By ELLEN BARRY
Published: November 13, 2009
http://www.nytimes.com/2009/11/14/world/europe/14flu.html?_r=3&hpw

LVIV, Ukraine — When patients began arriving in Vyacheslav Bonder’s intensive care unit two weeks ago, their lungs so saturated with blood that they could barely gasp, the only thing he could compare it to was a field hospital in wartime. As soon as he hooked one patient up to a ventilator, a second and third would appear in the doorway.

By that time, hospitals were clearing wards to make room for a wave of pneumonia cases, and people were crowding into drugstores to buy whatever they could get their hands on. Rumors were circulating that the government had ordered the city aerially sprayed with chemicals, to cure Lviv (pronounced luh-VEEVE) of disease or, in a grimmer version, to exterminate its carriers.

The panic lifted almost as quickly as it had arrived, and the World Health Organization announced Friday that the swine flu illnesses and deaths so far in Ukraine — 265 fatalities nationwide, with 87 in the Lviv region — were statistically no worse than those in other countries. But what happened here has drawn rapt attention from experts bracing for the epidemic to hit Europe, and especially the fragile health care systems of countries of the former Soviet Union.

Early findings are that serious cases mounted because the sick avoided hospitalization until their illness was dangerously advanced, stockpiles of Tamiflu were locked in centralized locations and the supply of ventilators fell short, said David Mercer, of the World Health Organization’s European regional office.

“It’s not like this caught us by surprise; we’ve known for months that this was coming,” said Dr. Mercer, who heads the office’s communicable disease unit. “We’ve been working very hard on plans, but sometimes the battle plan doesn’t survive the first contact with the enemy. We’ve had to change a lot of things on the fly.”

With the worst of the health care crisis here past, many in Ukraine’s western provinces are trying to puzzle out what led to it. Doctors blame the news media and politicians for spreading fear and misinformation. The mayors of Ternopyl and Lviv, which reported their first deaths from atypical pneumonia on Oct. 12 and 19, have complained that the federal epidemiological service refused to act without laboratory confirmation that the virus was present, delaying serious measures by nearly two weeks.

Others point to more remote causes, among them the desperate poverty of Ukraine’s health care system 20 years after the Soviet Union collapsed.

In Lviv, senior doctors earn a monthly salary of 1,500 hryvnas, approximately $184, pay so low that many physicians leave their practices to work as home health aides in Western Europe. Though health care is officially free, patients typically pay a stream of cash bribes for services as large as X-rays and as small as blood tests or linen changes.

Ukrainians rely heavily on home remedies, and that is what they did for the third and fourth weeks of October, resorting to garlic and lemons and waiting so long to check into hospitals that by the time they did, many were beyond treatment.

“Medicine is underdeveloped in Ukraine, and people don’t believe in it — it’s a vicious circle,” said Oleh Berezuk, a physician who heads the mayor’s administration in Lviv. “In a mature country, if you get sick you will not say, ‘Nobody can help me.’ ”

Now, the doctors at Lviv’s main pulmonological hospital have the shaky good humor of people who have come through a crisis, though portions of their hospital are clammy and unlighted (“to scare the viruses,” one doctor joked), and some of their breathing equipment dates from Soviet times.

Two weeks ago, though, doctors here thought they were looking at a medical mystery: the deaths of healthy young people — not the drunks or addicts they usually see — with lungs so inflamed that they resembled liver. Dr. Bonder recalls the numb realization that his ordinary protocol for treating pneumonia was having no impact at all.

“You would come in to work and the next time you looked at your watch it was midnight,” said Dr. Bonder, who heads the intensive care unit. “You didn’t even think what could happen next.”

Nurses and doctors were falling ill at an alarming rate, in part because of shortages of gloves and disinfectant. Irina Mykychak, the assistant director of Lviv’s regional medical department, said around 3,500 medical professionals fell ill, of whom 300 were hospitalized and 4 died.

When they did suspect H1N1, physicians were stuck in a Catch-22. Though the government had stockpiled Tamiflu in preparation for an outbreak they expected later in the year, the drug was available only at the region’s single infectious disease station — and only with proof that a patient had H1N1. Obtaining proof was a three-to-four-day process that required that samples be sent to Kiev, said Lyubomir Rak, the hospital’s director.

Nadia Rudnitskaya, chief of pulmonology, was carefully putting the pieces together. On Oct. 27, she examined the body of a 32-year-old man — the latest in a series of four deaths from four parts of western Ukraine that, as she put it, “shouldn’t have happened.” Dr. Rudnitskaya gathered her samples together and appealed urgently to Kiev.

Right then the logjam broke: The next day the governor ordered a quarantine and released the emergency stockpile of Tamiflu to clinics and hospitals. A day after that, Prime Minister Yulia V. Tymoshenko announced on television that the virus had “reached epidemic threshold,” and all of Ukraine was talking about H1N1.

“It was a riddle,” Dr. Rudnitskaya said. “There was an answer.”

For some, it came too late. Marta and Nazar Martin insisted that their mother, Galina, 43, check into a hospital on Oct. 23, after her cough worsened into shallow, labored panting. A dentist, she had been treating herself with intravenous antibiotics and flu medications, as she had always done before.

“No one knew there was an epidemic,” said Marta, 18. “Nothing was said, not at work, not on television.”

The hospital offered no answers either. Doctors first prescribed antibiotics for bronchitis, then punctured Ms. Martin’s spinal column to test for meningitis and encephalitis, then gave her an M.R.I. to rule out a brain tumor. With every new prescription, her children scraped up the money and set off to find a pharmacy where it was available, Marta said.

“A poor person would just die,” she said. “They will not start a medication until you pay for it.”

On Oct. 29, when information about H1N1 flooded the region, doctors and nurses showed up wearing masks for the first time, Nazar said. He watched incredulously; his mother had already declined so much that she was “half a corpse,” he said. After she died, the next day, samples from her body were sent to be tested for swine flu.

Her children estimate they paid 35,000 hryvna, or about $4,300, in cash payments to nurses and doctors during the week she spent in the hospital. The more they hear about swine flu, the angrier they get.

“Why didn’t they take measures before then?” said Nazar Martin, 19. “I’m interested in knowing what they were thinking. They took this seriously only when people began to die, when the death statistics began to rise. Where were they before then?”

“It’s on their conscience,” he said, of the medical authorities. “They should have done something to prevent it.”