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I have been actively working with a small rural community hospital in the remote mountain village of Orlik (population 2,200 serving a region of 40,000 in the Sayanie Mountains, southwest of Lake Baikal), and with four children's hospitals in Ulan Ude, capital of the Republic of Buryatia (population 350,000). They are the Children's Hospital No 1, a newly renovated critical care and outpatient center on the east side of the city; Children's Hospital No 2, an older hospital with at least one building 100+ years old on the west side of the city serving abandoned/unwanted children, children with epilepsy and similar disorders, as well as the normal range of childhood health challenges; the Children's TB Hospital, serving children either living with TB or coming from a home where TB is present ages one through eight; and the Ulan Ude Neonatal Care Hospital, again situated in a older facility.
By mid January, I will have made presentations on the use of the arts in healthcare in Kemerovo (central Siberia near Tomsk), Irkutsk, a major economic and cultural center west of Baikal, Gusinoye (Goose Lake) a small city east of Ulan Ude, and Moscow; and, if my grant is extended, will be shortly thereafter be making presentations in Vladivostok in far eastern Russia on the Japan Sea/Pacific Ocean, these under the auspices of the Moscow Fulbright office and U.S. Embassy's Speaker's Bureau.
The physical conditions of the hospitals vary. The Orlik Hospital has no running water. Patients and staff all use outside toilets (outhouses), or bedpans as the case may be. The buildings within the hospital complex are made of wood, some quite old, and some, such as surgery, recently renovated. The Ulan Ude Children's Hospital No 1 has been renovated and is quite bright, presentable and clean inside. But on closer inspection, poor construction techniques have resulted in approximately 20 percent of tiles having fallen off the walls (the cement walls underneath are turning to sand), water leakage through and staining walls, and some walls so thinly made that they bend under the weight of a painting or corkboard hung thereon. Ulan Ude No 2 has buildings over one hundred years old constructed of a combination of brick, stone and wood and flex with earthquakes and tremors resulting in quite a number of holes in the walls and ceilings revealing the lathe underneath; this especially true in the older sections. The TB Hospital, though also old, built during Soviet times, is in the best shape and probably will hold up the longest because of better construction techniques; although like many buildings of its age hallways are very narrow, stairs steep, and interior lighting poor though the amount of light coming in patient rooms (as is true with Hospital No. 2) can be quite spectacular as are the views. The Neonatal Care building is also of the Soviet era, in tough shape, kept dark inside because of medical requirements and, of consequence and coupled with the nature of the work, can be an emotionally difficult place to work.
Aspects of all hospitals would break your heart. A challenge for healthcare officials is the lack of accountability in the building trades and lack of opportunities for redress. There are buildings in the city built with care, but they are exceptions and extremely costly to build. None of the hospitals, by the way, are handicapped accessible. There are no elevators. Ulan Ude No 1's first floor is the most accessible of any being the entry is at ground level. Gaining the second floor requires people with disabilities be carried or struggle up.
It perhaps goes without saying that hospital supplies are generally quite limited, but high tech equipment is appearing, often at severe cost to the hospital and government resulting in shortages in other areas. Examples were most apparent at Ulan Ude Hospital No 1., which has a good array of excellent technology, and the Neonatal Care Hospital, equipment that stood in stark contrast to the physical surroundings.
What there is in full measure is doctors, nurses, administrators and support staff that are educated, competent, caring and dedicated to their jobs, and all open to ideas for finding ways to improve their situation, by that I most especially mean the situation of their patients. Thanks to various exchange programs by the US State and Commerce departments, as well as other agencies and private foundations, quite a number of senior hospital administrators have been able to visit the United States, or through the help of other agencies and governments, hospitals in Korea, Japan, Germany, England and elsewhere. Those visits have enhanced skills and desires, but people then return to their realities.
Perhaps what the hospitals could use most is intensive courses in English as few can read, write or speak the language wherein the vast majority of new medical information is being published. Coupled with that would be access to digital (high speed) technologies to enable them to access the information.
High on helpful strategies would be the introduction of the arts and humanities into hospitals. I have learned that many of the same challenges facing hospitals and hospital CEOs in the United States, and other western countries, are faced by their counterparts in Russia; staff burnout, the need to enhance community relations, create a more welcoming and healing environments; the need to uplift the spirits of patients and their families; the need to give patients a break from pain; the challenges of staff seeing more people in less time; and an aging population. Doctors and nurses are pleased to learn of the challenges in the US, and other countries, and to understand that the difficulties they face are often faced elsewhere.
Many hospitals executives and medical staff are aware of the value of the arts and desire to create more homelike and welcoming spaces. In a number of hospitals are examples of murals, some extremely well done, painted in some cases decades ago, that enhance their space, pitted and scratched they may be. The medical staff is up against well-entrenched traditions that paint floors brown, walls and ceilings white, and if they use a color, it is a bright blue found everywhere. For the most part, the walls are bare or cluttered with signs and posters admonishing patients that, world over, represent some of the worst visual clutter created by man.
There is a certain forlorn emptiness about the places. Children talk about the incredible boredom of being in a hospital; the crushing weight of the boredom and the dullness of the spaces. The only hospital with arts activities, indeed quite a few, was the TB Hospital, which actually was filled to bursting with happy kids. Hospital camp. Since they all lived in one of six big wards and, by age, ate and played together, they were in remarkably great spirits, not taking away from the seriousness of their diseases or the reality that many were orphans and had no family to visit them. For me a proud link is that the contemporary use of the arts in healthcare, that lead directly into the development of arts therapy, began in Saranac Lake, NY, a neighboring village to my hometown famed for its pioneering work in TB under the leadership of doctors Trudeau.
The Spirit of Orlik
One nice aspect of hospital life in Russia, is that there is no unwillingness to engage the patients, indeed everyone, into the work of enhancing the space. In tiny Orlik, starting with the children's hospital; after questioning people on their favorite colors, no easy task since I didn't speak either Buryat or Russian and the only English speaking person of the village was seeking medical treatment in a hospital in Ulan Ude , I came up with four color schemes for the walls and trim that were put to a vote. Perhaps no surprise, the adult's favorite colors were the least favorite of the children, and the children's top choice was the least respected by the adults. Fortunately everyone's second choice was the same and we went with that, perhaps also not surprising colors with a high Buddhist sense that being the prime religion in the community. Everyone pitched in painting, doctors, nurses, patients, the maintenance staff and even the cook; all except the very youngest patients who watched goggle-eyed. One young patient came up with the concept for a sky mural for the entry and largely painted it as well. This included a huge flower on the side of the clothes closet. When done the space went from all white to flooded with sunshine, blue sky, clouds, bright trim and the feeling that sunglasses might be in order. Two young ladies in their early twenties, one a hospital employee and another a farmer's wife, jointly designed and painted a mural for the café of such quality that they could easily win a scholarship to an arts school if one was in the offering. The head doctor and a volunteer turned the kitchen tables into a lively set of yellow and orange with a border of hearts. A planning discussion that determined fish as the most healing icons resulted in a border of fish painted below the ceiling in the patient rooms.
Next for Orlik, after a joint staff-patient planning meeting, is to expand the arts into the women's clinic, the therapy clinic and the community clinic waiting areas. In addition a new hospital logo was designed, and future plans include presenting concerts in the hospital by the Orlik Music School. This step is on hold as they await my return, they hope in late January.
Meanwhile the spirit of Orlik, as we all dubbed it, has spread through television and newspaper reports, as well as a power point presentation that I use with hospitals, and has generated much excitement. My power point presentations does show images of the reasons for and use of the arts and humanities in hospitals and medical education throughout the United States, Canada and England, but it is the photos from Orlik that really grab people's attention. While many heard or saw it on the news, the seeing the photos again, many featuring doctors they know, is a revelation. It says if they can do it, we can. In addition it provides a graphic image of the difference and impact an arts program can make.
Ulan Ude Children's Hospital No. 1
In Ulan Ude the first door opened was with the Ulan Ude Children's Hospital No 1, but not until a few months had passed, as my first priority, once reaching the city from Orlik, was to become acquainted with and fold into the academic life at the Academy of Culture where I am engaged as a Fulbright Scholar teaching courses in arts administration along with a course in decorative arts and advanced English. In addition I have been working closely on strategic planning with the Institute of Pandito Khambo Lama Itigelov and the Buryat History Museum, as well as visiting various English studies programs in high schools and universities and meeting with elected officials on arts and economic issues arts and social issues, such as aging.
My first meeting with the hospital was on October 18th following several weeks of trying to arrange a visit. Actually it was my second visit as I toured the hospital when I had previously been in Ulan Ude in May 2004. It was the first of many, all including decorative arts and arts administration students from the Academy so that they would have the opportunity to be part of the planning process, hear hospital concerns, and see the hospital situation themselves.
The first goal was to get support by the hospital to include the arts, which quickly resulted following our first meeting with the hospital's leadership and a grand rounds presentation for over one hundred. From our meetings and tours we learned that seventy percent of the patients came from the neighboring small cities and villages, that 27% were Buryat, 58% were boys, the majority of the patients were around ages eight to ten, though they ranged from a month to eighteen years, stayed in the hospital for up to six months and 60% of the in-patient's parents stayed with them (usually the mother). The initial priorities established were creating a sense of welcome, the clinic hallways including the café; and the in-patient section including the inpatient café, nursing stations, play room and at least one room.
The presentation of our initial suggested plans, this time at a meeting that included the hospital CEO, left the students understanding that in no uncertain terms cartoon imagery was not acceptable, the first floor entry and nursing stations were not a priority of the CEO (that the colors of the stairwells and walls was, as was the ability to disinfect anything and everything on the walls every ten days), and that the hospital planning team had not fully involved either the CEO or the department members in their side of the planning. The CEO's personal aesthetic was no adornment on the walls, be it murals or hung art works, preferring just overall atmosphere via wall coloration, a view not shared by others. An outcome was that the CEO decided to work directly with me on the wall coloring and delegate more authority to the departments and we were to focus on the clinics and in-patients areas and to revisit the planning process including more staff. Some of the information was bit directly conveyed, but the students recognized in such a fashion they were actually being given quite a measure of respect and they were having a rare opportunity to meet directly with hospital officials.
Thus it was back again to the tours and expanded planning meetings that slowly evolved into approved designs; first a wall border motif for the in-patient café, then animal designs to identify the patient room doors, then a fish border motif for the patient room, then designs for the nursing stations (these remained a staff priority); approval of paintings and a tile mural for clinic hallways (including the size of the murals as the initial proposals were considered two or three times too large); a large rainbow mural for the third floor; and designs for the playroom. In addition the arts administration students began planning arts activities that could be done with the patients in playrooms or bedside.
Along the way we learned that twenty percent of the tiles were popping off the walls. On close inspection of a large section missing in one patient room I discovered that the cement wall underneath was turning to sand. It had no structural integrity. To lightly brush it with ones fingertips was to cause sand to crumble off the walls. In addition, many interior walls were made of sheer sheetrock, approximately 3/8th of an inch thick - too thin to support the weight of any painting, tile or message board. On close inspection one could see the blue cloth covering walls of the hospital's presentation room were stained by water that leaked through the outer walls. It was a shock to me, and clearly a big disappointment to the staff who never expected to have to include to cementing tiles to walls as part of their job description, an activity that lead to temporary satisfaction at best as eventually the re-glued glued tiles also came undone because of the instability of the walls made worse by occasional tremors in this earthquake prone region.
We were also given a demonstration of how walls were disinfected, largely by a thorough washing with ammonia, leaving it stand on the walls for thirty minutes, and then rinsing off. Our art had to withstand an unstable foundation and rigorous cleaning. Positive was the students' response of being willing to do their best, knowing that some of their designs may not last long.
Buryat Russian Inspiration
As part of the planning process I reviewed our activities with the Buryat History Museum, who agreed to provide resource information to help stimulate creative solutions that reflected the Buryat culture. The Academy's own library served as a similar resource for information on Russian folk tales. Three outcomes from the History Museum was the design of a series of giant Hitching Posts, traditional designs that go back the Paleolithic era, that connect the healing energy of the sky with the earth. A row of six, brightly colored posts that look like stacked spindles, spheres and other shapes, will frame the path way leading up to the hospitals entrance and be both welcoming to the young patients while connecting people to their traditions and being a powerful statement that the hospital is sensitive to the indigenous people of the region. These posts will be blessed and the setting finalized by Buddhist lamas. In addition, a tile mural based on a Buryat Buddhist quilt was approved, and the animal shapes for the in-patient room doors were drawn from Russian folk tales as was one painting and a design for a nursing station. A series of doorframes, also approved, were taken from the colorful shutters of the houses of Old Believers.
Ulan Ude Neonatal Care Hospital
On November 2nd, about mid-way through the planning process at the Ulan Ude Children's Hospital No 1, I was introduced to the hospital administrator of the Neonatal Care Hospital located about six blocks from the Academy situated on a high ridge overlooking the Uda River. She first attended my lecture that day on arts and healthcare at the Academy and then invited me over to tour the hospital and share slides with her staff, which I did the following Monday. Of special interest to them was that Dr. Ardan, the doctor featured cheerfully painting away at the Orlik Hospital, was a former colleague who had worked there for ten years. They were thrilled to see him so joyously occupied.
The hospital is a relatively narrow and tall building, built during the Soviet era. Ceilings are tall, hallways narrow, and stairs are steep. The building shows it age and is in rough shape. The tiny patients, all born prematurely, are fortunate to live in high tech incubators set one next to another in dimly lit rooms where the only sounds are the mechanics of the machines, not that loud, but still a presence. The mantra is quiet, dark and clean.
The machines are in dramatic contrast to the condition of the building itself. Here the prime staff question was how could we create a more uplifting atmosphere for the doctors and nurses while maintaining the integrity of the space, dim and quiet, for the patients? Indeed enhancing the atmosphere for staff and patient family members within the requirements of neonatal care.
For those answers I turned to two colleagues, via the internet, who have either designed spaces for neonatal care or develop arts programming for such spaces, Paula Most, the director of the arts for Lifespan, Hasbro Children's Hospital in Providence, Rhode Island and Annette Ridenour, President of Aesthetics, a San Diego-based firm known for providing hospital interior design and ambience that draws on all the arts. Their recommendations were unanimous, including the introduction of music, 60 beats or less to mimic or reflect the beating of a mother's heart, Mozart and lullabies, preferably live, come immediately to mind; music that can help mask the mechanical sounds, enhance weight gain and child development, and contribute to a more positive working environment. In addition they agreed that borders featuring natural imagery (vines, animals, fish) and soft and muted colors that maintain the appropriate atmosphere while warming the space and making it more attractive for staff and parents. In such situations particular attention should be paid to staff offices they said to make them brighter and reflect the personality of the staff. If possible and available, they also recommend new directional lighting that can provide better lighting for staff while working with the patients in a manner that maintains the important darkened cocoon around the children.
Currently implanting some of these concepts is on hold until the return of the director at the end of this week, who has been on a six-week grant to Singapore for an intensive training session at a hospital there. Immediate next steps upon her return will be to finalize priorities and seek funding to put plans into action.
Funding for Ulan Ude Children's Hospital No. 1, First Steps
Currently models of the Hitching Posts for outside the Children's Hospital are being finalized so they may be presented to leading companies in the forestry industry to seek their sponsorship, in-kind contributions of the poles coupled with covering the cost of carving them. The goal is to install these in late spring after the snow departs.
To support the interior activities, we presented our concepts to the Assistant Minister of Health (Republic of Buryatia), this through an introduction arranged by the health professional Luba Azheyev, the wife of a prominent physician and close friend known for combining east and western medical techniques. Olga Kuznetsova, Vice President of Academic Affairs at the Academy served both as translator and 'closer" while I introduced the history, vision, plans and price, coupled with a power point overview of the arts in healthcare that included slides from Orlik. At this meeting were the directors of the Ulan Ude Children's Hospital No 2. and the director of the Ulan Ude Children's TB Hospital, as well as other staff members from the ministry of health.
The end result was the great enthusiasm for the plans presented and the Minister saying he would discuss funding options with the director of Hospital No 1, and asking me to visit the other two hospitals represented.
Initial Planning at Ulan Ude Children's Hospital No 2 and the Ulan Ude Children's TB Hospital
The tours have since been held and follow up meetings to provide grand ground presentations for the staff of each hospital and set priorities have been scheduled. Initial ideas for the TB Hospital are to enhance the small cramped first floor visiting room where parents may spend time with their children, the music room, the play areas, and the five wards, that hold approximately 30 children each. Of the wards-play areas, priority was suggested for the space of the youngest children, ages about six months to three years. The follow up meeting will include parents of patients and staff. Unfortunately many children are orphans, thus without parents, or come from homes where TB is present, or other health challenges, particularly alcoholism, and thus parent participation is either impossible or unlikely in many cases.
The Children's Hospital No 2., is a challenge of a vast magnitude in that the buildings, especially the oldest (late 19th early 20th century), are in many places, in brutal condition. Decades of earthquakes have taken their toll leaving many walls and ceilings in hallways, exam rooms and patients rooms pockmarked with deep holes exposing the lathe underneath. Many ceilings are covered with dried wet towel-toilet paper balls hurled and stuck up there by children reflecting their boredom and displeasure at the surroundings. Some matter stuck to the ceiling, of brownish colors, I dare not speculate on its origin. Good news is the one room that was renovated, a high tech and expensive solution that filled and sealed in the holes in a manner that is understood to withstand the regular shakings, seems to thus far be holding up and, more attractive, has not experienced the vandalism of other spaces. It currently is all white and starting to reflect the need of a paint job, say nothing of added color.
There are some bright spots. Several large murals, although a few quite pocket holed, are very well done and need just a bit of restoration. In addition, the dining room tables and chairs, produced by prisoners, are of wood decorated in traditional Russian designs, are quite attractive and dramatically improve the dining area. So too the use of pale natural wood cribs brighten and add warmth to the spaces of the youngest children, the vast majority of which include beds for their mothers who often stay with them,
Heartbreaking is the ward and other rooms with the abandoned children, children suffering some very challenging physical problems literally abandoned on the doorstep of the hospital, or coming from orphanages. Some could be enabled to live normal lives with the help of plastic surgeons, and some will always face challenges. One could tell here, and throughout, that the conditions added greatly to the stress of the physicians and nurses, but at the same time many dipped into their own modest salaries and limited free time to effect what repairs they could.
When asked by the director my impressions, I had to admit that for an artist it was quite exciting, one vast unpainted canvas filled with possibilities blessed with great light within and with which to work. I love the grandeur of the old building, the wrought iron railings, the high ceilings, large windows, and huge open walls. Further I saw the bored teenagers in the wards as a labor force to be tapped, and I knew that many members of the staff would pitch in. Here no long bureaucratic process stood in the way as the need for action is so great. I pointed out that many techniques of painting walls, such as painting with rags, could create textures that could be used to enhance spaces while hiding uneven surfaces. I agreed to patch and restore several key murals, and planning meetings are scheduled for next week, first a power point presentation, and then pulling staff and patients together to set priorities. I did strongly recommend that they switch from oil based to acrylic paints as they move forward to reduce the harmful fumes when drying, speeding the cleanup, and easing future maintenance.
Ulan Ude Children's Hospital No 1, Funding Continued.
Perhaps no surprise to the leadership of Hospital No 1, the Ministry of Health twisted their arms to come up the funding for materials, which they have agreed to do. A budget has been prepared and approved (15,000 rubles, with a 5,000 ruble potential addition). Next step is to go shopping, and then start painting. After the New Year, the Academy arts administration students will start scheduling concerts and arts classes in the hospital, activities that they will soon learn will expand to include Hospital No 2 as well. In addition I traded a lecture on cultural tourism for a for-profit consulting firm in exchange for a contribution by them to help sponsor a series of photos of children in traditional dress by a well-known local photographer. He is donating his time; the funds will pay for printing and framing.
Continuing the Work
At this point, the biggest challenge facing the hospitals of Ulan Ude, and the Academy along with the participating partners, is keeping me here at least two additional months to lead the initial efforts to implement the plans and help set up long term solutions; that and money for supplies, especially for Ulan Ude Children's Hospital No 2 and the Neonatal Care Hospital.
A two-month grant extension has been submitted to the Moscow Fulbright Office, which, with the help of the US Embassy in Moscow, has forwarded the request to the State Department urging early consideration (usually not given until February). We all wait with baited breath, assume it will happen and thus are purchasing paint and scheduling meetings (including a return to Orlik to expand the arts activities into the Women's, Therapy and Community Clinics and organize concerts for patients by the Orlik Music School).
Meanwhile our potential workforce is growing as the directors of two after-school arts programs for high school students have volunteered students and teachers to assist in creating art works for the hospitals. The director of one met while I was sitting in the cloak room of Ulan Ude Children's Hospital No 1 sharing plans with a German filmmaker, plans overseen by the director's son she found looking over my shoulder, and the other director met through my friend Dan Plumley who left me her name.
The basic value, aside from dramatically upgrading the conditions for hospital patients and staff alike in Ulan Ude, is to demonstrate that such change is possible when people and agencies start working together. Many people have lived here for so long under a system where initiative was discouraged, to break those habits requires dramatic examples that it's possible, and that the benefits are worth the effort. Further, the approach is to mine the region's rich cultural heritage for inspiration and uplift, and to tap into the patients and staff and provide them with the opportunity to experience that they can make a great difference in their own lives and the lives of others; this provided at a time in their life when such actions can result in an attitudinal sea change. These actions will be seen. The local and Moscow media will cover and broadcast the results throughout Russia, and through such cooperating agencies as the Society for the Arts in Healthcare, the C. Everett Koop Institute and the US Embassy in Moscow, to audiences throughout the United States, Russia and many parts of the world.
What's needed? Two to three thousand dollars in paint and arts supplies and a yes by the state department for my grant extension. Ultimately I will need to find a way back come late spring to oversee the manufacture and installation of the Hitching Posts, but that is a second chapter. Till then we all hurdle forward, trust to karma, and say our Pandito Khambo Lama Itigelov mantras.
Naj Wikoff, Fulbright Scholar, East Siberian Academy of Culture, Ulan Ude; Director Healing & the Arts, C. Everett Koop Institute; President Emeritus, Society for the Arts in Healthcare (12/21/05)
2006 North Country Public Radio, St. Lawrence University, Canton, New York 13617-1475