sible to obtain good medical and surgical care in Eastern Europe for a major illness. Primary ... workers, poor social status and professional recognition for nurses and almost complete .... where, for example, x-ray film became virtually unob-.
Medicine in I*rspective Doctoring in Eastern Europe HENRY WILDE, MD, Juneau, Alaska
Health care in Eastern Europe has not achieved world standards nor the goals of planners of socialist societies. With luck, perseverance, bribes or good connections, it is possible to obtain good medical and surgical care in Eastern Europe for a major illness. Primary and even secondary care usually are substandard, however, and often completely unacceptable to most Western foreigners. The reasons for this are complex but mainly rooted in different attitudes of health workers towards their patients, poor physical plants, poor salary structures, inadequate advancement opportunities for health care workers, poor social status and professional recognition for nurses and almost complete isolation of the average primary care doctor from hospital medicine. Two years as Regional Medical Counselor for the US Department of State in Eastern Europe provided an excellent opportunity to gain some insight into medical practices in Yugoslavia, Rumania, Bulgaria, Hungary, Czechoslovakia and, to a lesser extent, the USSR. Encounters wtth critically ill foreigners at hospitals in these countries demonstrated that good medical care can be obtained, if one is lucky to contact the right facility or has previously established channels of communication with the best professional talent. On the other hand, there was a substantial number of medical horror stories which present a picture of incompetence, lack of interest and plain dehumanizing treatment of patients. Such horror stories may, of course, be collected in most countries. In Eastern Europe, however, they seem to be more common than one might expect in a region that has a history of medical colleges and hospitals dating back several hundred years. What are some of the reasons for this? Could it be lack of medical manpower? There is no shortage of physicians in Eastern Europe. The number of patients treated daily by an average doctor is well within the acceptable range. Often, however, physicians do work under chaotic circumstances with poor patient flow and virtually no auxiliary support. Well-trained professional nursing staffs are a rarity and this seriously impedes the efficient delivery of health care. One reason for this is the fact that nursing is not considered to be a prestigious occupation. Educational standards for nurses are poor and working conditions dismal, which
leave the young working force to prefer employment in factories or offices. Local physicians are aware of this problem, but I have seen little effort on their part to alter it. Nurses are rarely treated as professional colleagues by doctors. This is evident in the general absence of nurses at medical conferences, and in the usual lack of formal participation by nurses during discussions of management problems.
Is Modern Equipment Lacking? Most mnajor teaching and referral hospitals in the region seem to have essential equipment. Some have outstanding equipment. One university hospital in Belgrade has the latest in x-ray units, yet I was not able to obtain a remotely acceptable gastrointestinal study at the same institution. Equipment is scattered and often not fully utilized, or it is used by persons who have not had the opportunity to develop real expertise in its operation. Maintenance is frequently poor and "downtime" considerable. Medical planning is often tilted to the construction of expensive show projects such as a new army medical center or specialty hospital which serves a relatively small population. Indications for the use of expensive equipment such as computed tomographic scanners are often questionable or of a political nature; a situation expected to be more common in the profit-making environment of a capitalistic society. There is, however, a problem of access to this equipment for average citizens. Outpatient clinics are usually poorly equipped and frighteningly dirty. They are, however, charged with providing
Refer to: Wilde H: Doctoring in Fastern Europe (Medicine in Perspective). West J Med 1983 Nov; 139:737-741. Dr Wilde presently is Regional Medical Officer and Minister-Counselor, American Embassy, Bangkok, Thailand. Reprint requests to Henry Wilde, MD, 3120 Wildmeadow Lane, Juneau, AL 99801. The views expressed are those of the author and do not necessarily correspond with those of the US Department of State.
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only basic medical services that could be done with very simple equipment, provided one had a mature and well-motivated staff. It has been my experience that lack of equipment is often used as an excuse for lack of willingness to provide services and use whatever tools are at hand.
Are the Physicians Incompetent? Medical education in most of Eastern Europe has been shifting from the Austro-Germanic mold of formal lectures with little practical bedside teaching, to a more clinical format resembling the French or AngloSaxon approach. Examinations, however, are still almost exclusively oral, infrequent and not very objective. International medical journals and current foreign texts are either not available to students or are extremely expensive. Most medical school libraries in Eastern Europe do subscribe to the major Western medical journals, but it takes a long time to circulate a single copy of a medical periodical through the entire staff of an institution. The situation is better in Yugoslavia where professionals, as do all citizens, enjoy the privilege of unrestricted travel abroad provided they have money. The rather poor performance of all Eastern European medical graduates on the ECFMG (Educational Council for Foreign Medical Graduates) examination, when compared with that of graduates from some developing countries, could suggest inferior basic medical education. Average pass rates of 1978 ECFMG candidates from Czechoslovakia, Hungary, Poland, Rumania, Yugoslavia, Bulgaria and the USSR were 24%. Those for 1978 candidates from Ghana, Kenya, Jamaica, Mexico, Lebanon, Malaysia, Singapore and Thailand were 69%. One must also consider that not necessarily the best foreign medical school graduates are lining up for the ECFMG or VQE (Visa Qualifying Examination) examinations. Most of the brightest young doctors of Eastern Europe will somehow manage to settle down to a local academic career. To be pitied are the majority of the physicians who work in outpatient clinics (health centers, polyclinics), often have had little teaching hospital experience, are remote from hospital medicine and are overwhelmed by patients with minor complaints who demand a signature on the mandatory sick-leave slips. Most outpatient clinics are housed in decrepit-looking buildings which frequently have been converted from other use and which only rarely have been provided with adequate laboratory or x-ray support. Physicians usually work out of a combined office and examining room where a patient has to undress with the doctor standing by. With a long line of patients waiting outside, it is often easier simply to exchange a few words, unbutton a shirt or blouse and write out a quick prescription rather than examine the patient. Such a clinic doctor has poor professional recognition and less job satisfaction. Most medical horror stories that have come to my attention have had to do with poor communication, 738
no continuity or coordination of care by different "specialists" and inadequate history-taking and patient examination. Poor follow-up care, overprescribing in lieu of diagnosis and disinterested treatment by physicians are also common complaints. One of the most irritating problems I have noted throughout Eastern Europe was the almost uniform unwillingness of local physicians to observe unclear clinical findings in a patient for a period of time without massive "shotgun therapy." This often added further symptoms, obscured signs, created anxiety and caused additional delay in diagnosis and specific treatment. A rather unexpected phenomenon was the government's support of some quackery and charlatanism that can be found in some Communist states. Examples are the Gerovital Institute in Bucharest and its very dynamic octogenarian director, Dr Ana Aslan. The procaine rejuvenation treatment, combined with conventional medicine practiced at that institution, has become an excellent hard currency earner for Rumania and is heavily advertised abroad. A line of "rejuvenating" cosmetics is also marketed successfully under Ana Aslan's and the Gerovital name. One large eye clinic in Moscow touts an unsubstantiated and, even by most Soviet ophthalmologists, disclaimed vitamin therapy for retinitis pigmentosa. The clinic attracts a substantial number of foreign patients who hope for a cure of this progressive disorder. Some medical practices and medications that have been discarded as ineffective or dangerous in the West have managed to hang on in Eastern Europe. Examples are the widespread routine use of progestational agents for threatened abortion and the common prescribing of chloramphenicol for minor infections. I have also been impressed by the long-term hospital stays for patients in most of the hospitals I have visited in Eastern Europe. Examples are the average one month admission for children with uncomplicated appendectomies (personal observation, University Hospital, Sofia, Bulgaria) and keeping a young person with simple lobar pneumococcal pneumonia in hospital until all x-ray findings cleared (more than a month in Belgrade University Hospital). It is not uncommon at most city hospitals to see large numbers of patients walking about the grounds looking perfectly fit. Games of soccer can also be observed when the weather is good. It is, on the other hand, frequently very difficult to find a hospital bed for a medical or surgical emergency, and most hospitals will be fully occupied most of the time. These practices must surely be eating up increasingly scarce health care funds. A distressing feature of hospital care in Eastern Europe is the very limited access to patients by family members. In front of hospitals it is common to see people standing outside the gate and shouting up to a patient who hangs out of the hospital window. I have even seen patients lower baskets on strings out of windows for their relatives to fill with fruit, snacks or reading material. This sight is even more common in THE WESTERN JOURNAL OF MEDICINE
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front of maternity hospitals, where access to a new mother is severely restricted. Short visiting hours can be rationalized by the fact that private rooms are extremely scarce and most patients are in large 8- to 20-bed wards where a horde of uncontrolled visitors would be very disruptive. This, however, is of little solace to a mother who is unable to visit her sick child other than for a quick glance into a large ward through a glass partition.
General Dissatisfaction With Medical Services I have observed that unhappiness with medical services is freely expressed by local citizens and foreign residents throughout Eastern Europe. In Western countries, lay criticism seems mainly directed at regional scarcity of services and their cost. Eastern European complaints are different. Local citizens and most resident foreigners will admit that some form of care is readily available to all in the Communist world. They do, however, feel that it is very often rendered arrogantly and impersonally. Problems are tackled without adequate history or examination, and the local public recognizes that a quick prescription or injection usually takes the place of logical evaluation and wellplanned treatment. A request from a patient for an explanation of a diagnosis and therapy is frequently viewed as an insult by physicians, who are unaccustomed to being questioned. Access to secondary or tertiary care is limited. Bribes in the form of a "blue envelope" (Yugoslavia) or pod stolem, "under the table" (USSR), are almost the norm. This does not include gifts to the nursing staff to insure adequate care postoperatively. Emergency care including major operations will, of course, be rendered without such gifts, but rarely by the "first team." Elective procedures all have very long waiting lists, which can be avoided by an appropriate gift or a friend in a high place. There are occasional drastic shortages of drugs throughout the Soviet Union and its satellites. They are less frequent, but not unknown, in Yugoslavia where, for example, x-ray film became virtually unobtainable for a period early in 1980. Basic medications such as penicillin have, at times, become unavailable in pharmacies in the USSR. I know of one episode when insulin was very difficult to procure in Bulgaria. When all this is seen in a setting where the population has been promised "free" care for all their medical and dental needs, and is charged up to 70% of their modest salary in taxes and social security deductions (Yugoslavia), it is easy to understand the growing dissatisfaction of the populace. On the positive side, it must be noted that a substantial number of ordinary Yugoslav citizens of all social backgrounds are referred abroad every year for specialized medical or surgical care. Heart surgery in the United States (about 1 million dollars worth in 1979), neurosurgery and cancer chemotherapy in Switzerland, renal transplants in France and some specialized orthopedic treatment abroad head the list. The substantial costs for these are borne by the YugoNOVEMBER 1983 * 139 * 5
slav Social Security System, after a board of local specialists rules that this type of treatment is not available locally. Evacuation of high-ranking party officials to Western countries, including the United States, from the Soviet Union and its satellites also is not unknown, but numbers have been small and such events have received little, if any, publicity.
Dental Care One sees many people with rotting or missing teeth on the streets of any Eastern European city. The physical plants of dental clinics, techniques and materials are crude and decades behind the times. A dentist works usually from one chair and with a shared assistant. There is little understanding of modern concepts of pathophysiology of oral structures and practically no meaningful preventive dentistry. Fillings are poorly placed (often not countersunk) and usually not polished or fitted to the bite. Crowns are made out of either plastic materials or shiny stainless steel (favored in the USSR). Gold is available but beyond the reach of common citizens. City water is not fluorinated, and dental floss is generally unknown and unavailable. Fluoride supplementation of infants' and children's diets is not practiced. There is no porcelain laboratory for the general public in the entire region. A porcelain laboratory had opened in 1979 in Zagreb, Croatia, and was doing a land-office business. Private dental and medical practice was, however, again phased out in Croatia, the only Yugoslav republic where it ever existed officially.
Medical Services Administration Would more competent medical services administration improve the system? Polyclinic and hospital administration is highly political in all of Eastern Europe. Directors, administrators and chiefs of service are either appointed by the government (usually with Communist party approval) or selected by the selfmanagement committee with party concurrence (Yugoslavia). It is not uncommon under both systems that a political activist with few professional qualifications ends up in the director's position. I know of a situation where an x-ray technician (a poor one at that) sits on the executive committee of a local hospital and thus determines the salary, fringe benefits and working conditions of his supervisor, the radiologist. One must understand that such an executive committee also has authority to assign scarce housing, and therefore exerts great influence on the staff's personal as well as professional lives. Needless to say, it is unlikely that this radiologist will risk offending his influential aide by criticizing the quality of his work. It is probable that professional and cost-effective medical administration could improve health care delivery in Eastern Europe. Allowing independent private practice in medicine and dentistry could also result in improvements of standards in the public sector. Experience in Croatia and elsewhere in the world (Thailand) has shown that innovations and new cost-effec739
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tive techniques are more likely to appear first in the private sector. Private practitioners would also take some of the burden from public clinics and possibly reduce graft and corruption which is demoralizing the entire system. Development of private practice is, however, unlikely to happen soon in Communist Eastern Europe. The concept is an anathema to socialist doctrine.
Foreign Residents and Tourists Foreigners do not understand the local language well in most instances, nor do the doctors usually understand theirs. Poor communication results in insecurity and leads to misunderstanding. If a foreigner comes from Western Europe, North America or the Far East, he has different expectations from a physician and dentist. The usual Eastern European doctor, on the other hand, does not understand the foreign patient's many questions and often interprets them as insulting and questioning his competence. This, in turn, can create a tense atmosphere and adds little to a comforting doctor-patient relationship. Furthermore, a foreign patient rarely understands the Eastern European health care system. He has not heard about "blue envelopes" or pod stolem, which are also not covered by Blue Cross, and he consequently gets the kind of care that the local doctor feels that he deserves. Those countries that have special clinics ("diplomatic clinics") for resident foreigners and tourists present further problems to an expatriate. Since a doctor's financial lot in Communist lands is not a rosy one, he, not being a saint in most instances, will tend to seek a job in a hospital or clinic where "blue envelopes" or pod stolem are ample and fairly distributed. An occasional bottle of scotch or carton of American cigarettes presented to him by a thankful foreigner does not make his car run or his wife happy. The "suspicious" and "demanding" foreigners also are more difficult to deal with. Many local doctors, therefore, feel that they are best avoided. This acts as a negative selection factor for jobs in "diplomatic clinics."
Public Health and Preventive Medicine A great deal of stress has been placed on public health in "East Bloc" countries and Yugoslavia. Immunization programs for children appear to function well and include bacille Calmette-Guerin (BCG) vaccination. The quality and handling of BCG vaccines appear to be, however, somewhat suspect. Many children do not convert their tuberculin reactivity after BCG, and childhood progessive tuberculosis still appears to be common. It is even seen in BCG-vaccinated children, an experience contrary to that of France and other Western countries with long-standing BCG programs. Measles vaccination is not yet comprehensive, and outbreaks of this preventable disease occur. Yugoslavia has, however, lately been giving measles vaccine to most children. A reasonably effective tuberculosis case-finding program, based on microfilming of populations in factories, schools and on the street, can be seen 740
throughout the region. Chest fluoroscopy, however, is still widely practiced in outpatient clinics where x-ray film shortages are not uncommon. Enteric fevers are relatively rare. The incidence of hepatitis is only slightly greater than in North America, and most outbreaks occur in rural areas due to contaminated well water supplies. Giardiasis is a common seasonal problem in the Soviet Union; few long-term foreign residents in Leningrad seem to escape at least one episode. The persistent occurrence of this disease in this large modern city is still denied by Leningrad public health authorities. Rabies is endemic among wild animals throughout continental Europe, but dog control in cities functions very well in the region, and the disease does not pose a threat to urban populations. There seems to be very little respect for workman's health protection in the Communist world. Driving through the countryside, one is greatly impressed by the many factories spitting black smoke from chimneys and covering entire communities with a thick layer of dirt. I have seen asbestos workers cut boards without respiratory protection. Many other procedures are done in an environment which, in most Western countries, would result in instant closure of the enterprise. Air pollution of cities is an increasing problem due to the use of brown coal. With the high cost of oil and natural gas, little can be done at present to improve this situation which is particularly bad during the winter in Belgrade and Budapest. Venereal disease (gonorrhea, nonspecific urethritis, genital herpes and syphilis) are not uncommon. Moscow seems to have experienced a small epidemic during 1979 and 1980. Prostitution is not rare in Eastern Europe and in the Soviet Union. Most Warsaw Pact countries have a community of "ladies of the night" who seem to cater exclusively to foreign residents and visitors, presumably with police concurrence. They are particularly visible around the tourist hotels of Prague, Budapest and Bucharest. A whole chapter can be written about the terrible state of public toilet facilities throughout Eastern Europe. Most require great urgency and rubber boots for safe entry. Serbia is also notorious for pollution of its countryside and city streets by garbage. The author has seen policemen throw soft drink bottles or paper sacks on city streets, and that in full view of the public. The important highway between Zagreb and Belgrade is literally a garbage dump. This probably has little effect on public health but connotes a general apathy and lack of pride in one's country. It seems to carry over into the working place, which often looks equally disorderly. This attitude might also contribute to an increased accident rate, poor work motivation and low productivity. Absentee figures of up to 25% of a factory's work force are not exceptional throughout Eastern Europe. The deterioration and lack of repair of buildings in the cities of Yugoslavia and Czechoslovakia, in particular, have resulted in a new public health hazard: injuries from falling bricks and stucco. Any recent THE WESTERN JOURNAL OF MEDICINE
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visitor to Belgrade, Prague or Zagreb will confirm this hazard. It was first brought to my attention by a local anesthesiologist, and again when I was almost killed by a huge stucco piece crashing about 10 feet from me onto the sidewalk of a major city street in Belgrade. During two years of travel through Eastern Europe, I have not seen any evidence of a serious antismoking campaign. Nonsmoking seats on Warsaw Bloc and Yugoslav airlines are either not designated or the signs are totally ignored. Hard-drug abuse does not seem to be a serious problem in Eastern Europe. Cannabis is used by a small number of young people in most Balkan countries where it has been known for generations. Alcohol abuse is, however, an admittedly serious problem throughout the region, and the USSR has a highly visible poster campaign dealing with "the evil of drink."
The Future The general economic difficulties that have befallen the Western world are shared by the Communist East. Work ethic is declining everywhere. Idealism and enthusiasm for social changes are giving place to cynicism and selfishness. The utopia that was promised one or more generations ago has not materialized, and the region is falling behind the West in social, ethical
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and economic development. Every Warsaw Pact country I have visited seems to have a two-tier consumer economy: the visible one and one that takes place entirely pod stolem. Desirable goods and services are sold or rendered only in return for special favors or hard currency, or to close friends and higher officials. This takes place in special stores (for party officials or those with hard currency) or simply by secreting desirable goods behind the counter. Most Soviet bloc countries have special hospitals or special sections of general hospitals strictly reserved for high officials. Most ordinary citizens understand the system and know how to procure better services in polyclinics or general hospitals by paying bribes. The wide distribution of corruption that one finds in Eastern Europe is truly amazing, even to someone who has spent almost two decades in Africa, the Middle East and Southeast Asia. This sad state of affairs does little to instill good work habits or compassion for one's comrades in newly graduated health workers. They either learn cynically how to float with the system, or become bitter and drift along doing a bare minimum. Priorities seem to be shifting from ambitious social programs to more immediately pressing needs such as the purchase of oil and defense spending. Health care is not likely to receive many added resources in this changing environment.
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