Pediatric neurology referrals in Armenia: lessons we can learn.

The pace of change in medicine—in the world—means that we cannot afford to live in silos. We need to reach beyond our borders, to teach, and to be taught, by people from other disciplines, with other politics, from other cultures. On that premise, and considering the prevalence of ethnic Armenians among his in-laws, one of us (Dr Bingham) arranged a 5-month sabbatical in Armenia. In addition to conducting collaborative teaching exercises and clinical work, the project, sponsored by the Fulbright Scholar Program of the US State Department, aimed to better understand working relationships between pediatric neurologists and pediatricians in the context of referral. Having survived in the last 100 years a genocide, decades of totalitarianism, a major earthquake, a border war, and a massive exodus of its population (10 million diasporan, 3 million native Armenians), Armenia represents one of the oldest, and perhaps most resilient, cultures on earth. Like several other post-Soviet countries, Armenia is a land-locked, developing country in central Asia. Its health care system, in transition from the former Soviet system, combines a fee-for-service system with a governmental insurance program1 for children under age 7 years, or for individuals who have disabilities, or belonging to other socially vulnerable groups. Despite fragmentation, the authority of the central Ministry of Health, and of hospital directors, reflects a health care bureaucracy that persists from the Soviet era.1,2 Pediatric clinicians thus cope with a hierarchical administrative system that has historically been disinclined to foster self-regulation.2 Semi-structured interviews with a convenience sample of Armenian clinicians (20 pediatricians, 6 pediatric neurologists) revealed strikingly similar referral scenarios between the United States and Armenia, and the continuing impact of the Soviet health care system, a “single payer” system … Address correspondence to Peter Bingham, MD, Department of Neurology, 1 South Prospect St, Burlington, VT 05489. E-mail: peter.bingham{at}uvm.edu