MOSCOW — They are small as physician assistants go, about 2 inches long, and slithery. They wiggle about for a bit on Elena A. Kalinicheva’s back before getting down to what they do best: sucking blood.
Leeches — yes, leeches — are still widely prescribed in Russian medicine, about 10 million of them every year, in many cases as a low-cost substitute for blood thinners like warfarin.
“When you do it the first time, you think, ‘My God, leeches!'” Kalinicheva said. “But after you go through it, you understand there is nothing to worry about.”
In Russia, a medicinal leech costs less than $1, and a typical application requires three to seven of the ravenous little creatures. Leech treatments, available throughout the country, take 30 to 40 minutes, though the resulting wounds ooze blood for an additional six hours or so until the natural anticoagulant in leech venom wears off.
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Though Russia under President Vladimir Putin is muscling its way back onto the world stage militarily, economic development has lagged woefully, and that includes the medical system.
In developed countries, leech applications are often, and perhaps unfairly, associated with quackery, like the once popular practice of bleeding patients.
In fact, leeches are creeping back into Western medicine — as many as 6,000 are used annually in the United States, the BioTherapeutics, Education and Research Foundation estimates — but not for the same purposes as in Russia.
The Food and Drug Administration in the United States cleared the sale of leeches as medical devices in 2004 — along with maggots — while European pharmaceutical companies have focused on isolating therapeutic, blood-thinning chemicals in the venom and delivering it in a less creepy manner.
The FDA has approved leeches for draining blood, for example using them to remove excess blood from severed body parts that have been reattached.
In the Russian tradition, the therapeutic benefits are seen in the venom, a natural anticoagulant prescribed as a preventive treatment for stroke and heart disease, at a fraction of the cost of pharmaceutical blood thinners.
Russians are in theory covered for most doctor care and drugs under a socialized medical system written into the post-Soviet Constitution in 1993. Modernizing this state health care was a priority that Putin enshrined in decrees early in his third term as president. They set ambitious targets for medicine: Doctors’ salaries would double by 2018, the end of Putin’s term; life expectancy would rise by four years.
But the oil price collapse, sanctions and military spending intervened. Russia remains a poor country, albeit one with geopolitical ambitions. The average income in Russia is $642 a month, compared with $3,584 in the United States, according to government statistics in both countries.
“We need investment, and in medicine new technology requires state investment,” Yevgeny Gontmakher, an economist and authority on the Russian health care system, said in a telephone interview.
In rural areas, doctors are often too scarce to find in a timely manner. Russian life expectancy for men and women, at 70.3 years, has hardly budged since Putin issued his decrees and is still 10 years lower than the European Union average of 80 years.
Similarly, while government-approved “vitally necessary” drugs are theoretically covered, in practice they are as likely as not to be out of stock at the state-run pharmacies that distribute them free. Left to pay out of pocket at clinics or commercial drugstores, patients gravitate toward cheaper options, like leeches.
Kalinicheva, a secretary in a Moscow office, said she had suffered from intolerable lower back pain before trying leeches, applied weekly at a walk-in medical center, the Hirudotherapy Clinic.
She said she had chosen leeches for cost savings and to avoid taking painkillers. “I wanted something natural, to minimize the chemicals,” Kalinicheva said.
At the clinic, Dr. Irina A. Pankova applies leeches to treat glaucoma, prostatitis, hypertension and many more ailments. She encourages patients to use them in conjunction with standard drug treatments. As they engorge themselves with blood, the leeches bulge to six to seven times their original size before dropping off. They are used only once, to avoid spreading disease.
On a recent day, a steady stream of patients traipsed through the door, took seats and flipped through magazines, awaiting their turn.
Medicinal leeches cost 90 cents each in Russia, compared with $15.50 for leeches sold by Leeches USA, a medicinal leech supplier based in Westbury, New York.
They are raised in leech farms where, in Russia, women in white laboratory coats follow a procedure little changed over the decades.
They set out glass jars teeming with medical leeches, or Hirudo medicinalis; a colander with a fine, porous surface; a bolt of cheesecloth; and a jug of fresh cow’s blood.
“The leeches are hungry,” Natasha Bogdanova, an employee of the International Center for Medicinal Leeches, observed as she ladled warm blood into the cloth-lined colander.
It is not a job for the squeamish. At feeding time, the “leech raisers,” as they are called, plunge their hands into the glass bottles of leeches, retrieve the little bloodsuckers and put them in the blood-filled colanders.
“I’m not afraid,” Bogdanova said with a shrug. “I’m used to it. It’s my job. A job is a job.” One leech slithered up her wrist as she spoke.
In Europe, pharmaceutical giants Sanofi and AstraZeneca have marketed medicines based on leech venom, delivering the benefits without the actual creatures. In 2016, Sanofi sold 29,300 units of its leech-derived topical ointment, Exhirud Heparin, according to the company.
Like researchers in richer countries, scientists in the Soviet Union were trying to transform live leech therapy into pharmaceutical products in the late 1980s, said Gennady I. Nikonov, director of the leech farm, who got his start in a laboratory at Moscow State University trying to isolate medicinal compounds from leeches.
The effort unraveled with the Soviet breakup and is still foundering for lack of money. Nikonov has continued the work, and his company has prospective pharmaceutical products but, like so many other areas of Russian industry, lacks investment to bring them to market. That would require expensive clinical trials.
And so for now the leeches are sold, squirming and hungry, in glass canning jars, waiting for their patients. It works, as it has for centuries. “Why give up the experience of past years?” Nikonov said, shrugging.
Nikonov estimated that Russian leech farms produce 10 million specimens a year; his farm alone accounts for about 2 million. The FDA does not keep statistics on U.S. leech use, a spokeswoman, Stephanie Caccomo, said, but the numbers are small.
Most U.S. patients “would prefer a pill or something else without the yuck factor,” said Dr. Ronald Sherman, a former professor of medicine at the University of California, Irvine, and director of the BioTherapeutics, Education and Research Foundation.
Some Russians prefer to apply leeches at home. At a store run by the leech farm, Nadezhda K. Loba, 64, turned up with a plastic water jug and an order for 100 leeches. She applies them at home, on her temples, to treat conjunctivitis.
For an added measure of frugality, Loba noted, “you can use them repeatedly for yourself,” by departing from clinic practice and saving them after an application.
“If you take care of them, change their water, they can be used for a long time,” she said. “Think about it: Leeches don’t run out.”