The ventilator problem

Russia has way more machines that can keep coronavirus patients breathing than Italy did — but that doesn’t mean the pandemic will be any easier.

Whether or not Russia’s healthcare system will be able to withstand the coronavirus pandemic is an open question. One way to move toward an answer is to compare conditions in Russia to those in Italy. Local doctors working in the hard-hit Lombardy region have repeatedly pointed to a shortage of ventilators, devices that can be necessary to keep patients breathing in severe cases. Data collected by Meduza indicates that Russia’s supply of ventilators is quite extensive: Even the number available per capita in some geographically peripheral regions, not to mention Moscow, significantly exceeds ventilator supplies in Western countries. That said, ventilators alone are not enough to overcome the pandemic. In a number of other areas, comparing Russian and Italian health infrastructure doesn’t bode well at all for Russia.

Italy is among the countries hardest hit by the novel coronavirus. According to the World Health Organization (WHO), as of March 19, there were almost 36,000 confirmed cases of COVID-19 in Italy, and 2,978 of those individuals had died, meaning that the virus is spreading faster in Italy than in any other country. Every day, hundreds of new cases and deaths are recorded despite a March 10 nationwide quarantine order.

Northern Italy is engaged in an especially vicious struggle against the virus. The country’s COVID-19 outbreak began in Lombardy, which remains the epicenter of Italy’s pandemic. Even in the wealthiest areas of one of the most highly developed countries in the European Union, healthcare systems are buckling under the weight of a crisis for which they were catastrophically unprepared. In one viral Facebook post, surgeon Daniele Macchini of Bergamo compared the working conditions in his hospital to the effects of a war or the aftermath of a tsunami. The number of patients infected is rising geometrically, more and more doctors and nurses are contracting the virus themselves, and every ventilator is worth its weight in gold.

Why are artificial breathing aids necessary, and how extreme do they get?

Between 20 and 30 percent of COVID-19 patients who are hospitalized require intensive care. Among those patients, 47 to 71 percent require artificial lung ventilation in order for their bodies to absorb enough oxygen. That number is equivalent to between two and four percent of all infected patients.

In especially severe cases, Extracorporeal Membrane Oxygenation (ECMO) may be used. This complex procedure involves redirecting the patient’s blood through a device outside the body that adds oxygen and removes carbon dioxide, fulfilling the key functions of breathing without relying on the patient’s lungs. ECMO may be called for in 0.1 – 0.3 percent of COVID-19 cases, but its effectiveness in the pandemic is still in doubt. The procedure carries an increased risk of blood clots and infections, and ventilators may be even more effective if used with additional steps. For example, patients who do not regain enough oxygen may be turned onto their stomachs during ventilation to increase the space available to their lungs, and doctors can artificially shut down muscle activity to decrease the patient’s oxygen needs and their body’s resistance to the ventilation process.

Given the risks involved, ECMO devices are rarely used, including in Russia. For example, the Yudin City Clinical Hospital, which has the largest number of intensive care unit (ICU) beds of any Moscow institution — 144 of them, to be exact — has used ECMO only five times within the last year. The necessary equipment is expensive, and using it requires highly specific skills. The WHO has recommended using ECMO in COVID-19 cases only if an experienced specialist is available.

How many ventilators and ECMO machines are there in Russia?

Meduza collected data from open sources to find out how many ventilators and ECMO devices government hospitals have on hand in most of Russia’s regions as well as Crimea. We also compared those numbers to the population of each region. The results are in the table below; regions are ranked by number of ventilators per capita. While we have included the relevant statistics for Italy, the U.S., the U.K., and Ukraine as benchmarks, there may be differences in exactly how those data were collected from country to country. For example, while the figures for Russia only account for public institutions, the U.K. data cover private and military ones as well.

REGION	VENTILATORS PER 100,000 RESIDENTS	NUMBER OF VENTILATORS	ECMO MACHINES PER 100,000 RESIDENTS	NUMBER OF ECMO MACHINES
Khanty-Mansi Autonomous Okrug (Yugra)	56.8	951	0.18	3
Samara region	42.6	1,353	0.03	1
Amur region	42.5	336	no data
Moscow (city)	40	5,077	0.23	29
Kirov region	39.6	500	0.08	1
Arkhangelsk region	38.4	419	0.18	2
Sakha Republic (Yakutia)	37.2	361	no data
Sakhalin region	37.1	181	0	0
Tomsk region	37.1	400	0.37	4
St. Petersburg (city)	35.2	1,898	0.46	25
Lipetsk region	35.1	400	no data
Sverdlovsk region	35	1,510	0.05	2
Chuvash Republic (Chuvashia)	34.7	422	0.08	1
Altai Krai	34.6	802	0.04	1
Republic of Crimea (status disputed)	34.3	656	no data
Republic of Karelia	32.5	200	0.16	1
Yaroslavl region	31.5	395	no data
Vladimir region	31.4	426	0.07	1
Tambov region	31.2	314	no data
Penza region	30.7	400	0.08	1
Murmansk region	30.5	226	0.27	2
Pskov region	30.3	190	0.16	1
Republic of Tatarstan	28.2	1,100	no data
Orenburg region	27.7	542	0.05	1
Russia	27.3	40,000	0.1	124
Kemerovo region	27.3	726	0.08	2
Ryazan region	27.1	300	no data
Irkutsk region	26.5	633	no data
Republic of Bashkortostan (Bashkiria)	25.5	1,031	no data
Republic of Buryatia	24.9	246	0.1	1
Krasnoyarsk Krai	24.6	705	0.03	1
Chelyabinsk region	24.5	849	0.06	2
Astrakhan region	23.9	240	0.3	3
Zabaikalsky Krai	22.8	242	no data
Saratov region	22.1	536	no data
Vologda region	22.1	257	no data
Kursk region	21.9	242	0.09	1
Orlov region	21.8	160	no data
Mari El Republic	20.9	124	0	0
Novosibirsk region	20.4	570	0.18	5
Tula region	20.3	297	no data
Udmurt Republic (Udmurtia)	20.2	303	no data
Perm Krai	20	520	0.04	1
Kostroma region	19.1	121	no data
United States	18.8	68,000	no data
Kaliningrad region	18.8	190	0.2	2
Omsk region	18.7	361	no data
Ivanovo region	17.9	178	no data
Krasnodar Krai	17.6	1,000	0.07	4
Belgorod region	16.8	260	no data
Rostov region	15.3	643	0.05	2
Voronezh region	15	348	no data
Leningrad region	14.3	268	no data
United Kingdom	12.9	8,175	no data
Sevastopol (city; status disputed)	12.9	58	0.22	1
Tver region	9.4	118	0	0
Ukraine	8.6	3,600	0.08	15
Italy	8.3	5,000	no data
Kaluga region	4.8	48	0.1	1
Bryansk region	no data		0.08	1
Moscow region	no data		0.01	1
Smolensk region	no data		0.11	1
Nizhny Novgorod region	no data		0.03	1
Republic of Mordovia	no data		0.13	1
Komi Republic	no data		0.12	1
Khabarovsk Krai	no data		0.08	1

These data paint a relatively optimistic picture for Russia: The country significantly surpasses Western countries in terms of ventilator availability. For example, on average, there are 27.3 ventilators in Russia for every 100,000 people, while in the U.S., according to official data from Johns Hopkins University, ICUs have a total of 62,000 ventilators. That makes for only 18.8 ventilators per 100,000 people. In Russian state hospitals, there are 40,000 ventilators, and hospitals are also purchasing new ones as the coronavirus pandemic escalates.

Meanwhile, according to Italy’s national emergencies ministry (known as the Protezione Civile), there are about 5,000 ventilators for the entire country. That makes for 8.3 ventilators per 100,000 residents — less than half of the same figure for Russia’s Ivanovo region, which has about the same population density as Kentucky. Italy has made an urgent attempt to buy enough ventilators to double the national supply, but medical equipment manufacturers worldwide are already struggling to keep up with the flood of orders triggered by the pandemic, according to Reuters.

In the United Kingdom, where doctors from the National Health Service (NHS) are also warning that the country is catastrophically unprepared for the coronavirus pandemic, Parliament’s Health and Social Care Committee has counted a total of 8,175 ventilators throughout the country, including those intended for children and those located in private clinics and military storage. That’s only 12.9 machines for every 100,000 people, which is also less than almost any region in Russia.

“Moscow is completely equipped with the necessary equipment. There are approximately 5,000 ventilation apparatuses accounted for in the city at this time. 265 additional machines are on reserve for potential coronavirus patients,” Moscow’s Healthcare Department told Meduza. It is nonetheless worth noting that not all of those ventilators are available for immediate use at any given time: Other patients who can’t breathe on their own may be connected to them already.

On top of its 40,000 state-owned ventilators, Russia can also draw on the resources of its private clinics, which could be mobilized to respond to a sudden spike in cases. There is also a private rental market for ventilators in Russia. It is currently used primarily by relatives of spinal muscular atrophy (SMA) patients for in-home care, but some of its devices could be redirected to hospitals. This does not mean that Russians will be able to count on using their very own ventilator by any means. While “ventilators” are sold freely in the country, and they can cost anywhere from 100,000 rubles ($1,252) for mobile versions intended to work only part of the day up to several million rubles for full-fledged machines, only specially trained professionals can use these devices. Without a specialist nearby, rental ventilators will be useless.

Currently, at least according to official case counts, Russia is “behind” many other countries in the typical timeline of the COVID-19 pandemic. As of March 20, 2020, the country’s national consumer welfare agency Rospotrebnadzor had reported 253 confirmed infections. The first confirmed death of a coronavirus patient in Russia occurred on March 19 in Moscow’s Infectious Disease Hospital No. 2. The patient was 79 years old and chronically ill; her cause of death was recorded as “a bursting blood clot, not pneumonia,” said Moscow’s chief pathologist, Oleg Zairatyants.

Most Russians who have been infected with the novel coronavirus are currently being treated at Moscow’s City Clinical Hospital No. 40. On the morning of March 20, the hospital’s lead doctor, Denis Protsenko, wrote on Facebook that none of those COVID-19 patients has yet required artificial lung ventilation.

So it’s not that bad? Russians have reliable protection from the pandemic?

An abundance of ventilators actually may not be a decisive advantage in this crisis. Vladimir Budyansky, an anesthesiologist and critical care physician who moderates the 14,400-member Facebook group “Medical Emergencies,” told Meduza that there are various kinds of ventilators. Some are advanced devices produced in the West that can provide 24-hour ventilation for patients experiencing health crises of various levels. Others are “old-fashioned,” in his words, and can’t be used for contemporary lung ventilation procedures at all.

“On top of that, artificial lung ventilation is quite a fine-tuned, complicated process,” Budyansky said. “It requires a lot of other things [aside from the ventilator itself]. There are anesthetic devices that still allow for ventilation, but those are supposed to be for operations, and they don’t have a range of settings. Using a ventilator with a patient in the ICU or the emergency room is something of a different, more complex task that can take five to 10 days, sometimes months — not several hours, which is what it can take on the operating table,” he explained. “There are mobile ‘ventilators’ that are housed in ambulances — those are meant to ventilate patients for anywhere from one to 12 hours. In short, this isn’t a single kind of device; it’s a spectrum of various different devices. It’s like with cars: Some are for driving off-road, and some are for driving in cities.”

Aside from the question of whether the ventilators available actually fit patients’ needs, there’s the fact that if a patient has to be on a ventilator, they’re already in critical condition. That means they need a whole set of critical care procedures, specialized equipment, and medical professionals who can use that equipment and put those measures in place. In Budyansky’s opinion, this is where Russian medicine loses out to Italy.

“The Italian healthcare system is considered one of the best in the world in all the rankings that are out there. It’s always been in the top five. I’ve seen their level of training myself. All else held equal, we’ll have a relatively spotty situation with treating critically ill patients in some regions of the country,” the doctor explained. “Their problem wasn’t so much with the ventilators as it was with beds, with the fact that they had to turn operating rooms into intensive care units on the fly.”

“But let’s say we take your average ICU: 20 beds, and each one has one person on artificial ventilation. We have the same equipment they do, there are doctors, there are nurses. I think that in a lot of situations, we’ll have it worse for a variety of reasons. For example, when they say they don’t have enough nurses, for them, that means there used to be one nurse per patient, and now, there’s one for every two. Well, we’ve got one nurse serving three or four or five already. So what’s twice as bad as usual for them is two times better than what we have normally,” Budyansky concluded.

Story by Ivan Golunov, Alexey Kovalev, and Darya Sarkisyan

English version by Hilah Kohen