Business in Ukraine

By David L. Nordstrom

When I learned that the second largest nation of Europe had graduated the first class from its only school of public health, I wanted to see this school myself. Trained and experienced in medicine and public health, I wanted to observe the development of this new actor first-hand. Coincidentally the school had an opening for a visiting Fulbright Scholar from August through December 2006.In a bold new step, the National University of Kyiv Mohyla Academy School of Public Health enrolled its first students in 2004. The two-year master degree program is a “work in progress” that prepares students for professional positions in teaching, research, and consulting. The program is an official partner of the School of Public Health at University of Maastricht, Netherlands.

It is significant that this new school is located at a general university rather than at one of Ukraine’s 15 medical universities. This decision has certain advantages. The course content is not focused on disease diagnosis and treatment but also emphasizes the study of disease causation and prevention. Both health professionals and others are included in the student body.

This new graduate study program functions despite uncertainty regarding the career prospects for graduates. Master degrees in general are new in the country. As a “post-communist” or “transition” nation, Ukraine has few positions for citizens with such training. Neither the current Ministry of Public Health staff nor Sanitary and Epidemiologic Service staff has such education. The managers of hospitals, clinics, and research institutes in Ukraine are usually physicians without training in either public health or management.

The new school’s location is important for another reason. As noted at the recent annual conference of Ukrainian Association of Fulbright Alumni, Kyiv Mohyla Academy is one of the very few institutions in Ukraine where student admission and promotion decisions are based on the applicant’s ability rather than on bribery, plagiarism, or cheating.

What is Public Health?

“Public health” has different meanings in Ukraine and in the United States. In Ukraine, the phrase seems to mean the government hospitals and clinics where doctors diagnose and treat illnesses in individual patients. In the U.S., public health means collective action to abate hazards and prevent disease in whole groups of people. Indeed, Soviet era health spending favored hospital and clinic construction, operation, and services. The budget for surveillance and control of disease and hazards to health was limited.

The newly selected head of the WHO Country Office in Ukraine recently told an audience at Kyiv Mohyla that the Ministry of Public Health priorities for its current work with WHO are HIV/AIDS, Tuberculosis, and Mental Health. These choices were apparently based on the size and severity of the burden in Ukraine, the risk of diseases spreading to more people, and the availability of international assistance.

In western countries, much of the improvement in life expectancy occurred in the 19th century as a result of rising standards of living, including better housing and sanitation, etc. For many people in Ukraine, this increase in living standards has not yet arrived. According to a 2000 nationwide survey by Kyiv International Institute of Sociology, only 8 percent of rural dwellings had central heating, 10 percent had an indoor toilet, and 30 percent had a bath or shower. One-quarter of the total population of this country lives below the official poverty line.

What are some examples of public health achievements in contemporary Ukraine? Distribution of free clean needles to drug users to limit spread of HIV infection, ban on alcohol in workplaces, ban on alcohol in blood of motor vehicle drivers, minimum age of 18 to buy cigarettes, underground walkways for pedestrians, ratification of the international treaty for tobacco control, and mass transit.

Is the Soviet legacy relevant?

“Whereof what’s past is prologue, what to come
In yours and my discharge.”

WILLIAM SHAKESPEARE,
The Tempest, act II, scene i

Public health work is to some degree culture-bound in all societies. Kyiv Mohyla faculty held a panel discussion on the USSR legacy and how it may still influence medicine and public health in this old-new country. When a student asked what to read to prepare for this panel discussion, she was told to talk with her parents about the past. Her response was that the past was too painful to discuss.

A young nation-state, Ukraine still shows signs of its Soviet legacy. Marxist-Leninists viewed many health threats as transient in the transition to communism and as problems that would be resolved spontaneously without public health action. The government that came to power in the October 1917 revolution was wary of the professional autonomy of physicians. It disbanded private medical associations and kept the salaries and status of most doctors low.

Fifteen years after attaining statehood, Ukraine still lacks a national, professional organization of physicians. Perhaps as important to the advancement of medicine and public health, Ukraine lacks trusted journals, such as The Lancet in England or JAMA in the United States, which can serve as channels of communication among physicians, scientists, public health specialists, policymakers, and patients.

In the Soviet era, epidemiology was concerned almost exclusively with detection and control of infectious diseases - even after noninfectious diseases such as heart disease became the leading causes of death. Medical universities lacked full-fledged departments of epidemiology or biostatistics. Government outlawed the teaching or research of genetics, a decision with bad consequences for both science and health.

Another legacy of the Soviet period is a tendency for individuals to rely on the state to care for them rather than to take responsibility for their own health. Deeply embedded cultural practices from the Russian Empire such as drinking, smoking, poor diet, and lack of physical activity worsened under communism. Among the first 14 countries from four continents to complete a World Health Organization (WHO)-coordinated national mental health survey, Ukraine has the highest rates of alcohol abuse (20 percent) among men and of major depression (20 percent) among women. Rates of alcohol and drug disorders are six times higher in Ukraine than in Germany, and rates of mood disorders are two and one-half times higher.

While statistical and epidemiologic data were state secrets in the USSR, a series of health interview and examination surveys in Ukraine have provided important information on people’s health status and their health knowledge, attitudes, and practices. Students and faculty of Kyiv Mohyla Academy have compiled an inventory and collection of 20 such surveys conducted during the past decade.

What can Kyiv Mohyla students do in public health?

Public health students also must choose their priorities for study and work. A thesis is required for the master degree, and students are exploring a wide variety of subjects in medicine and public health. Examples are the reasons for the declining rate of breastfeeding; quality of nutrition in meals in kindergarten; smoking cessation by pregnant women; risky behaviors among university students; quality of screening, diagnosis and treatment for tuberculosis in prisons; the supply and efficiency of blood transfusion services; and the effectiveness of continuing education for hospital and clinic administrators.

Kyiv Mohyla students are learning to perform two essential tasks of public health specialists: to estimate risk and to communicate risk. Risk estimation is taught in epidemiology, which is the scientific study of the frequency and determinants of disease in human populations.

To illustrate risk estimation, the example of suicide can be used. Suicide is the most frequent type of injury death in Ukraine, and the nation’s suicide rate is one of the world’s highest. The Ukrainian risk of suicide is six times higher in men than women. In men, the annual risk of suicide is 45 per 100,000 population, while the annual risk of motor vehicle injury death is 25 per 100,000. For comparison, the annual risk for Ukrainian men of HIV/AIDS death is 5 per 100,000.

Many of the students at Kyiv Mohyla hope to become managers in health care facilities or in government planning or administrative agencies. In this role, they will need to communicate risk to their superiors, staff, and patients.
For example, how will they communicate the risk of hospital-acquired infections? They also will function in a complicated environment of finance and services during periods of changing roles of national, regional, and local levels.

At the school of public health, students are learning modern principles and practices of health promotion from dedicated and experienced instructors. Posting messages on clinic walls is no longer regarded as an effective method of changing patient behaviors. This approach does not even work with highly educated and motivated western doctors. Observers at a major American hospital recently reported that doctors there rarely wash their hands even though soap and water are readily available.

Kyiv Mohlya students learn that medical care, which can be useful after illness appears, is no guarantee of population health. Although individuals choose their behaviors - both safe and risky - they choose them within a specific social and environmental context. The two in five Ukrainian adults who smoke do so in a country whose tax and other policies allow the widespread availability of cheap cigarettes but do not cover drug treatment for smoking cessation.

Opinions differ about the appropriate role of the state in influencing health behavior and status. Ukrainian history is filled with examples of malign behavior by state actors: World Wars I and II, mass famine and starvation, the Nazi occupation, and the Chernobyl nuclear power plant explosion. Consequently the level of trust between citizen and state is highly strained. Given this background, it is not surprising that Kyiv Mohyla students express doubt the prospects for passage of effective public health legislation and implementation of existing laws.

Looking forward

Countries with the best health indicators are the ones that modify the conditions that lead to health hazards and resources in their populations. After seeing the faculty, staff, and students of Ukraine’s school of public health in action, I believe that this proud and independent nation is poised to make substantial progress in the years ahead.

David L. Nordstrom, PhD, MPH, was a Fulbright Scholar at Kyiv Mohyla Academy School of Public Health from August through December 2006. The views and opinions expressed above are exclusively his own and are do not necessarily reflect those of the Fulbright Scholar Program, the U.S. Department of State, or the National University of Kyiv Mohyla Academy.

Tags: Medicine in Ukraine by Vitaliy Tretyakov
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By Glen Willard
Many people still think of Ukraine as the breadbasket of Europe or of the former USSR. And indeed, with a third of the world’s richest black soil (locally called chernozem), Ukraine was at the turn of the 20th century a world leader in agricultural production.

True chernozem, according to the Columbia Encyclopedia, is black, but there are various gradations into gray and chestnut-brown soils. It forms in areas that have cold winters, hot summers and rapid evaporation of precipitation. Generally only tall grass is found native on chernozem. It has large quantities of nutrients, excellent structure, and good water-holding capacity, making it very suitable for agriculture. It is most widely distributed in Ukraine, where it forms a large part of the good agricultural soil.

In the late 1920s, Stalin and the collectivization of Soviet agriculture eliminated many of the peasant agrarian reforms that the Czarist government had begun as early as 1906 under P.A. Stolypin, who served as Interior minister and prime minister between 1906 and his death in 1911. Even after Stolypin’s assassination in Kyiv, reforms during his tenure produced great agricultural harvests and the country was a world leader in grain production into the early 1920s.

While Ukraine contributed greatly to agricultural production to the whole of the USSR, its production potential was severely limited by Soviet agricultural methods and practices. Further, Ukraine’s agricultural production, like that of all other production, particularly industrial, fell precipitously in the years following the breakup of the Soviet empire in 1989. It was only at the beginning of the late 1990s that Ukrainian agriculture began to recover and make progress.

Background and purpose

For the past several months, and of late on a somewhat ad hoc basis, I’ve been attempting to acquire some knowledge and understanding of the present status of the agricultural industry in Ukraine. That knowledge, I believed, would then allow me to form some opinions as to the future potential and importance of the industry to the overall economy of Ukraine. Admittedly, in advance, I was hoping to come to a conclusion that, at least at some point in the future, Ukraine would again be the “breadbasket of Europe” (or of the FSU, Asia, Eurasia, or wherever). In short, I began predisposed to look for and find a happy ending to a story or stories on agriculture in Ukraine. My research continues. I plan more articles on the subject as I discover more.

I am presently in the middle of my studies. Beginning with little knowledge or background in farming in Ukraine or of the agricultural industry in general, I have not yet reached the point where I can draw conclusions. While I’ve interviewed many in the industry, including professionals, academics and some in government, I must continue my education. As yet, my shortcomings I fear lie in the area of how it all works together. This is partly caused by not having spent enough time analyzing statistical information, laws and regulations, governmental subsidies that may exist and agricultural loan programs.

I have, however, seen some bright spots, and I’ve met a lot of interesting, talented and dedicated people. As I progress, I’ll try to bring some of their stories and experiences together.

No-Till Agriculture Conference

I saw a truly remarkable event occur between November 18 and 23 at the Agro-Soyuz Corporation’s agricultural facility headquarters in Dnipropetrovsk region. A conference, “NT-CA, Sustainable and Effective Agriculture” was held at the site. This was an international conference to educate Ukrainians and others concerning the benefits of a no-till systems approach to profitable and environmentally sound farming.

Before discussing no-till farming, I’ll describe what I felt was most remarkable about the event. First, it was a gathering of approximately 600 participants, each of whom paid $300 to attend, plus the cost of their food and lodging in nearby Dnipropetrovsk. Most of the registrants were from Ukraine and Russia, which had 280 and 200 participants respectively. Kazakhstan was well represented with 70 participants and the others were from a number of other countries including Belarus and Armenia.

The quality of the international experts, with their years of knowledge, expertise and practical experience was also impressive. Speakers came from the United States, Canada, Australia, France, Germany, Brazil, Chile and Paraguay. Some of the experts were academics, some came from government and research institutes, and others were farmers with advanced degrees. All had extensive practical farming experience and most provided lectures on very specialized subjects.

The facilities provided by Agro-Soyuz were superb from any standpoint one could imagine. Located on a farm, the infrastructure was truly impressive. The 9,000-hectare farm had fields dedicated to various crops, a large grain-storage facility, a swine operation, a dairy herd and even an experimental ostrich farm. The campus also boasts a 124-hectare Concept Farm, where a nine-crop rotation system is being studied over a 10-year period. Agro-Soyuz has also operated a Farm Resources Center for several years, where farming applications are both studied and taught. The teaching is mostly through inexpensive or free seminars for Ukrainians as well as for those who come from throughout the world.

For the international conference, a new office building and teaching facility was built. It contains classrooms, an auditorium, telecommunications and Internet connections, and audiovisual systems. In addition, the center has a complete press facility with all that visiting journalists might require.

No-Till Farming

No-till farming has been around for several decades. Its use has rapidly spread for the last decade. No-till brings biological and environmental considerations to the farming process, as it helps prevent soil erosion, helps retain soil fertility and moisture. It also requires fewer and more environmentally safe fertilizers and chemicals, resulting in greater crop yields. It is profitable partly because it saves labor, because there is little need to repeat plowing and furrowing. Other benefits include a “greenhouse effect” benefit, in that less carbon dioxide is released.

Though no-till is used throughout the world, it has not gained much popularity in Europe and Asia. My understanding is that it might wreak havoc with governmental processes in Western Europe, where farming is heavily subsidized and EU-regulated. In many other countries however, no-till has taken root and is expanding. In the United States along, no-till farmining is practiced on 22.4 million hectares, or more than 19 percent of all agricultural land. More than 45 percent of Brazil’s agricultural land uses no-till methods, and in Paraguay, no-till usage has reached 60 percent of that country’s farmland.

In Ukraine, Agro-Soyuz and other companies are the European pioneers in the application of no-till cultivation. The methods may help Ukraine regain its status as a “breadbasket” nation.

Tags: Agrarian Sector by Vitaliy Tretyakov
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