Judy Twigg is a professor of political science at VCU. Her research focuses on health sector reform in post-socialist countries, and on US-Russia collaboration in medicine and public health. In addition to her work at VCU, she is currently serving as a senior associate (nonresident) with the Russia and Eurasia Program at the Center for Strategic and International Studies, where she directs the Eurasia Health Project. Dr. Twigg is also a consultant to the World Bank and the U.S. federal government on issues relating to health, demographic change, and health systems reform.
How did you originally become interested in studying Russia and Eurasia?
I started working on Russia back when it was part of the Soviet Union, in the 1980s. The timing was pretty much perfect for someone who’s interested in that part of the world. I first traveled there in the middle of 1985, just as Gorbachev came into power. I got to see that whole transition as a young person, on the ground, watching people’s expectations and attitudes change about what they expected the role of government to be. Originally, my work focused on the military and security industries. In the mid-1990s, though, after the Soviet Union collapsed, suddenly not many people were that interested in the Soviet defense industry anymore. But I was also interested in bigger questions of political economy: how is it, within the framework of this socialist economy, that a government provides goods and services for its people? I got involved in the health sector because, especially in the socialist context, defense economics and health economics share a lot of similarities.
It’s interesting to me that you switched from studying the tools of war and destruction to studying the industry of healthcare and healing. How did that shift in focus come about?
The thing that grabbed my attention was the serious health and demographic crisis that overtook Russia in the early 1990s, and so I started to write about the political economy of the health system that was governing how people accessed care. Russia was building a system of universal health insurance at the same time that its healthcare system was completely falling to pieces, and so I was interested in those dynamics at a systemic level and also in how individual citizens and families were being affected.
Why has your research shifted from Russia to Ukraine? What’s significant or different about that country and its health care system?
Ukraine has experienced a health crisis very much parallel to Russia’s. Ukraine has faced many of the same challenges over the last two decades with alcohol abuse, HIV/AIDS and tuberculosis, overall premature mortality, reduced life expectancy, extremely low birth rates, and a precipitous population drop. But then obviously Ukraine came to everybody’s attention in a big way at the time of its Revolution of Dignity in 2014. As the United States’ relationship with Russia deteriorated a few years ago, Ukraine came on the front lines of that conflict as a country that could fall either way, developing as a more European-looking country or remaining in the Russian orbit.
Over the last year or so, Ukraine has finally taken serious steps toward reforming its healthcare system. All of the other former Soviet countries walked down this path quite a while ago, and so Ukraine is the last one to try to reform a Soviet-era, archaic, hugely corrupt healthcare system with all kinds of inefficiencies and inadequate funding. People weren’t even getting basic vaccines, and they had to pay out of pocket or illegally under the table for access to care.
You called the Ukranian healthcare system corrupt. What do you mean by that, and how does it impact their citizens?
We shouldn’t have a conversation about Ukraine without addressing corruption. That issue emerged in a big way two summers ago with an outbreak of polio in the country. There are only a few countries in the world that still have endemic polio, and the world is so close to eradicating it completely, and then you get two cases of it in a rich country like Ukraine? What on earth was going on? It turns out that vaccination rates had declined dramatically due to vaccine shortages. These corrupt businessmen were trying to control the import of vaccines into the country so that they could make money skimming off the top of government contracts. It’s truly a nightmare, where you have a handful of corrupt politicians and businessmen getting fabulously wealthy, and the flip side of that, the consequence, is that you don’t have enough vaccine to go around and kids get polio. How appalling is that? The good news is that the polio outbreak catalyzed a lot of attention to the problem and led to some meaningful reforms currently underway.
What are some examples of problems with the Ukrainian healthcare system that you think still need to be reformed?
In a system where you don’t provide enough money for healthcare to begin with, you can’t afford to waste the few resources you have. But the rules of their game create all kinds of incentives for inefficiency. Primary care physicians are paid according to how many patients walk through the door – regardless of whether those patients are effectively treated — and so they tend just to sign referrals to pass people on to more expensive specialists. There’s no incentive to treat people well at that first point of contact, and definitely no systemic attention to health outcomes. And then the specialists, in the hospitals, are paid according to how many people are kept in those hospital beds overnight, so there’s an incentive to keep people as inpatients for as long as they can. That leads to incredibly long lengths of hospital stay, and excessive hospitalizations for things that we would treat on an outpatient basis here in the U.S. They need to find a way to flip that – it’s not good for the patients, and it’s not good for health budgets. They need to find a way to save money by doing more preventive care, screening patients appropriately so that you catch cancers and heart disease and high blood pressure early, not only because obviously it’s better for the patient that way, but also because it’s much less expensive to prevent a disease than it is to treat it.
Why should Americans be concerned about health crises on the other side of the world?
The most basic thing, obviously, is needless suffering and lost lives. The worst thing in the world is kids dying from diseases that can be prevented for pennies. But it’s also lost productivity, lost contributions, all of this creativity and innovative potential that’s unrealized around the world because people are poor, because they’re sick or dying. We’ve made huge progress in global health over the last couple of decades, but our current “America First” political climate is threatening those gains. We need to keep realizing that everyone benefits when we invest in human well-being everywhere.
Judyth Twigg will be presenting the College of Humanities and Sciences Elske v.P. Smith Lecture on the topic of “Demography as Destiny: Politics and Human Capital in Putin’s Russia” on Thursday, March 29th at 2:00 PM in the University Student Commons, Richmond Salons I & II. The discussion will place the Dr. Twigg’s research on health and population trends in Russia within the context of likely political and foreign policy developments following Russia’s March 18, 2018 presidential elections.
Written by Megan Schiffres