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Inspiring Social Transformation: From Soviet Decay to a National Health Service for Ukraine

1 April 2019

Public Lecture of A/Minister of Health Dr. Ulana Suprun at The Seventeenth Annual Stasiuk Lecture, Cambridge, 1.03.2019 (As Delivered)

Good Afternoon!

Thank you for the invitation to speak about the social transformation underway today in Ukraine. I’d especially like to thank Dr. Olenka Pevny and the Cambridge Ukrainian Studies program for inviting me to give the Seventeenth Annual Stasiuk Lecture in Contemporary Studies .

On February 20, Ukraine commemorated the 5th anniversary of the Revolution of Dignity; the day that will be marked in history as “Bloody Thursday” when over 100 protesters were shot by members of Ukraine’s interior ministry security service. The people that died that day have become known as “the Heavenly Hundred” although, that is a mis-translation. The correct translation is “Heaven’s Company” and the difference is significant. Sociologists who have studied the Maidan Revolution have identified three phases: Мітінґ or Protest, Табір or Camp, and Sich, in honor of the military administrative center of the Zaporozhian Cossacks from the 16th to the 18th centuries.  And indeed, from Jan 16, 2014 when the parliament adopted what became known as the “Dictatorship laws” up until February 20, the Revolution of Dignity had all the hallmark signs of a national uprising.

The main units around which the Maidan was organized were called Sotni which translates as “company”. Just like in England’s history, a Lord had a company of men, who worked the land and when called to duty, also served to defend that land. The term company continues to have both a business understanding and a military one, but it also holds something deeper, a connection that popular culture today would call ‘brother’s in arms’. Ties that connect one another to family, with the community and to the nation, and around the world today.

Small businesses around Ukraine provided funding and actively took part in supporting the students and then the protesters. For example, A “company” of lawyers self-organized to provide free legal aid for students who were detained by the authorities on weak and immoral grounds. Eventually, self-defense units arose that took to protecting people on Independence Square that were then united into one larger body, called the Maidan Self-Defence companies, that was headed by today’s speaker of Parliament, Andriy Parubiy. There was even a women’s company.

At that time five years ago, there was a whole system of underground hospitals and medical aid facilities because the wounded and injured were being kidnapped from hospitals and arrested or just disappeared.  Uniquely, the Maidan medical system focused on the person; his or her life and health were the center of attention, unlike the then healthcare system in Ukraine.

Since the re-establishment of independence in 1991, Ukraine had not managed to change its obsolete Semashko healthcare system inherited from the Soviet occupation. The system existed for the sake of supporting an inefficient and overstaffed infrastructure rather than to provide services to patients fueling a paternalism in medicine which if questioned, was tantamount to anathema.

The quality of care was low, and patients were treated as a source of income, with cash payments demanded at the time of treatment. Rather than being at the center of the system, patients were often treated as if they were “in the way”. Dignity and equal access to care were absent. This led to head doctors and staff reporting to authorities, essentially becoming informants, when injuries commensurate with Maidan participants’ appeared at their facilities. Providing any care to the injured was seen as collaboration.

Lord Nigel Crisp wrote, “healthcare is a social and cultural construct: the health system of a country is a product of history, politics and culture quite as much as it is of science, education and resources. Changing or reforming the health system is therefore as much a social and cultural movement as a business and management challenge.”

He also wrote: “You can’t just transport a system from one place to another – but we can all learn from each other.” And here he is partially right. The best elements from various systems can be applied together as long as the culture of a country is ready for change. In plainer terms, there is no need to re-invent the bicycle.

But Lord Crisp is right. Any healthcare system, is a reflection of a nation’s culture.

When Russian first invaded and occupied Crimea and then when Russia again invaded and occupied the Donbas, the response by civil society was overwhelming. Ukrainian volunteer battalions and a few small units of the special operations were some of the first on the front. Their response was evidence of a change in the culture.

But they encountered heavy losses. Tactical medicine was non-existent in Ukraine. People serving in the military were lucky if they heard a lecture on how to use a bandage or inject pain killers. No one knew how to treat the most important and dangerous cases, such as critical internal bleeding, blocked airways or a pneumothorax.

Injuries that have been identified by the US Army as survivable after years of research and evidence that was then incorporated into training for the armed forces. And indeed later, were adapted for civilian use. The philosophy or the culture upon which the training was developed is simple: Every soldier is a national treasure.

But in Ukraine, the old Soviet principle in military tactics prevailed – if the Germans attack with a million troops, we need double that to win. A hopeless Malthusian approach to modern war.

The energy of the Maidan was redirected towards helping people on the front line both civilian and military. Medics, Red Cross volunteers, doctors, nurses, even some former military who served in Iraq, who tended the injured at medical points throughout the Maidan and on the streets of Kyiv, were now looking for ways to help the volunteer battalions and Ukraine’s combined military in the Donbas. Many of them wanted, as everyone did, to rush to the front. They after all, had acquired a unique experience: administering first aid while being shot at, or what military medicine calls “care under fire”.

But that would have been a mistake. To win the war, we needed a “force multiplier” that would provide the government with time, to reorganize and stabilize the country.

Patriot Defence was created in 2014 as a humanitarian initiative of the Ukrainian World Congress and eventually evolved into its own non-governmental organization, whose main goal is teaching people to save lives. Because bandages don’t save lives, people do.

Our first step was finding experts in tactical medicine – Tactical Combat Casualty Care – with field combat experience so they could help train the Ukrainian warfighters. Patriot Defence found several former members of Her Majesty’s Armed Forces who had the training and experience that Ukraine was lacking.

British veterans were the first to introduce the famous tactical medical C-A-B-C algorithm. Together, we created a small but enthusiastic community of instructors, necessary to train a large number of people. Indeed, based upon our recommendations, international partners included TCCC training at Ukrainian military bases in Ukraine.

NATO-standard first aid kits were also distributed but only on the condition that the person receiving the kit, completed the course. Although this sounds obvious to the western ear, in Ukraine this was a break with existing mores. And another example of a change in the culture, where quality trumps quantity.

Today, Patriot Defence continues its mission, having trained 36,170 members of the armed forces, 454 members of the new police patrol and 480 doctors, both civilian and military. In the first three years of Russia’s attack on Ukraine over 260 thousand kilometers were clocked on vans donated by Winner Ford Ukraine traveling through Ukraine’s Donbas training military units. For comparison’s sake, that six times around the equator. Care under fire and tactical field care are today well-known concepts throughout Ukraine’s combined armed forces. But much more work needs to be done to secure the changes that were achieved.

What Patriot Defence instructors knew is that we wanted to help those defending Ukraine from invasion and occupation to help defend themselves. We took the training to the men and women in the trenches, members of the special operations, and at the same time we introduced the training to cadets. By training the special forces, the “tip of the spear”, and the rank and file holding the line, we changed the culture on the ground. Before this, both groups were convinced they were “canon fodder.”

But here was a group of people that wanted them to be able to defend themselves from injury and death, because that group and the larger volunteer community, valued them. In so doing, the change in culture created a demand from their officers for more training, and a market for a new operational medical system was born.

And today, many of the special operations units that we trained have officially adopted the same courses into their curriculum, institutionalizing and systematizing tactical medicine. I’d like to share with you a short 6 minute video of a training organized by Patriot Defence, that was made by #BABYLON’13, a film collective that also was born on the Maidan. Fair warning: there is graphic language and difficult scenes.

I sent this video to the “fathers” of tactical medicine. Dr Frank Butler and Dr. John Holcomb. Both of them judged it as being a great example of combat medical training. And not just because of the medical knowledge gained. Employing veterans from war as actors in field training gives new recruits the opportunity to see reality. In what wasn’t shown, in the hours long conversations between a wounded veteran and a warrior about to be deployed, in that exchange of story, of experience, of the smell and touch and sound of war, lives are saved. Bonds stronger than steel are forged. Respect is earned and dignity nurtured.

The winter of 2013-2014, the winter that changed us, ignited a transformation in the relationship construct between people, between families and friends, and between government and society. Although Ukraine gained independence from the Soviet Union in 1991, reform was characterized by legacy system support and little was done to change social mores, essentially letting a wound fester, leaving in place a mentality incongruous with the 21st century.  True societal changes began to take shape only after the Revolution of Dignity. The change underway in Ukraine's healthcare system is a metaphor for the transformation occurring in society. A new social contract between the government and the individual is based on shared values, the protection of the rights of all Ukrainians, and adherence to the rule of law.

In August 2016, I was approached by the Prime Minister of Ukraine to help bring about a transformation of healthcare in Ukraine. To Prime Minister Groysman’s credit, he agreed to my one demand: to bring in a team not connected to special interests, with little political experience but with a desire to bring about change and build a new system, a team that would get the job done. A team that consisted of experts and stakeholders, and patient advocacy NGOs.

Literature about inertia against making system changes abounds. However arduous it is to express resistance to change well, when I first walked through the Ministry of Health, I happened upon a statue of Hippocrates, in a dark damp musty basement, his hand was broken and he was facing the wall, like a prisoner.

Our mission in the ministry and for the entire country became clear to our entire team on that day: to return Hippocrates to his rightful place in the entrance hall, with his face toward the people, toward patients.

For the past 70 years, Ukraine has been a prisoner. Norman Davies wrote: “the socio-economic transformation, however, was achieved through the most appalling cruelty, violence, terror and mass murder. The USSR built the world’s first major concentration camp system: the Gulag. Millions died during forced collectivization and during the artificial famine produced in Ukraine.” “…vast numbers of ordinary men and women were simply shot at random to create the ultimate totalitarian climate where no one felt safe.” The Holodmor, the famine genocide, took millions of lives and World War II millions more. Life expectancy during 1932-33 in Ukraine was lower than during the war in 1942. Quoting Robert Conquest, the system Stalin built “was not designed to generate the stream of information necessary for self-regulation, but to respond to orders from the regime.” In a system of total control, innovation is absent and respect for one’s profession vanishes. A minority of people would try to SOLVE a problem because the prevailing norm was to SURVIVE the problem.

Although Ukraine’s constitution declares that “healthcare is free” as populists would like to have you believe, concrete rules and guarantees did not exist. Instead, the system consists of informal agreements and connections. Most families risked going bankrupt in case of a disease or injury.  99 percent of state financing went into treatment instead of prophylaxis, with poor results: Ukrainians live on average 11 years shorter than their European neighbors. But, most importantly, it was impossible to guarantee a certain quality of medical services in a system centered around survival and money-making schemes, or more commonly understood in the west as insurance fraud.

We found ourselves in a classic post-Soviet ‘ministry of silly walks’, where everything depends on the system-forming gate-keepers, paying patronage to authority and distributing government funding to personal projects and superstition. The social environment is characterized by loyalty to one’s clan and is more important than a person’s life, where doctors buy diplomas, job postings, as well as the ability to practice and share a part of the informal cash payments from their fellow citizens with their superiors. There is no professional development because skills are not important, proof of vaccination can be bought and sold and some of the doctors even believe that holy icons are just as effective as evidence-based protocols.

A system like this allows members of the Academy of Medical Sciences in Ukraine to publish articles about miraculous icons in the 21st century. Peer review is a fantasy.

In the Web of Belieft, W. V. Quine and J. S. Ullian wrote: “Proper science aims at truth wherever it lies, rather than at support for a profitable industry.” For example: The anti-vaccine movement aims to undermine medical science resulting in the redirection of personal and family resources to the homeopathy industry.

Commissioning papers to prove the existence of miracle healing icons aims to support a profitable industry. But is it the fault of the church or organized religion per se? To me the answer is no, unless it can be proven that these works were somehow requested by the church hierarchy. For now, what we can say, is that this kind of pseudo-science aims to support the most profitable of industries: Corruption, Incorporated.

The old Soviet medical system was financed by tax payers and funding was distributed on the basis of a region’s population and the number of beds in a hospital. The state paid for beds and not for services. Decree Number 33 regulated the flow of costs to hospitals as well as designated the number of personnel required to staff the facilities. We called them “zombie hospitals.” Good doctors knew this was the source of corruption. The first thing we did was to cancel this decree. This raised a powerful wave of criticism and anger – the medical “elite” began prognosticating the collapse of the system, unless the change be undone. Our colleagues in the government asked us to avoid making such radical changes to the system. Fear is what guided their decision making.

We did cancel the decree. And the system did not collapse. Instead, it benefited from the ability to make choices based on the need of the patients rather than an outdated regulation.

There are three numbers one needs to know about the state of Ukrainian medicine.

The first is 103.  A standardized exam is given to students when they complete high school with scores ranging between 100 and 200.  There was no minimum requirement to get into medical school, and students with scores of 103 were getting in, then paying bribes to pass their classes and exams. The Ministry has now increased the minimum required score to 150, raising the bar for entry and improving the quality of students.

The second number is 37%. In 2017, the Ministry introduced 30 questions from the US Medical Licensing Exam into the Ukrainian standardized exam for interns. Only 3% of Ukrainian interns had a passing score on these questions. Their average score was 37%. This resulted in the Ministry adopting new standardized exams in medical schools, adding the US International Foundations of Medicine exam in year 3 and year 6 of medical education. The exam questions are confidential.

The third number is 0.4%.  That is the number of practicing physicians who have a working knowledge of medical English. If you search for a listing of “medical journals” in Wikipedia you will discover that the overwhelming majority of them are in English. English is the language of medicine.  We have now introduced English proficiency exams in year 3 of medical school.

All of these changes were met with fierce resistance by the medical university system. And the reason is simple: in the past, failing a medical school test could be solved with the right kind of money. The exam questions could be bought as well as your diploma. Both students and professors were forced to pay up to the rector through pyramid schemes. And the money was all off the books.  

On your website, I found some information about the Head of Department of Medicine in Cambridge, Ken Smith. Could you imagine the Head of Department of Medicine in Cambridge spending 7,5 million dollars of the Univesity’s budget to purchase expensive equipment for his private business? Or maybe a scenario with him leasing a Cambridge campus to a commercial organization on the cheap? Or even him winning a court case disputing the breaking of his contract due to severe violations and the court returning him to his post as department head, with no recourse available for university management to take any measures against him or towards holding an open selection for a new department head? Something that sounds out-of-this-world in Cambridge is reality in Ukraine in the Odesa national medical university. The rector, Valeriy Zaporozhan, has been at his post for 27 years in a row, up until 2018, when we decided to break our contract with him. Legally. His official salary amounted to 12,000 dollars in 2017, however, in the same year, he declared 8,000 Euros, 147,500 dollars US and 9,529,695 UAH in cash (another 340,000 dollars US). His wife also declared in one of many bank accounts 546,000 dollars in her possession. As rector of a medical university, he sets an example and is responsible for preparing future doctors.

By raising the admission score for the students who want to pursue medicine and implementing IFOM in Ukraine the system will begin to inculcate quality doctors. Doing so, makes it futile for people like Zaporozhan to sell medical diplomas and we made a powerful enemy.

The procurement of medicines and medical supplies used to be one of the easiest ways to make money off the system. The multi-million-dollar schemes involved a large number of people ranging from the ministry administration, middle management officials, doctors and leading MOH experts, that took part in the making of the medicine procurement lists, the distributors that artificially increased prices, the producers of pharmaceuticals who paid bribes in order for their products to be included in the procurement lists, to Members of Parliament and, finally, law enforcement bodies, which were responsible for the security of the aforementioned systems.

However, the arguments between different pharmaceutical and medical clans within the system lead to a catastrophic disruption in procurement which left the whole country without medical supplies in 2014.

The parliament adopted a law in 2015 which handed the state’s procurement procedure over to international organizations such as UNDP, UNICEF and Crown Agents.

With the help of a single adopted law, it became possible to annually remove 6 billion hryven (the equivalent of over 200 million dollars) out of corrupt officials’ reach.

But adopting a law is one thing and putting the law to practice in a corrupt system is a whole different story. Dozens upon dozens of documents were laying on my desk when I first walked into the Ministry in 2016 waiting for a signature. These were the documents allowing the delivery of medicines which had earlier been artificially blocked from being imported to Ukraine. The department responsible for this process had all of its employees quit their jobs. An act of sabotage. It was the sabotage of medicines’ procurement for a nation of 42-million. Just as a person is capable of doing good, that same capacity can be applied to do harm.

We unblocked this process. And then encountered even more resistance. The leader of resistance and biggest defender of the corrupt Soviet system, was a chief doctor who headed the National Heart Institute, a state-owned medical institution that was directly subordinated to the Ministry of Health. He accused us of failure to provide medicines for the treatment of patients, and for blocking their work, and blamed those same international organizations like UNICEF, UNDP and Crown Agents for inefficiency and professional negligence.  

Later we found out that under Yanukovych this chief doctor, named Todurov, submitting his individual “shopping lists”, to the Ministry for procurement using budgetary funds, and that almost all of the stents purchased for the national healthcare system would go to his establishment. The patients paid out of pocket for all procedures and medical supplies at this institute, even if though the stents were already paid for by taxpayer funds. Essentially, insurance fraud writ large.

Todurov also opened branches of the Institute in several cities creating his own personal business under the guise of the National Heart Institute, selling services to the local health departments at inflated prices. In his attack on the Ministry of Health and Crown Agents, he called on the help of all his influential "patients", including many politicians, public figures, judges and prosecutors and even, ambassadors.

At the height of the conflict with the lobby of the old corrupt system, new important allies began to appear. For example, Dr Maxim Sokolov, an interventional cardiologist who, from the mid-2000s, had proposed to various health ministers the idea of creating a network of angiography centers all over the country that would work 24/7/365 and dismantle Todurov's cynical hybrid "business model" of monopoly on cardiology procedures.

Together with the Prime Minister, the Ministry successfully launched this project, and today the network of includes 34 angiography centers where patients with myocardial infarctions can get cardiac stents at no cost (6 more will go to the round-the-clock regime and 13 other centers will be opened in 2019). In areas where this system was applied, survival rate for patients with heart attacks has increased by 20%.

With the help of Crown Agents, for the first time in Ukraine's history, we were able to supply 100% of stents for urgent care for people with heart attacks (23 thousand stents in the past year). The price per stent is 40% of the cost of the kit for the procedure. And if earlier the inflated cost of the stent was 280 dollars, now it costs about 130 dollars. There are also standard stents, which we currently procure for about 70 dollars, when previously they had cost three times as much.

Transparent procurement, the same rules for everyone and ethical professional doctors provide patients with the best results. Boris Todurov and Maxim Sokolov today remain on the opposite sides of the barricade in the struggle between the past and the future.

The plan to change the situation in Ukraine's health care existed for a long time. The problem was the lack of political will to deal with thousands of Todurovs and Zaporozhans all over the country. Put differently, the culture of the political establishment was incongruent with the prevailing culture of Ukrainian society. When we began to act against the old system, our main ally was Ukraine’s civil society, which for years was waiting for a team who dared to challenge the system. It was the perfect storm of political authority, expert knowledge, and patient advocacy.

The key objective was to change the main principles of the system: money in the system should follow the patient where quality services are provided. Both patient and doctor should have the opportunity to choose where they receive care and where they work. Institutions that do not provide quality services must be re-profiled, reorganized or closed. Taxpayer funds must be transparently distributed throughout the system with clear algorithms and it must be easy to follow. When this system is efficiently applied, the role of intermediaries is reduced and the temptation for personal profiteering becomes moot.

Due to the wide coalition of the Ministry with patient and anti-corruption organizations, physicians, public opinion leaders, religious organizations, patriotic and veteran movements, business associations and international partners - in the fall of 2017 we managed to adopt a new law: “On state financial guarantees for public health services” together with a healthcare care coalition in the Parliament of Ukraine.

The law allowed for the creation of a single payer national health insurance that would sign contracts with medical institutions on clearly defined, equal for all conditions, reimbursing them for provision of guaranteed services packages to citizens without intermediaries. The implementation of the new rules is scheduled to roll out over the course of 3 years - 2018, 2019 and 2020.

The new institution was named the National Health Service of Ukraine. You know this name and it's not accidental.

The model we have adopted for Ukraine is comparable to Britain’s–using budgetary funds to pay for health services. Indeed, the situation in Ukraine today is analgous to the one in the United Kingdom in the 1940s.

For one thing, vitriol from our critics is on par with that faced by the founders of the NHS.  The difference being that medical practice was private, while in Ukraine a grand lie polluted the environment.  Healthcare was state sponsored and free of charge. Politicians, including the chairwoman & members of the parliamentary public health committe continue to contaminate the public debate. I often think that we need a system in politics like the Kyoto Protocols for the environment: if a politician wants to lie, they should pay a princely sum. We’d end up with a civilized debate or a new national trust fund.

In fact healthcare is private (head physicians lead the institutions for 20-25 years until they can "pass" the leadership to someone from their close circle or family) and the transfer is paid for (not officially, but in cash under the table).

British Health Minsiter Nye Bevan’s contemporaries had harsh commentary on the proposed changes:

Andy McSmith in the Independent wrote: “A letter in the British Medical Journal described Bevan as "a complete and uncontrolled dictator" and the doctors who had co-operated in creating the NHS were called "quislings", Quisling being the former head of the puppet government in Nazi-occupied Norway. One leading member of the BMA reckoned a nationalised health service was "the first step, and a big one, towards national socialism", in which Bevan and succeeding health ministers would fill the role of "medical Führer".”

Similarly, In the first few weeks at the Ministry, I was blamed for organizing the medical genocide of Ukrainians, they called me Dr. Death, an agent of the Department of State, a daughter of a Nazi.

But change that comes at the right time is impossible to stop. In April 2018, the "Doctor for Every Family" campaign was launched in Ukraine allowing each Ukrainian to freely choose a family doctor, general practitioner or pediatrician. In April 2018, all the opponents of change declared the campaign would fail and that there was a total lack of support in the medical community.

As of today, in 11 months, 2 out of 3 Ukrainians have chosen their physician (in total more than 25 900 000 Ukrainians); 24 477 doctors are already working in the new system – that’s 97% of all public primary care facilities and several hundred private institutions and single physician practices. This is the start of that new social contract between patient, doctor and the state.

The salaries of primary care doctors increased 2-3 times as the money now follows the patient and the doctors’ salaries correlate with the number of signed declarations with patients–known as capitation. Now that the primary care physicians are not dependent on their chief doctors, they much more openly support the changes and do not want to return to serfdom. It is grueling to see politicians trying to explain to doctors that nothing good will come from the medical transformation when their colleagues are already receiving higher salaries and improving their working conditions.

Today, the opponents of change hear nothing negative about the primary care. But lies circulate at those levels of medical care where changes have not yet begun, blaming the current adiminstration for the problems that have been accumulating in the Soviet system for decades. It is especially ironic that our biggest opponents are those whom we deprive of the opportunity to benefit from the inefficiencies of the system.

For physicians at other levels of care, the changes have to be fully operational from 2020 - before that their salaries are determined by the "tariff net", which defines all salaries of employees of government institutions, including healthcare facilities, regardless of the quality or quantity of services rendered. Medical facilities are now changing their status to that of non-profit corporations still owned publicly, which will free them from this “tariff net.”

The movement of all funds currently operated by the NHSU can be tracked on their website. Transparency is basic. Anyone can go to web-site and see how much money in a particular month has been transferred to a specific institution or doctor. The amount only depends on the number of signed declarations by the doctors of the institution. No officials, deputies or investigators can lobby for more money to come to their friends or relatives or to chief physicians.

At least half a billion dollars coming from taxes paid by Ukrainians are annually out of the sphere of the influence of corrupt officials. The next phase of the 2020 transformation involves transferring the entire health budget to the NHSU administration - which is more than $ 3 billion a year.

These new principles change the culture of people working in the field. These new rules promote the development a new relationship between Ukrainian doctors and patients. Now both groups have choices and clear understanding of the rules and responsiblities. Previously, patients were assigned to a facility depending on their place of residence, and doctors received low wages regardless of quality and workload. Now a patient can choose a doctor - anywhere regardless of their place of residency registration, and the doctor does not depend on the “tariff cage" or bureaucrats and has a clear financial incentive to provide quality services.

There are still many different other types of changes that we are introducing. But all of them have a common feature – they are all burdened by an almost total domination of myths and stereotypes. Lies and half-truths are powerful tools of disinformation especially of authoritarian states. We do not have billions or pharmaceutical oligarchs or a budget like Russia whose information network lies on an industrial scale. We use the most democratic and at the same time the most effective way of fighting in the area of communications - the truth.

We deliberately chose social networks like Facebook and Twitter to communicate with our main audience - Ukrainians aged 18 to 45 who do not watch television or do not trust it at all. Through them, we broadcast the most important information to other important groups - older people and teenagers. The results of the campaign for choosing family doctors confirm that this strategy has been successful, since no expert forecasts predicted such an outstanding result.

Today we observe a new trend in the information space, the national dialogue in Ukraine – it is, the destruction of myths. This is a new field created by posts on my facebook page in order to dispel myths:

for example that you can not get a TB test site wet,

or sit on something cold

or that vaccination causes autism.

It began as a form of educational communication, but turned into a popular trend, and today dozens of media and civic organizations are actively monitoring and destroying myths and stereotypes that are deeply rooted in the culture of Ukrainians.

In February 2018, we wrote a post that it’s okay to get the site of a TB test wet, and it turned into one of the most popular memes. So popular so that the Ukrainian-Maltese company 4A Games even mentioned it as an easter egg in the super popular game Metro Exodus about a post-apocalyptic Russia, where at the beginning of the game in one of the locations you can find the inscription, "Мочи Манту!” which means, “Wet Your Mantoux!!!" The game was released on 02/15/2019 and was already maligned by Russian TV as Russophobic. A Ukrainian gamer reached out to me and sent me this screenshot from the game.

I know it sounds funny, but the effects of the many years of anti-vaccination campaign by Russian intelligence services throughout the planet are not. Over the past 2 years, 30 people have died from measles in Ukraine and more than 60,000 have become ill.

All this is the result of the myths and lies about vaccination, which are distributed by millions of tweets and comments, thousands of publications and fakes. Their goal is to engender doubt in parents, and convince people that vaccination is harmful. Just as in the summer of 2014, Russian media tried to hide traces of Russia’s role in the downing of MH17 and create the artificial narrative that Ukraine is a failed state. They just need to make good people across the globe see the world as a struggle between a lesser and greater evil. And to do nothing.

Truth remains our strongest weapon, and the will power to voice the truth is frequently unpopular and displeasing to the establishment. But don’t underestimate Ukrainians. Just like anywhere else in the world, ordinary citizens experience a lack of openness and honesty. The problem is that in Ukraine, the United States, the European Union, and in the United Kingdom populists and special services of the Russian Federation have weaponized disinformation. Their goal is to capture the elite in other countries and hold the truth hostage.

The truth can be painful. Any doctor who has had to explain a cancer diagnosis to a patient knows this. But a patient is undeterred by the pain of truth, despite it being complicated or not. Because respect for your audience is paramount. In the 21st century, the truth needs to be fought for and set free.

The struggle for the health and the value of human life is an element of the culture war that did not begin yesterday - and will continue long after our term in the Ministry of Health of Ukraine is over. Ukrainians are different today and are just beginning to realize the promise of their full potential. The changes accomplished during the past 5 years in the midst of Russia’s war against Ukraine should inspire everyone to stand beside Ukraine today. Ukrainians will fight to defend these changes.

In today's world, with all its hybrid challenges and threats, real action to protect the value of human life and health can be the centripetal force that unites society. And if Ukrainians cannot compete with the British when it comes to the age of its fundamental institutions, we can definitely share the experience of long struggles for our lives.

We are essentially “decommunizing” the old Soviet Legacy healthcare system and creating one based on choice, guarantees and quality. The cultural change is more and more evident at every stage of the transformation.

And what about Hippocrates? We returned to his rightful place in the entryway of the Ministry of Health, facing out towards the people. Though his arm is still bandaged, our patient is healing quickly.

Thank you!

Дякую за увагу!

Please follow the link to read the full speech in Ukrainian