against HIV infection, tuberculosis, diabetes. And now to oncology. And you correctly noticed: money is invested in solving a very specific problem.
Why don't our oligarchs do this?Ivan Dedov: It is difficult to answer for compatriots who have fabulous resources.
We have lost the traditions, the culture of genuine patronage, which was in Russia and thanks to which clinics on Devichy Field appeared in Moscow, the current Institute named after him. Sklifosovsky, First City Hospital, 33rd hospital, Morozovskaya, etc. And not only in Moscow, all over Russia. And how they built it! What a design!
It seems that our young oligarchs are going through the first phase of financial euphoria from unlimited material possibilities, playing with expensive "toys". I am sure that the mentality of genuine patronage will mature in modern Russia. Obviously, we need a different attitude to charity on the part of the state, and maybe a special law on this matter. Although many of our citizens, without advertising themselves, provide assistance to orphanages and boarding schools, science, culture.
Is diabetes a disease or a lifestyle?There are many questions for you, as the country's chief endocrinologist.
Especially about diabetes, insulins.Ivan Dedov: Give them to me.
We will try to answer everyone.
Agreed. But we will voice some questions now. For example, a reader Samsonova from St. Petersburg, asks: "What discoveries have been made in the field of diabetes? Maybe they are being kept secret for commercial purposes?"Ivan Dedov: There are no secrets.
Diabetes today is an open world problem. Last year, at the UN plenary session, it was decided that the main challenges to the world community and, consequently, the main priorities in health protection in the near future are four non–communicable diseases: cardiovascular, oncological, diabetes mellitus and chronic obstructive pulmonary diseases. They bear about 70 percent of all encumbrances – economic, social, moral and ethical. I've been dealing with diabetes all my life. The first state federal target program in the field of health protection in Russia was devoted specifically to diabetes. The program has proven to be extremely effective. We met with President Yeltsin twice about it.
I think he signed it?Ivan Dedov: Yes.
We have created a diabetological service in Russia. Everything that is in the world of diabetology today is also in Russia: technologies, medicines, medical supplies. Diabetes mellitus is a complex, heterogeneous, heterogeneous disease. For example, in type 1 diabetes, insulin-producing beta cells break down. Is it possible to restore cells? Or how to prevent their death? Genomic and postgenomic technologies underlying predictive, personalized medicine have already been created. It is promising to determine the risks of developing diabetes in children, to predict possible defects of the immune system, through which diabetes develops.
We must learn how to mitigate these risks. Vigorous scientific research is underway to grow new cells and whole organs, including cells of the pancreas, thyroid, and parathyroid glands, which are also subject to autoimmune aggression when the immune system mistakenly identifies various tissues and organs as foreign, attacks and destroys them. The cultivation of cells, tissues and whole organs is the so–called cellular technologies and regenerative medicine – today one of the breakthrough directions in medicine. These technologies determine the success of transplantology and reconstructive medicine.
The question of creating a center or centers of cellular technologies and regenerative medicine in Russia has long been overdue. The problem of personalized medicine is immense. It is necessary to clearly define which technologies are most in demand today, which genomic, proteomic and other markers can be used to determine the risks of, say, myocardial infarction or stroke, and formulate recommendations for primary and secondary prevention of socially significant non-communicable diseases. Personalized medicine is also the selection of highly individual, maximally effective medicines.
In Denmark, diabetics on average live as long as those who do not suffer from this disease. It is not customary to say "diabetic", "diabetic" there. They say otherwise: "A person who has diabetes mellitus." They proceed from this postulate. In addition, they have, perhaps, the best insulins in the world, with which there are no problems. And we have only proclaimed that diabetes is not a disease, but a way of life. Another reader's question: "Tell me," asks Nadezhda Repina from Moscow, "when will the drug galvus be included in the list of drugs given to diabetics for free? I am a diabetic, and independent spending – 3-4 thousand rubles a month – is significant for me."Ivan Dedov: Galvus is a drug from the incretin family, which has recently entered the arsenal of diabetologists.
It is included in the federal list of vital and essential medicines. But each region plans to provide patients for free from its resources. Not everyone succeeds. This is a good drug. But not a panacea. Optimal combinations of antidiabetic drugs are determined by consensus of diabetologists of the world, they are well known, they are included in the standards of the Ministry of Health of Russia on diabetes. I am ready to explain to everyone personally.
The cultivation of cells, tissues and whole organs is one of the breakthrough directions in medicine today.
Are domestic insulins competitive, say, with the same Danish ones? Can they compete with them?Ivan Dedov: No.
We do not yet possess the medicinal forms of insulin, the technologies that foreign companies possess. Three of the leading international companies have a wide range of insulin dosage forms, with the help of which you can choose the most optimal combinations for both a child and an elderly person.
And in the future?Ivan Dedov: I'll say this.
This year, almost all patents for insulin analogues are coming to an end – both for ultrashort and prolonged peak-free. I think now different companies will come, manufacturers of insulin crystals, who are ready to offer the domestic pharmaceutical business the full range of these forms of insulin. And there are plenty of plants for the "bottling" of dosage forms in Russia.
Lost prestigeGrowing cells is very fashionable now.
But so far it's more about experiments?Ivan Dedov: So far in Russia, as far as I know, no team has a license for these technologies and cell lines that are truly verified according to international standards, which are safe and effective for transplantation.
All the directions that have been developed in Russia are still experimental. It is necessary to create national centers. I would like to be a member of the Academy of Medical Sciences. We have platforms for this, where we could create a "leading biomedicine center", with genomic, postgenomic and cellular technologies, personalized and translational medicine.
How is medical science funded? What ambitious tasks are you ready to set?Ivan Dedov: The question is not simple.
Only recently have positive developments in financing begun. More funds are being spent on the modernization of healthcare. Powerful modern centers of high-tech medicine and perinatal centers have been opened in the regions. So far, only small financial supplements have been used for science. The financing of science is moving from budget to program-targeted, expanding the volume of grants. An increase in the number of funds is planned. By 2018, it is planned to increase their volumes to 25 billion rubles. In December 2012, the strategy for the development of medical science for the period up to 2025 was approved, where all aspects of the development of medical science are presented in detail.
The problem of science is not only in financing. First of all, this is the most acute issue of personnel, this is the attitude of society to science, scientists. Is it prestigious for a young man to link his fate with science?Ivan Dedov: Over the past 20 years, Russia has lost a huge scientific potential: more than 250 thousand capable, talented, creative scientists, including doctors, have left the country.
Of course, the migration of scientists takes place in other countries, but not on such a scale. For example, in France and Germany, from which 3-4 thousand scientists have left, the issue of migration of scientists has been defined before the leaders of the countries as a catastrophe, as a historical decline in the prestige of the country. Hence: to return scientists at any cost and suspend their migration. We are trying to stop this process. I won't say that everything is working out. Moreover, the "technology of inviting" our scientists by foreign missionaries is being improved, the methods are more sophisticated.
What is the sophistication?Ivan Dedov: Screening is taking place at the level of schools, at the level of institutes.
Candidates of our youth are carefully studied: they are invited to study, to various courses, seminars, Olympiads. Unfortunately, the prestige of science has been reduced in Russia. Americans conducted a survey at home: is it prestigious to do science, to be a scientist? And here are the answers: 55 percent of respondents said it was very prestigious, 25 percent said it was very prestigious, and 20 percent said prestigious. Almost 100 percent of residents overseas believe that it is prestigious to be a scientist.
What about us?Ivan Dedov: Somewhere from 5 to 15 percent of us said that yes, it is prestigious.
But once it was very prestigious to be a scientist. A system of selection was worked out, according to talents. For example, there was incredible competition during the selection for graduate school! According to Darwin, there was "natural selection". And today what? Paid... and to graduate school. They do their work in a corporate way, write, defend dissertations – at least a managerial career is ahead. This is a whole "industry", which, alas, does not increase the prestige of scientists and science. There are two or three times more dissertations defended in Russia than in America. But this is not a criterion of the level of scientific research. We are trying to fight, we are reorganizing the Higher Attestation Commission, but so far it is ineffective.
Without a social elevatorHow is medical science funded?
Ivan Dedov: The budget of the Russian Academy of Medical Sciences is about 27 billion rubles, excluding financing for the construction of new facilities.
A total of 5.8 billion rubles, that is, 20 percent, goes to science. The rest is for the development of healthcare. Only 20 percent "for everything, about everything" and including the salary of scientists. By the way, today the base rate for scientists, both without a degree and for doctors of sciences, is the same – 4,400 rubles. Who invented it? It is impossible to specify! Everything else is allowances from grants, programs, etc. The salary of a scientist in the field of basic medical science is on average about 15-17 thousand rubles.
What is it for Moscow? Pennies! In clinical centers, the average salary is 35 thousand rubles or more, working conditions are very decent, someone receives 50-100 thousand rubles a month. We don't have a social elevator for scientists. What is the prospect for young people in science? After medical school, he finishes his residency (2 years), postgraduate studies (3 years). He is 28-30 years old. In the future – a family and children, but in reality he has "no stake and no yard." 17 thousand rubles is the average salary of a scientist in the field of fundamental medical science
It is believed that a scientist can buy a house for his own money.Ivan Dedov: For what?
Foreign missionaries come to Russia, who choose our personnel for projects. Gates, when he came to Russia two years ago, said that 51 percent of his employees are Russians. And the recruitment continues. The demand for our specialists: mathematicians, programmers, biotechnologists and biotechnologists, doctors – does not fall. It is a pity that in our country science is in little demand by business.
Consolidation of scientific, technological and financial potential is necessary for the development of medical science and healthcare in Russia. A huge number of research centers – 212 – are located in the system of the Ministry of Health, RAMS, FMBA, etc. Duplication of scientific projects is inevitable. Huge amounts of money are spent on projects declared as projects "aimed at radically improving the health of the nation", and are carried out in various ministries, departments, agencies, corporations. Performed without independent expert evaluation. Often the results of such projects are unknown. Until there is a professional independent expertise in Russian science, there will be no genuine grant system. This is all the more important now, when the country's leadership supports the idea of long-term solid grants for 3-5 years, so that young talented scientists are given the opportunity to realize their potential at home, and not abroad.
Can you identify the areas of medical science where we are on top?Ivan Dedov: Virologists have a very strong position.
Traditionally, very strong cardiology, neurosurgery, cardiac surgery, pediatrics, hematology, immunology, endocrinology.
And where are we lagging behind the most?Ivan Dedov: In pulmonary pathology, in fundamental oncology.
It is necessary to invest attention and large financial resources in these complex and sometimes dramatic by nature areas of medicine.
See the riskWill we ever learn to predict the development of a cancerous tumor?
Or will we continue to identify it at late stages, when help is problematic?Ivan Dedov: Hope for genomic, proteomic technologies, i.e. personalized, predictive medicine.
At the presidium of the Academy, we decided to create several personalized medicine clinics. Here, for example, orphan (rare) diseases, the most severe, not curable. They occur when a mutation of one gene occurs and hemophilia, stunting, cystic fibrosis and other diseases can develop. There are many of them, these orphan diseases.
Genomic technologies make it possible to quickly and affordably determine the complete genome in a family with orphan diseases, and determine the risks of their development. Further, with the help of IVF and preimplantation technologies, we can give this family the happiness of a healthy child. And these are proven technologies. For example, in a family with hemophilia, where a boy with this disease was already born, in one of the four newly grown embryos we found DNA that did not include the pathological gene. And a healthy girl was born in the family.
High-tech centers are being created in the regions, and there are not enough specialists to work in them. Do we invest much more in technology than in brains?Ivan Dedov: Yes, this is a big problem in the regions.
I remember how they were looking for a chief doctor for a new center in Penza. And now the center is magnificent. The solution of the personnel problem on the ground largely depends on the position and understanding of the governor. Where the leaders of the region actually, and not in words, care about the health of their population, there are different results. Examples of this are Penza, Krasnodar, Voronezh, Lipetsk, Krasnoyarsk, Tyumen, Novosibirsk, etc.
At the last session of the Russian Academy of Medical Sciences, it was not the first time that the middle age of academy members was discussed. What is he like today?Ivan Dedov: On average, 73 years old.
We have 239 full members of the academy. There are many of them who are over 80 years old, and they are all in good shape. There are 228 corresponding members, they are on average five years younger. It was necessary to introduce an age limit for the first time at the academy elections. The Presidium of the Russian Academy of Medical Sciences appealed to the country's leadership with a proposal to organize new regional branches of the Academy. After all, 85 percent of medical science is still represented by representatives of Moscow, St. Petersburg and Novosibirsk. All of them are worthy members of the Russian Academy of Sciences, but it is difficult for talented scientists from the regions of Russia to compete with the "proteges" of well-known academic schools, although the election procedure is very democratic and objective. But this is how it happened for regional scientists. The organization of regional branches of the Russian Academy of Medical Sciences is very prestigious. The Academy is ready to support the initiative of the governors to create 4 regional branches: Far Eastern, Ural, Southern and Volga. Regional offices are real "growth zones" of young talented scientists.
District therapist Elena Bloshenko from the city of Cola complains: "There has been a devaluation of medical education. Patients are afraid to go to young doctors. Many non-core universities have opened medical faculties, and it is unknown who they are training. Are you setting a task to deal with this wild phenomenon?"Ivan Dedov: The colleague is right.
The problem of training medical personnel in universities is very acute. We are discussing this problem with the Ministry of Health of the Russian Federation, with the rector's corps of medical universities. There is a common opinion: an objective analysis of the training of physicians in newly organized faculties is needed. It is necessary for the Ministry of Health of Russia, together with the heads of the regions, to objectively assess the quality of medical training. To train doctors without having a material and technical base and a teaching staff is not the training of political strategists in attics and basements. The Ministry of Education and Science of Russia needs to coordinate with the Ministry of Health the procedure for issuing permits for the opening of medical faculties.
"RG" prescribes iodized salt to readersThe nurse Anton Vronsky from Krasnodar asks:
"Salt iodization is carried out in European countries, as it was once in our country. Is there now a problem of endemic goiter or other diseases associated with iodine deficiency? Why have we forgotten about this simple means of prevention?"Ivan Dedov: As the chief endocrinologist of Russia, I am ashamed to admit that we cannot solve the obvious issue for 10-15 years.
In the world, only two countries – Ukraine and Russia - do not have a law on the mandatory use of iodized salt in the food industry. And this is population prevention, an excellent basic protection of the body from iodine deficiency. A person needs to consume at least 150-200 micrograms of iodine per day. Pregnant women – up to 300. From the fact that there is no iodized salt, cretinism, hyperplasia of the thyroid gland, the risks of developing a malignant tumor are often encountered. When a pregnant woman does not receive such salt, miscarriages, defects of the cardiovascular system, the birth of a stillborn child, etc. are possible.
We have been saying this for more than ten years in a row. We met specifically on this occasion with deputies of the State Duma of various convocations, with the invitation of international experts from the UN, WHO, UNICEF. They nod: yes! But in the future, the course of "thoughts is lost."
All over the world, the use of iodized salt in the food industry is recommended for the population prevention of iodine deficiency conditions – this is a legally fixed prevention. Group and individual prevention has been developed for pregnant women, children and adolescents. Iodine is used for the biosynthesis of thyroid hormones, which determine human intelligence, bioenergetics, differentiation, i.e. specialization of all tissues. These are the key hormones in the development of a child and the vital activity of any living organism, including humans. No matter how brilliant the child's parents, his grandparents, thyroid hormone deficiency leads to the birth of a cretin!
What prevents it? It's not hard to do!Ivan Dedov: Elementary.
In the Soviet Union, there was an order of the Council of Ministers on this matter. And that's enough. So Tatarstan introduced the mandatory use of iodized salt and saved the population from many terrible troubles.
Is it really impossible to do this on a national scale?Ivan Dedov: We have prepared a corresponding bill, but it has been discussed for ten years.
So, maybe after our publication it will finally be accepted?Ivan Dedov: We hope very much.
There is no other way! After all, we are talking about the health of the whole nation and each individual!
Returning to the main topic of our conversation – about the prospect of science in Russia, including medical... I am an optimist! I am convinced that it just takes time to return to the leading group of countries. There is no alternative! Science is the business card of the state, the nation, the main resource and historical perspective!
Portal "Eternal youth" http://vechnayamolodost.ru01.02.2013