Health Care

Days after Serbian Health Minister Ljeposava Milicevic said the entire health care system would come under republican auspices to put both funds and health care under control, a scandal broke out in the hospital in Subotica after 18 patients died in unexplained circumstances following surgery. The 18 patients underwent stomach operations, all of them felt well after surgery and all died within two days of the operations. The only serious work being done is covering up the mess.

A month after the first deaths we still don’t know who to blame; doctors, medication or something else. There has been no published findings by a Serbian health ministry expert commission. The whole mess where people died one by one while doctors pretended nothing was happening until the 18th patient died paints a full picture of the once prominent Subotica hospital: bad relations among staff, sloppiness by some doctors, the issuing of death certificates without autopsies. The hospital has been operating under a so-called restrictive regime for months because of a shortage of basic materials. They only take in emergency cases, mainly people who go to surgery right away.

The gynecology clinic in Nis set a record in sloppiness early last year when the wrong patient went to surgery for cancer and the right patient was sent home cured after medical records were swapped by the hospital administration. Still, the two women did have the same name. The operated woman fared worse despite the fact that she was brought in by a hospital employee. The cost: an unnecessarily removed organ. When she found out that the lab reports came back negative, she sued the hospital for damages. When the whole thing was made public by a republican health inspector this year, clinic director Petar Miladinovic resigned. Informed sources said it wasn’t only over that case. Last year, the clinic went through an epidemic of red infection caused by escherichia coli with 21 babies infected. The infection is caused by dirty hands, in a maternity ward of all places.

Stories of increased death rates in hospitals over the past few years, even rumors, are not denied by official statistics. The number of patients who died in hospitals grew by 28% in 1994 compared to 1991. Over 100,000 people died in Yugoslavia every year since 1991 or 16,000 over the average before the war and sanctions.

"Considering the conditions we work in, the people get good health care. Even basic things are missing. There are no gloves in hospitals, no syringes, let alone the antiquated and broken down diagnostics machines," Dr. Zoran Djurisic, assistant director of the Dragisa Misovic hospital, told VREME. "Only health care, the education system and farmers worked in this country during the sanctions and today. The economic giants stopped and we are dramatically spending our own essence now and if this continues there can be no return. It’s like a lethal disease. At some point nothing helps any more, not medication, money or knowledge."

Before the former Yugoslavia broke up, the World Health Organization (WHO) threatened to throw the country out of its membership because just 3.2% of the national income was earmarked for health care. The country was bigger then and the money wasn’t so small and we weren’t as sick. Only the people who decide about health care were happy with the endurance of the system during the sanctions and afterwards. Health care staff were declared heroes, which is partly right, and more people died than usual. Amid the national euphoria, statement were made like Milicevic’s that "the world expected us to fare much worse in terms of health care under the sanctions".

During the worst of the crisis, directors of health care institutions banned doctors from telling patients and their families that there was no medicine available. Luckily, most doctors disobeyed and told their patients what medication they needed.

The latest report by the federal health care institution for 1994 said the FRY health care system employed over 120,000 people: 20,962 doctors, 4,060 dentists, 2,023 pharmacists, 7,548 college trained and 53,632 high school trained nurses. The rest of the number are clerks, cleaning staff, drivers and others. Dr. Nada Kovacevic, professor of the Belgrade University School of Medicine and a gastroenterology expert at the Serbian clinical center, said that amid the poverty and lack of organization the system functions only thanks to doctors and other medical staff. "In the rest of the world, machines are used, here we use people, highly educated specialists. From this institution alone, 16 anesthesiologists have left along with several surgeons over the past two years. And a large number of nurses. They leave for England, New Zealand. Graduate students leave as well. The clinical center is a highly specialized institution and it’s a great shame that experts are leaving it." Over 2,000 doctors have left the health care system in the past two years. Officials said that’s because they’re opening private practices while doctors said only a small number do that and that most go abroad.

"Only the people who have to stay here. The number of patients is huge and there’s no new equipment being brought in. The ultra-sound machine we work with in Serbia’s main medical institution is 10 years old," Dr. Kovacevic said. "Given this number of examinations, it paid itself off in two months. Up to a year and half ago I did 40-50 examinations a day. Now I do 30. Under WHO rules the number of patients on this machine should not exceed eight a day. A few days ago, three of us doctors had 105 patients on two machines."

Kovacevic said that besides the shortage of medication, the center also lacks alcohol, soap, paper towels, detergent, sheets which should be changed after each patient.

The Serbian clinical center is the biggest and most important health care institution in the republic with 25 medical institutions, clinics, institutes including the emergency center. It has a staff of over 6,700. They examine patients from other hospitals and outpatients. Examinations on the ultra-sound machines are scheduled once a month and the quota is filled within two hours. Everyone else who comes in has to wait. Patients from other hospitals don't wait and people from other parts of the country skip the line. Belgrade residents have the hardest time getting in because they live in the city and can always be told to come back another day.

Health care for Yugoslavs is stressful, tiresome, humiliating and expensive - and they’re increasingly sick and dying. During the sanctions checkups were increasingly rare as well as hospital treatment. Only the people in the worst situation had the privilege of undergoing treatment. Compared to 1991, the number of hospital beds dropped by 3,000 in 1994. The hospitals have a total of 57,116 beds or one for every 184 people. Although they’re hard to come by, the hospitals keep their beds filled less than 70%. Perhaps there would be room in hospitals if there was enough medication and other materials, food and heating. It’s hard to understand statistical figures on free beds and the daily picture of the emergency center or some other high frequency hospital in Belgrade where patients are put on cots, pregnant women are put two in each bed or patients who are sent to the hospital for treatment are turned away.

Sick people, primarily the ones without enough money, spend hours waiting to see a general practitioner who might send them to a specialist where they have to wait in line again. Dr. Jasmina Kupresasin of the Stari grad health care center said there aren’t enough general practitioners and that the waiting list for a cardiologist for example is two months long.

All health care institutions in Serbia will share six billion dinars this year, with the ones in Belgrade getting 1.4 billion. That’s the money that came into the republican health care fund from taxes. For the first, the state is a co-financier with budget funds of 82 million dinars or 0.7%. Serbian MPs calculated that the state allocated 20 times less for health care than for the police. Those funds are insufficient even for a moderate recovery and normal operations and salaries.

Everyone owes everyone else in the health care system: funds owe funds, hospitals owe the pharmacy industry and suppliers. Every patient over the planned number gets them deeper into debt. Free health care exists only on paper.

The state pays back the system with low prices and secret instructions not to send people to specialists. A country that allocates less than 100 USD per person for health care can’t have a system or be healthy. There’s only survival, secret and public prices. The free health care becomes very expensive and everything has to be paid for.

At the moment, the most valuable document (in foreign currency) is a certificate for treatment at the Military Medical Academy (VMA) When it was opened, half the facilities of the VMA were intended for civilians. Today a certificate for the well equipped, neat, clean and popular hospital is extremely difficult to get. Only foreign currency helps.

Health care institutions don’t like talking about internal prices although they are completely legal. They say there’s no other way to survive or maintain their equipment. An examination on an early diagnostics machine costs 600 to 750 dinars. There’s a total of 10 of those scanners in the country and half of them are usually out of commission with long waiting lines for the others. Under international standards, one scanner is enough for every 100,000 people. If all of them worked the ratio here would be one scanner per million people.

Doctors have fallen to bribes over the past few years because their humane, important and exhausting job doesn’t bring a salary high enough for a decent living.

None of the people who talked to VREME denied that some doctors cured people for money besides their salaries. They didn’t deny the price lists which were never published but are known to patients. They said the number of those doctors is fortunately not large and that mainly doctors in high ranking posts charge their patients. Giving birth costs about 2,000 DEM, a vein operation about 2,500, a kidney operation 2-3,000. Hospital beds rank high on that list and promises that the best doctors will operate on you. Sometimes that costs more than the operation itself. The price includes everything the state ignores as criteria: titles, knowledge, reputation, comfort, care and the real cost of the intervention. Instead of going to hospital funds, the foreign currency ends up in someone’s pocket and since the patients were sent in by general practitioners the operation is paid for by the system. Doctors who tried private practice said the doctors who oppose private practice are the ones who illegally charge for their services. Their explanation sounds reasonable: those people earn huge amounts of money, don’t pay taxes, have no expenses and share the responsibility with their health care institution. Slowly but surely, health care is becoming a big business for some people. They trade in everything and anything. Medication that arrived as humanitarian aid ended up in private pharmacies or practices. One rumor says the liquor patients bring to their doctors ends up in Belgrade’s cafes and restaurants.

The health ministry reacts when things get too far out of hand as in the case of Radomir Popovic, director of the psychiatric clinic in Gornja Toponica. While horrifying pictures of starving and dying patients toured the world, Popovic the psychiatrist stole 30,000 DEM in humanitarian aid for his patients. He got three years in prison. No one knows what happened to the money but a large number of his patients died because there was no heating, food or medication.

Along with top level medicine, ordinary medicine faces infant deaths, tuberculosis and a large number of stress affected patients. Venereal diseases are on the increase along with heart problems and cancer.

Tuberculosis is back on the verge of the year 2000 which was declared doomsday for the disease. The disease, caused by insufficient food and lowered living standards, claimed 43 lives in the 1992-94 period.

That alarming situation was confirmed by Dr. Olga Djuric, director of the lung disease institute in the clinical center: "We register 33 cases per every 10,000 Serbians. In Vojvodina that number is rising and it stands at 63 in Kosovo. Patients with low immunity are in the greatest danger. Prevention has almost died out. Patients come in on their own with the disease in developed stages. The disease is contagious and expands quickly."

Years of disease are coming.

Infants

Infants died at a rate higher than 18% only because there wasn’t any adequate care, good diagnostics, funds, medication and equipment. Despite the rise in the number of sick children in 1994 the total number of visits to doctors dropped by 25.5%. Among school children that percentage is slightly lower (13.5%) compared to 1991. Or for example, the number of syphilis cases in 1994 grew by 34.5% compared to 1990.

Dr. Dusan Scepanovic, Director of the Children’s Clinic

High Risk

"I called influential people whose children we operated and got up the courage to tell them not to think everything is going smoothly and that they should help so that all children get the same treatment"

Dr. Dusan Scepanovic, surgeon and head of the Children’s Clinic in Belgrade, is said to always knock first on the door of potential financiers of his clinic before knocking the door down.

"The doors wouldn’t open on their own. When we started renovating and buying equipment five years ago we only had the support of the population, our reputation. We started by collecting money in a container outside the clinic. The final balance was 20,000 DEM from individuals and the economy. I have to say that Jezdimir Vasiljevic donated a million DEM to the clinic," Scepanovic told VREME.

"Siemens donated 1.6 million DEM in equipment but they’ll get it back from our big donor the Serbia Post and Phone Company which signed an agreement with Siemens recently. So we got the most modern equipment for surgery and intensive care. When we complete the ground floor in three months we’ll open a modern diagnostics center."

The crowd is huge at the clinic every day with 200 to 350 kids going through the emergency room daily.

"I had 30 patients the other day. My colleagues have that many and more. I never heard anything more stupid than the saying kids are little men. Every identification of adults with kids in health and sickness has consequences; from delinquency to cures. It’s hard working with kids, it’s a huge mental burden. It’s also a high risk job, especially for a surgeon, anesthesiologist and even pediatrician. Few children's surgeons live long after retiring."

VREME: Are children sicker than they were?

"Certainly they are. First there was Chernobyl then the sanctions and everything else from stress to poverty. Excluding respiratory infections which are the most frequent and routine operations, in our experience kids get more carcinomas and the number of violent deaths is not small - primarily in traffic accidents. The increase in malign diseases forced us to fight harder for diagnostics machines. The number of carcinoma cases account for 25% of our patients. Kids up to 12 months of age have a 90% chance of being cured. The clinic includes the biggest leukemia center and there’s a lot of that as well."