Vasily Vlasov, President of Evidence-Based Medicine. About society. How to create a regional branch of OSDM

The speech of the Minister of Health and Social Development of the Russian Federation Tatyana Golikova at the beginning of this year at a meeting of the Presidential Council dedicated to demographic policy issues was commented on by the vice-president of the Society of Specialists evidence-based medicine, doctor medical sciences, Professor Vasily Vlasov.

Fertility

“AiF”: – Vasily Viktorovich, in the last two years we have seen some population growth, and the Ministry of Health takes credit for this.

Vasily Vlasov: – Population is determined by mortality, birth rate and migration. The mortality rate in our country, unfortunately, remains quite high and still exceeds the birth rate. The population is increasing slightly due to migration. For some reason, we generally believe that migration is bad for the country. But the United States, for example, accepts hundreds of thousands of migrants and only flourishes from this.

“AiF”: – Since 1999, there has been a slight increase in the birth rate...

V.V.:– ... due to the fact that the number of women of reproductive age has increased. Plus it worked " maternal capital" People hastened the birth. But this may be precisely an acceleration, and not an increase in the birth rate: women can still give birth to one child, but do this not at 30, but at 27 years old. And then the number of young women will decline and the birth rate will fall.

“AiF”: – The Ministry reports: since 1991, the number of abortions has decreased by more than 2 times.

V.V.:– There are fewer abortions – that’s good. The availability of contraceptives has increased, and new ones have appeared. But while the number of abortions is declining, the number of births remains stable. The question arises: is it possible to limit access to abortion so that the birth rate increases? There are two sides to the discussion of this issue. The first is not medical. Attempts to ban abortion are based on the view that a woman is not a person, but a carrier of a uterus in which a person grows. This is categorically unacceptable; a woman should have freedom to control her body. Second, there is no evidence that banning abortion leads to an increase in the birth rate. But it has been proven that the ban on abortion leads to an increase in maternal mortality, many times over and in a very short time.

New technology

“AiF”: – Another contribution of medicine to demography is the birth of children using IVF. Some in vitro conceptions are funded by the state.

V.V.:– In my opinion, financing IVF from public funds is very stupid.

"AiF": - What about stupidity? And other countries do this.

V.V.:“We have very little money in healthcare. While there are many problems that can be solved relatively cheaply. Therefore, the most important task is to solve the problems that are bleeding, using available means.

“AiF”: – Where didn’t they give the money?

V.V.:– Oncology. In our country, at best, a quarter of cancer patients receive adequate treatment. Three quarters do not receive it. Although they should be provided with full treatment from the federal budget. We still do not provide chemotherapy to patients with drug-resistant tuberculosis. In our country, most people whose kidneys fail do not receive hemodialysis. They die within a few months. We have virtually no transplantation...

From a demographic point of view, IVF is nothing. From the point of view of spending precious healthcare resources - over 373 thousand rubles to “receive” one child - this is simply stupid.

Dubious initiative

“AiF”: – The Ministry proposes to evaluate the reproductive function of each citizen already in adolescence. I think this is terrible.

V.V.:“When our Minister of Health announced this, the remaining hair on my head stood on end. I thought it was a slip of the tongue. No, the ministry has already ordered the development of a method for assessing reproductive function at great expense. Although in reality today there are no ways to evaluate it. For example, when they say that a marriage is infertile, they do not use laboratory tests, but the fact that a man and a woman have been sexually active for a long time, but pregnancy does not occur. This is the only criterion for determining an infertile marriage. A man may have terrible sperm quality, but if his wife has two pregnancies and two children within 5 years, this marriage is not considered infertile. Even if the wife gave birth to these children from a neighbor.

“AiF”: – I’m shocked at the thought that all the boys at school will be forced to masturbate in a test tube?!

V.V.:– Well, yes, there is no other way to evaluate sperm! And then let’s imagine that some Petya actually has poor sperm quality. Nothing can be done about it. But Petya grows up knowing that he has defective sperm!

“AiF”: – And the whole class will know it!

Social problems

“AiF”: – In Russia, maternal mortality is 320 cases per year. Although the decline in this mortality rate is most likely due to global medicine, it is declining everywhere.

V.V.:– Maternal mortality depends on many factors that need to be described in non-medical terms. For example, if people live in normal homes and eat normally, then women are healthier, they have fewer infections... If medical care is available, it means that a woman, when she experiences pregnancy complications, will not die from these complications. Reducing maternal mortality is about more than just good maternity facilities. This is mainly a social problem.

“AiF”: – Of course, we must fight for every life, for every unit in this number of 320, but, on the other hand, in our country 500 thousand people a year die from the consequences of alcohol, 400 thousand from the consequences of smoking.

V.V.:- Yes, this is what you need to do. And we have already shouted about this a hundred times. In Russia, men live 20 years less than in Western Europe, and the gap is not closing yet.

Around the medical examination

“AiF”: – Clinical examination is considered useful. And you claim that there is no need to test everyone for everything.

V.V.:– Clinical examination is a very expensive system, and it was never implemented, it was only proclaimed on paper. Meanwhile, identifying diseases if there is no way to treat them is immoral. If a person has a growing tumor that we cannot treat, it should not be detected under any circumstances. If we do not identify it, then the person, for example, lives carefree for another three years. And if we detect this cancer in him and do not treat him, then from the moment of detection he becomes dying.

In addition, clinical examination has another disgusting quality: when they begin to examine healthy people, they make a huge number of false diagnoses. You've probably heard this statistic: About one in three people receiving medical care is being treated for a disease they don't have. He either has another disease, or no disease at all. This is data from foreign studies. This is the situation when providing routine medical care, but when providing assistance based on an early diagnosis, it is much worse!

“AiF”: – No matter what specialists we interview, everyone says that the disease must be identified as early as possible, then something else can be done.

V.V.:– This is a plausible opinion that has never been proven scientifically. Based on scientific evidence, we can determine when early diagnosis is needed and when it is not. For example, it is necessary to examine stool for occult blood. Colon tumors can be treated well. This cheap and effective test is not included in our clinical examination program. But there is no need to test blood to detect prostate cancer in men. This test produces many false positives, and all men who are treated for prostate cancer are subject to traumatic treatment that adds little to their life expectancy.

Treat effectively

“AiF”: – What measures, in your opinion, can improve the demographic situation?

V.V.:– Construction of kindergartens, protection of women’s career growth, preservation of their jobs while they are on maternity leave, all sorts of benefits, parental capital...

The quality of our life depends not only on medicine, but also on social conditions. Among purely medical measures, it is necessary to mention accessibility effective treatment. Only it increases life expectancy.

The main thing is that the population is healthy and happy. The mere fact that there will be not 140 million of us, but 180, will not add happiness to each of us.

The Russian reaction to the development of the severe acute respiratory syndrome (SARS) epidemic in the world is increasingly reminiscent of panic. Eastern regions are urgently closing their borders, sanitary and epidemiological services are issuing orders to disinfect everything, medical officials with enviable pathos are declaring full combat readiness... At the same time, a different kind of revival has arisen - you can rush in and make money on panic by offering “life-saving” devices, medicines, disinfectants . How justified is this fuss, does the real scale of the threat correspond to the movements of the authorities, are the recommendations of specialists appropriate with such scant information about the nature of the disease? There is only one coordinate system that allows you to answer these questions. This is evidence-based medicine based on rigorous scientific data. A well-known expert in the field of evidence-based medicine, director of the Russian branch of the Cochrane Collaboration (an international organization of scientists that summarizes the results of all scientific clinical trials in the world), Doctor of Medical Sciences Vasily VLASOV answered questions from columnist Tatyana BATENEVA. - Following the experts of the World Health Organization, our experts recommend treating SARS with specific medications, which are very expensive. But while WHO gives recommendations carefully, with reservations, ours are more specific and categorical. What is this confidence based on? - On nothing, or rather, on the reasoning that theoretically these drugs could be useful. But now that medicine is armed with drug testing methodology, treatment options must be determined scientifically. That is: we don’t know how to treat it, but we can suspect that antiviral drugs need to be used. This means that we take the three most probable ones and begin to treat patients according to a random sample: some with this, others with that, etc. Thus, we will find out which is the most effective. But, unfortunately, they treat with whatever comes to mind, so today no one can say that these drugs really work. - But do experts know what and how approximately can act in this or that disease? - Exactly, they have ideas that some medications affect the microorganism, and some affect the patient’s body, so that it becomes stronger and resists viruses. But in reality healthy body it can't be made stronger. Now, if children in Africa, who are very poorly nourished, lack vitamin A, then it is enough to give them one capsule of the vitamin per month - and soon their resistance to infections sharply increases. If a child does not have a clear vitamin deficiency, it is almost impossible to increase his resistance to infection. All these popular ideas that you need to drink kefir, “cleanse your intestines,” eat multivitamins, take a bath cold water- and you will become healthier, unfortunately, have no scientific basis. - So, it makes no sense to use immunomodulators in the treatment of SARS? - No, there is some truth in this. Because among the people who end up in hospitals, there are always many who have insufficient nutrition and unfavorable living conditions. These deficits must be filled. But the problem is different: in such a situation, there are always a lot of people who want to sneak in “their” drugs on the quiet. There are many such drugs (supposedly immunomodulators), but in reality there is no evidence of their usefulness. - On what basis do experts confidently recommend specific antiviral drugs for the treatment of SARS, since the nature of the virus has not yet been fully clarified? - One gets the impression that these drugs are recommended only because they have been tried. What their actual effectiveness is is not reported. Therefore, now in Canada and Hong Kong, where the scientific base is sufficient, normal tests will begin - patients will be treated according to the rules of evidence-based medicine. Considering that the disease is acute and widespread, such a study can be performed very quickly, literally in 3-4 weeks. - What are tests “by the rules”, who determines these rules? - These rules were developed by modern evidence-based medicine, and they are quite simple. We have a question: does this medicine help or not? We know how to get the answer. For example, if just 10 people were treated with some drug and said that their flu was going well, this is not a result. Because the flu goes away on its own, and the best known drugs reduce the manifestation of its symptoms by just one day. It is necessary to compare one with the other. For example, the seller may offer you paint as white. But you cannot be sure of its color until you compare it with a standard white paint. And then you can see that it is not white at all, but yellow or gray. Our experience allows us to see something only when we compare. - Should we compare the medicine with a placebo, that is, a dummy, or one medicine with another? - Various comparisons allow us to draw different conclusions. Why are placebos traditionally used? In relation to a huge number of medical interventions, previously we simply did not know whether they worked or not. To answer this question, it was necessary to compare them with nothing. A placebo is nothing. Placebos can only be used for research purposes - if we do not treat the control group with anything at all, they may feel inferior and begin to treat themselves with the same or other drugs. And the results will be unreliable. The second rule of “good” trials is randomization, that is, random sampling of patients, literally by drawing lots. Because if we don't do this, there may be only young patients in one group, old patients in another, wealthy patients in one, poor patients in another, our friends in the group receiving a promising drug, and everyone else in another. ... And this will also affect the result. - From the standpoint of evidence-based medicine, what do the authorities’ efforts to prevent the importation of SARS into us look like - closing borders, disinfecting transport, measuring the temperature of all those arriving from China and other measures? - It is almost pointless to carry out disinfection with a bleach solution in buses and trolleybuses in Moscow. Firstly, bleach is terribly ineffective: it is useful for a limited time, it is toxic, and it has little activity against viruses. Secondly, it is generally impossible to carry out disinfection for the future until the presence of the virus in transport, roughly speaking, has not been proven. Disinfection is the killing of infection. No infection - no killing. - Then why is all this being done? - According to the favorite principle of officials - “don’t stand there like a fool.” Measures to close the border can be assessed in the same way. It doesn’t matter whether there will be 10 crossings on the border with China or one. Because if there is contact between people, the infection will be brought. It is possible, of course, to completely interrupt this contact, but this will be catastrophic in terms of consequences for both our Far East, and for northern China. As far as we know, no other country in the world closes its borders. You can, of course, filter and identify people with fever at airports. But when a person becomes infected, a latent stage usually occurs, when it is not yet clinically manifested. There is no fever, runny nose, or cough yet, but there is already a lot of virus in him, and he releases it - he sneezes, talks, and at the same time small droplets of saliva with the virus fly out. No thermometry, no thermal imagers will be able to identify such people. In addition, even after recovering, a person can remain a carrier of the virus for the rest of his life and excrete it. Another problem is erased forms. Usually the number of light and erased forms of any viral disease many times higher than the number of heavy ones. - So, you can do nothing at all and “humbly wait for the end”? - Why? The most reasonable thing in this situation is to educate the population, explain how to behave in case of certain symptoms, how to protect themselves from infection. And spending a lot of money on measures that are obviously ineffective is hardly wise.

Vasily Viktorovich Vlasov(born June 15, 1953, Novosibirsk) - Russian doctor, Doctor of Medical Sciences, professor (1994) National Research University Higher School of Economics, Department of Management and Economics of Health Care. He is a member of the Formulary Committee of the Russian Academy of Medical Sciences, the Interregional public organization “Society of Evidence-Based Medicine Specialists” (OSDM, President, 2008 - present), a member of The Society for Epidemiologic Research, International Epidemiologic Association.

Biography

Parents are military doctors Olga Ivanovna Vlasova and Viktor Vasilievich Vlasov.

In 1976, he graduated with honors from the Faculty of Training of Aviation Doctors of the Military Medical Academy (Leningrad) with a specialty in medical and preventive care.

In 1976-1979 - doctor of the Long-Range Aviation Regiment, Zyabrovka metro station (290 ODRAP).

In 1979-1988 - head of the laboratory at the Irkutsk branch of the Central Scientific Research Aviation Hospital.

In 1988-1995 - head of the department of aviation and space medicine of the Military Medical Faculty at Saratov State medical university; in 1994, he was awarded the title of “Professor” in the Department of Aviation and Space Medicine. In 1996-2001 he headed the department at Saratov State Medical University, in 2001-2006 he was a professor at the Department of Mathematical Modeling in Medicine at MIPT. From 2004 to 2013 - leading researcher, professor at the Moscow Medical Academy named after. I. Sechenov.

Started working at HSE in 2009.

Head of the Russian branch of the Northern European Cochrane Collaboration Center (The Cochrane Collaboration; 1998-2012, now Cochrane), leading researcher at the Center for Preventive Medicine of the Ministry of Health of the Russian Federation (State Research Center “Preventive Medicine” of the Ministry of Health and Social Development; 2003-2007).

Included:

European Advisory Committee on Health Research (EACHR, WHO Europe);
steering group (Steering group) of the WHO network to support evidence-informed health policy (Evidence-informed Policy Network, EVIPNet, WHO Europe);
international expert group at the UK Regional Health Authority in the West Midlands (Member, International advisory group, National Institute of Health Research Collaborations for Leadership in Applied Health Research and Care, NIHR CLAHRC WM, UK).
editorial boards magazines “Deputy Chief Physician: Medical Work and Medical Expertise” (since 2008), “European Journal of Public Health” (since 2009), “Health” (since 2010).
RAS Commission on Combating Pseudoscience and Falsification scientific research

Editor-in-chief of magazines " International magazine medical practice" (2001-2008), "Evidence-based medicine and clinical epidemiology" (2008-2011).

Scientific activity

In 1979 he defended his candidate's thesis (in the specialty 14.00.32 Aviation, space and marine medicine), in 1993 - his doctoral dissertation (in the specialty 14.01.04 Internal Medicine, Aviation, Space and Marine Medicine).

Main areas of research:

epidemiology of chronic diseases
occupational health,
translational problems (transfer of scientific research results for use in healthcare),
ethical problems of medicine and healthcare,
efficiency of health systems.

Consistent critic of the scientifically unsubstantiated activities of the Russian Ministry of Health and Social Development (now the Ministry of Health). Vasily Vlasov often acts as an expert in the field of new infections, addictions, methods of studying and treating them, effectiveness medicines and medical care organizations. Thus, he became one of the first epidemiologists to say that the Ebola virus will not reach Russia, but noted that the danger of deadly infections for Russia is high. Author of the first modern [in which country?] epidemiology textbook for universities.

New cases of death from influenza have been recorded in Russia. Two people died in Penza and Saratov. According to doctors, patients came for treatment too late medical care. In total, almost 10 thousand people were hospitalized in Russia due to the flu and ARVI epidemic. How to protect yourself from this disease? Why don’t doctors always manage to cope even with a known virus? What is the picture of influenza incidence in Russia? This and much more was discussed on Vesti FM by Elena Shchedrunova and the President of the Society of Evidence-Based Medicine Specialists Vasily Vlasov.

Shchedrunova: Hello. Today we will talk about the flu and the prevention of this disease. Although, according to the Ministry of Health, over the previous week the total number of cases decreased throughout the country, however, in certain groups - infants under two years of age and middle-aged people - the number of cases increased. What's happening with the flu epidemic today? This is exactly what we can call it, and in some regions of our country, in my opinion, there are four or five, there is a very high threshold of cases, the epidemic threshold is exceeded there by almost 70%. Is the situation this year different from what happened before? We will learn all these things today from our expert. This is the President of the Society of Evidence-Based Medicine Specialists Vasily Vlasov. Vasily Viktorovich, hello!

Vlasov: Hello!

Shchedrunova: To begin with, what is evidence-based medicine? So that people understand who they are dealing with.

Vlasov: Evidence-based medicine is a type of medical practice where patients are tried to be treated only in ways that are scientifically proven.

Shchedrunova: Now about a scientifically based method of treating influenza and influenza-like diseases, because the statistics say exactly this. Although, as far as I understand, these things are still separated in the same statistics...

Vlasov: They are trying to separate these things. But it’s very nice that you used the expression “influenza-like illnesses,” and it’s nice that you started using this expression at all. Until recently, we used to say “acute respiratory viral infections”, “acute respiratory diseases”, thus trying to create the illusion that it is clear what we are talking about. In reality, when people get a cold, they get a cold, and what pathogen caused the disease is usually, in the vast majority of cases, unknown.

Shchedrunova: Moreover, as far as I understand, no one is really trying to find out what kind of pathogen it is...

Vlasov: Well, if they were cheap and good means, then they probably would have tried. But since the means are expensive and unreliable...

Shchedrunova: Is this true all over the world?

Vlasov: Yes, it's like that all over the world. Let us suppose, laboratory methods, which are used for scientific supervision, are terribly expensive. But even with these methods, if some observed groups are examined, it is still possible to find out what kind of suspected infection is there in 70% of cases, and a significant part of the cases is still unclear. That is, he was sick, his eyes were red, his nose was running, his throat was red - it looked like a flu-like illness, but it was impossible to identify what it was. It's a pretty common story.

Shchedrunova: Apparently, something personal, some kind of personal virus has become active.

Vlasov: Well, there could be many circumstances. For example, just a technical error. That is, they took a sample, but it deteriorated, roughly speaking, while the analysis was being done. Maybe an unknown pathogen. There are many unknown pathogens in the world. There is an illusion that we have counted all the microbes; in reality, we have far from counted them and will not count them for a long, long time.

Shchedrunova: Maybe we still haven’t counted them all, simply because those whom we have counted, we found some means of fighting against them and, having extinguished them, we got those about whom we know nothing, and therefore did not extinguish , which previously were simply not visible against the background of those that were extinguished...

Vlasov: This mechanism also takes place: those microbes that were previously suppressed emerge. But still, the most important thing is that humanity primarily studies those infections that are common. If such a dangerous frequent infection appears, as, for example, AIDS appeared 30 years ago, then humanity takes on this infection, studies it, they say, now we know these viruses and begin to develop treatments. And those infections that are less common, perhaps even very dangerous, remain unrecognized and unstudied for a long time. Well, if only a few thousand people a year suffer from this infection worldwide and they are scattered, so what? That is, from the point of view of humanity, this is such an insignificant value that it is not visible, it disappears.

Listen in full in audio version.

Department of Health Management and Economics. Member of the Formulary Committee of the Russian Academy of Medical Sciences, the Interregional public organization “Society of Evidence-Based Medicine Specialists” (OSDM, President, 2008 - present), member of The Society for Epidemiologic Research, International Epidemiologic Association.

Biography

In 1976, he graduated with honors from the Faculty of Training of Aviation Doctors of the Military Medical Academy (Leningrad) with a specialty in medical and preventive care.

In 1988-1995 - head of the department of aviation and space medicine; in 1994, he was awarded the title of “Professor” in the Department of Aviation and Space Medicine. In 1996-2001 he headed the department at Saratov State Medical University, in 2001-2006 he was a professor at the Department of Mathematical Modeling in Medicine. From 2004 to 2013 - leading researcher, professor at the Moscow Medical Academy named after. I. Sechenov. Started working at the Higher School of Economics in 2009.

Included:

European Advisory Committee on Health Research (EACHR, WHO Europe);
steering group (Steering group) of the WHO network to support evidence-informed health policy (Evidence-informed Policy Network, EVIPNet, WHO Europe);
international expert group at the UK Regional Health Authority in the West Midlands (Member, International advisory group, National Institute of Health Research Collaborations for Leadership in Applied Health Research and Care, NIHR CLAHRC WM, UK).
editorial boards of the journals “Deputy Chief Physician: Medical Work and Medical Expertise” (since 2008), “Andrology and Genital Surgery” (since 2008), “European Journal of Public Health” (since 2009), “Health” (since 2010).

He has repeatedly stated that in Russia and the CIS, domestic and imported drugs that do not have proven effectiveness are actively advertised and used, and are also included in state lists (in particular, in the Russian VED), including drugs positioned as antiviral for influenza and ARVI. Among the reasons, he, as a participant in the Cochrane Collaboration, names the fact that in Russia only their developers can engage in clinical trials of drugs (in such a situation, the publication of positive results is several times higher, according to estimates of publications submitted to the FDA), prescribed by Russian laws state examination reports the results only to officials, but does not publish them in mandatory, as well as the impossibility of revoking the registration of drugs that do not have proven effectiveness.

In 1996, he began teaching the country's first compulsory course in biomedical ethics at Saratov State Medical University.

He is engaged. His wife, Irina Aleksandrovna Vlasova, is a journalist. Daughter Anna Vasilievna Vlasova is a doctor, editor.

Publications

Vlasov V.V., Plavinsky S.L. Options for drug provision for Russia: lessons from European countries and around the world. M.: Mediasfera, 2013.
Vlasov V.V. General medical practice: national guide T. 1. M.: GEOTAR-Media, 2013.
Vlasov V.V., Lindenbraten A.L., Komarov Yu.M. Main provisions of the strategy for protecting the health of the population of the Russian Federation for the period 2013-2020. and subsequent years. M.: Committee of Civil Initiatives, 2013.
Vlasov V.V. Epidemiology / 2nd edition. M.: GEOTAR-Media, 2006.
Information technologies for evidence-based medical practice / Ed. ed.: V.V. Vlasova. Baku, Yuldus, 2005.
V. V. Vlasov. Introduction to evidence-based medicine. M. Mediasfera, 2001, 362 p.
V. V. Vlasov. Medicine in conditions of resource scarcity. M. Triumph, 2000, 447 p.
V. V. Vlasov. Efficiency of diagnostic studies. M. Medicine, 1988, 245 p.

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“Yes, I didn’t say a word about the sovereign,” the officer justified himself, unable to explain his temper otherwise than by the fact that Rostov was drunk.
But Rostov did not listen.
“We are not diplomatic officials, but we are soldiers and nothing more,” he continued. “They tell us to die—that’s how we die.” And if they punish, it means he is guilty; It's not for us to judge. It pleases the sovereign emperor to recognize Bonaparte as emperor and enter into an alliance with him—that means it must be so. Otherwise, if we began to judge and reason about everything, then there would be nothing sacred left. This way we will say that there is no God, there is nothing,” Nikolai shouted, hitting the table, very inappropriately, according to the concepts of his interlocutors, but very consistently in the course of his thoughts.
“Our job is to do our duty, to hack and not think, that’s all,” he concluded.
“And drink,” said one of the officers, who did not want to quarrel.
“Yes, and drink,” Nikolai picked up. - Hey, you! Another bottle! - he shouted.

In 1808, Emperor Alexander traveled to Erfurt for a new meeting with Emperor Napoleon, and in high society in St. Petersburg there was a lot of talk about the greatness of this solemn meeting.
In 1809, the closeness of the two rulers of the world, as Napoleon and Alexander were called, reached the point that when Napoleon declared war on Austria that year, the Russian corps went abroad to assist their former enemy Bonaparte against their former ally, the Austrian emperor; to the point that in high society they talked about the possibility of a marriage between Napoleon and one of the sisters of Emperor Alexander. But, in addition to external political considerations, at this time the attention of Russian society was especially keenly drawn to the internal transformations that were being carried out at that time in all parts of public administration.
Life meanwhile real life people with their own essential interests of health, illness, work, leisure, with their interests of thought, science, poetry, music, love, friendship, hatred, passions, proceeded as always independently and outside of political affinity or enmity with Napoleon Bonaparte, and outside of all possible transformations.
Prince Andrei lived in the village for two years without a break. All those enterprises on estates that Pierre started and did not bring to any result, constantly moving from one thing to another, all these enterprises, without showing them to anyone and without noticeable labor, were carried out by Prince Andrei.
He had, to a high degree, that practical tenacity that Pierre lacked, which, without scope or effort on his part, set things in motion.
One of his estates of three hundred peasant souls was transferred to free cultivators (this was one of the first examples in Russia); in others, corvee was replaced by quitrent. In Bogucharovo, a learned grandmother was written out to his account to help mothers in labor, and for a salary the priest taught the children of peasants and courtyard servants to read and write.
Prince Andrei spent half of his time in Bald Mountains with his father and son, who was still with the nannies; the other half of the time in the Bogucharov monastery, as his father called his village. Despite the indifference he showed Pierre to all the external events of the world, he diligently followed them, received many books, and to his surprise he noticed when fresh people came to him or his father from St. Petersburg, from the very whirlpool of life, that these people, in knowledge of everything that happens in the external and domestic policy, far behind him, who was sitting in the village without a break.
In addition to classes on names, in addition to general reading of a wide variety of books, Prince Andrei was at this time engaged in a critical analysis of our last two unfortunate campaigns and drawing up a project to change our military regulations and regulations.
In the spring of 1809, Prince Andrei went to the Ryazan estates of his son, whom he was guardian.
Warmed by the spring sun, he sat in the stroller, looking at the first grass, the first birch leaves and the first clouds of white spring clouds scattering across the bright blue sky. He didn’t think about anything, but looked around cheerfully and meaninglessly.
We passed the carriage on which he had spoken with Pierre a year ago. We drove through a dirty village, threshing floors, greenery, a descent with remaining snow near the bridge, an ascent through washed-out clay, stripes of stubble and green bushes here and there, and entered a birch forest on both sides of the road. It was almost hot in the forest; you couldn’t hear the wind. The birch tree, all covered with green sticky leaves, did not move, and from under last year’s leaves, lifting them, the first green grass and purple flowers crawled out. The small spruce trees scattered here and there throughout the birch forest with their coarse, eternal greenness were an unpleasant reminder of winter. The horses snorted as they rode into the forest and began to fog up.
The footman Peter said something to the coachman, the coachman answered in the affirmative. But apparently Peter had little sympathy for the coachman: he turned on the box to the master.
- Your Excellency, how easy it is! – he said, smiling respectfully.
- What!
- Easy, your Excellency.
"What he says?" thought Prince Andrei. “Yes, that’s right about spring,” he thought, looking around. And everything is already green... how soon! And the birch, and the bird cherry, and the alder are already starting... But the oak is not noticeable. Yes, here it is, the oak tree.”
There was an oak tree on the edge of the road. Probably ten times older than the birches that made up the forest, it was ten times thicker and twice as tall as each birch. It was a huge oak tree, two girths wide, with branches that had been broken off for a long time and with broken bark overgrown with old sores. With his huge, clumsy, asymmetrically splayed, gnarled hands and fingers, he stood like an old, angry and contemptuous freak between the smiling birches. Only he alone did not want to submit to the charm of spring and did not want to see either spring or the sun.
“Spring, and love, and happiness!” - as if this oak tree was saying, - “and how can you not get tired of the same stupid and senseless deception. Everything is the same, and everything is a lie! There is no spring, no sun, no happiness. Look, there are the crushed dead spruce trees sitting, always the same, and there I am, spreading out my broken, skinned fingers, wherever they grew - from the back, from the sides; As we grew up, I still stand, and I don’t believe your hopes and deceptions.”
Prince Andrei looked back at this oak tree several times while driving through the forest, as if he was expecting something from it. There were flowers and grass under the oak tree, but he still stood in the midst of them, frowning, motionless, ugly and stubborn.
“Yes, he is right, this oak tree is a thousand times right,” thought Prince Andrei, let others, young people, again succumb to this deception, but we know life - our life is over! A whole new series of hopeless, but sadly pleasant thoughts in connection with this oak tree arose in the soul of Prince Andrei. During this journey, he seemed to think about his whole life again, and came to the same old reassuring and hopeless conclusion that he did not need to start anything, that he should live out his life without doing evil, without worrying and without wanting anything.

On guardianship matters of the Ryazan estate, Prince Andrei had to see the district leader. The leader was Count Ilya Andreich Rostov, and Prince Andrei went to see him in mid-May.
It was already a hot period of spring. The forest was already completely dressed, there was dust and it was so hot that driving past the water, I wanted to swim.
Prince Andrei, gloomy and preoccupied with considerations about what and what he needed to ask the leader about matters, drove up the garden alley to the Rostovs’ Otradnensky house. To the right, from behind the trees, he heard a woman's cheerful cry, and saw a crowd of girls running towards his stroller. Ahead of the others, a black-haired, very thin, strangely thin, black-eyed girl in a yellow cotton dress, tied with a white handkerchief, from under which strands of combed hair were escaping, ran up to the carriage. The girl screamed something, but recognizing the stranger, without looking at him, she ran back laughing.
Prince Andrei suddenly felt pain from something. The day was so good, the sun was so bright, everything around was so cheerful; and this thin and pretty girl did not know and did not want to know about his existence and was content and happy with some kind of separate, certainly stupid, but cheerful and happy life. “Why is she so happy? what is she thinking about! Not about the military regulations, not about the structure of the Ryazan quitrents. What is she thinking about? And what makes her happy?” Prince Andrei involuntarily asked himself with curiosity.
Count Ilya Andreich in 1809 lived in Otradnoye still as before, that is, hosting almost the entire province, with hunts, theaters, dinners and musicians. He, like any new guest, was glad to see Prince Andrei, and almost forcibly left him to spend the night.
Throughout the boring day, during which Prince Andrei was occupied by the senior hosts and the most honorable of the guests, with whom the old count's house was full on the occasion of the approaching name day, Bolkonsky, looking several times at Natasha, who was laughing and having fun among the other young half of the company, kept asking himself: “What is she thinking about? Why is she so happy!”
In the evening, left alone in a new place, he could not fall asleep for a long time. He read, then put out the candle and lit it again. It was hot in the room with the shutters closed from the inside. He was annoyed with this stupid old man (as he called Rostov), who detained him, assuring him that the necessary papers in the city had not yet been delivered, and he was annoyed with himself for staying.