Thanks to recurrent eye infections, chronic eye irritation and chronic inflammation of my left Eustachian tube, I’ve had more than my share of doctor visits over the last three or four months. It appears (and I say “appears” because hypothesizing is the best anyone has been able to do up ’til now) that the pollution in Tirana is more than my system can handle. The good news: the infections are no longer a problem. The bad news: the low-level irritation is chronic and shows no signs of abating. As a result, my contact lenses are in a drawer and I wear glasses instead, I no longer use mascara or any other eye make-up, I have to flush each nostril twice a day with 200 mls of saline, I drop artificial tears into my eyes 4-6 times per day and —
best worst of all — I spend 30-40 minutes a day with warm compresses on my eyes.
Eight-to-ten doctor visits later, I’ve had lots of opportunity to see parts of the Albanian medical system first-hand. In addition, I’ve heard the experiences of other Peace Corps Volunteers and had multiple discussions with Albanian co-workers about their experiences. What follows are some thoughts and observations about health care in Albania*.
*Point of clarification: Peace Corps Albania has its own doctors — family-practice physicians who are our first line of defense when a problem arises. In my case, I was referred to specialists and have seen multiple ophthalmologists and ENTs, both in hospitals and private practice settings.
People of means go overseas when they have less-than-routine problems or need surgery.
First, as noted in my earlier post Hope Against Hope, it’s a well-known fact that there are many Albanian doctors who have “purchased” their degrees. Does this mean that they haven’t gone to medical school? No, but it does mean that they received one or more “assists” in completing their degrees or certifications. As a result, people with above-average salaries and discretionary income often go overseas when they have less-than-routine problems or need surgery. One of my co-workers travels to Brussels when she needs diagnostic testing. Another co-worker told me of a friend with cancer who moved to Greece temporarily to get treatment there. In my earlier post I mentioned a woman who is heartbroken at the prospect of leaving her homeland but is afraid that her hyper-allergic daughter will die as a result of the inadequate Albanian medical care.
In a country like Albania, where the Albania “brand” has virtually no cachet or credibility, brands that convey “anything but Albania” win. One of the top hospitals in Tirana is the American Hospital, except that it’s Turkish (clearly truth in advertising is not a thing here). Hygeia Hospital is known as “the Greek hospital.” When people refer a doctor, they are quick to say that he/she is Greek/Turkish/British/American or that he/she studied in Vienna/London/ the U.S. In the same way, pharmacies often have names like “the Greek pharmacy,” “the French pharmacy,” and so on. It’s not clear to me that these pharmacies are any different from any of the hundreds of other pharmacies around, other than the fact that their names reflect countries where the medical care is better than it is here.
If you have diarrhea, put your feet in a bucket of hot water and you will get better. If you’re having trouble sleeping, that can give you an eye infection.
Folk remedies and old-wives tales are alive and well in Albania. This is not a surprise in a country that was hermetically sealed for nearly 50 years, where the standard of living is low and where, even now, there is minimal cross-pollination with other countries. Here are some of the things I’ve heard — either from well-educated Albanians or from doctors themselves:
- It’s good to get a lot of sun in the summer because you won’t get sick as often in the winter.
- If you have diarrhea, it’s because the lower half of your body got a chill; if you sit with your feet in a bucket of hot water you will get better.
- Have you been sleeping well? Because if you’re having trouble sleeping, that can give you an eye infection.
- The weather has gotten colder (meaning the daytime temperature has dropped from this summer’s 90s to 70) and it’s not good to get cold air in your ears.
- My cold isn’t going away because I hurt my back and now the cold is stuck in the muscles. Once my back is better, the cold will get better.
Overall, Albanians have a lot of concerns about cold and its ability to make one ill. This past summer, people told me stories of riding in blazing hot furgons — their windows completely closed — because the cool air would be deleterious to the riders’ health. Another person told me of an office where the air conditioning was never set more than a few degrees cooler than the outside temperature because anything cooler would be unhealthy. Even in the summer, it’s cause for scolding to go outside with wet hair. “Maybe it was too cold” or “maybe you got cold” is sort of the default comment when talking about most ailments.
As for folk remedies, number one on the list is “have a shot of Raki.” Raki (Albanian moonshine….40% alcohol) is believed to be the solution to pretty much any medical situation.
Visits to the doctor are quite different than they are in the U.S. Don’t let the closed exam-room door fool you, doctors have an open-door policy that says, “interrupt me any time — no matter who you are.” During my various visits I’ve had the following experiences:
- Another doctor walked in and engaged my doctor in about seven minutes of conversation (they were talking Shqip and so I’m not sure what the topic was). He then lingered in the exam room watching the doctor examine me.
- A former patient stuck his head in the door just to say hi. The doctor and former patient then caught up for a while, talking about their families and their various adventures in the time since they last saw each other.
- A medical assistant came in to consult with the doctor about a bill.
There’s also a difference in how (and how much) information exchange goes on. My experience in the U.S. has been that, at the end of a doctor visit, there’s a re-cap where the doctor reviews: 1) the diagnosis and the likely cause of the diagnosis; 2) the recommended treatment, time-frame for improvement and signs of improvement; 3) how use take/use the recommended treatment, 4) things to look out for (problems/concerns), and 5) when (if needed) to come back. I’ve seen four or five specialists and “recap and review” is not part of the visit; in fact, the doctor may not even articulate the diagnosis unless asked. Mostly, they write the names of medicines on a piece of paper, sign and stamp the paper and hand it to you saying, “Take this to a pharmacy.”
My frustration over my own situation has morphed into sadness and a sense of powerlessness as I realize that Albanians live with this system every day.
In the case of my eyes, I saw first saw the doctor because of an full-on eye infection. After several false starts (more on this below) the treatments began to work and the most severe symptoms subsided. But some problems remained and I made multiple trips to the doctor in an effort to get things under control. It was only when I expressed concern about the fact that I had had the infection for more than six weeks that he explained that he was no longer treating me for an infection but for blepharitis — chronic inflammation of the eyelids, which had most likely caused the original infection. He had never named the condition, nor explained the progression of my symptoms, nor mentioned that I was now dealing with a condition not likely to subside.
Walking a Mile in the Shoes of an Albanian (a guided meditation)
Up to this point I’ve been sharing my experiences as a American navigating healthcare in a less advanced, less sophisticated country. Nothing thus far is that surprising and certainly nothing thus far is particularly troubling or upsetting. Now though, I am going to shift gears and tell you some stories that, in my opinion, are distressing. And, as you read I ask that you forget about “Sue the PCV dealing with the Albanian healthcare system,” and instead approach these anecdotes through the lens of “this is what it’s like for Albanians to get medical care.” Over these last months, experiencing the fits, starts and snafus described below, my frustration over my own situation has morphed into sadness and a sense of powerlessness as I realize that Albanians — even Albanians who can afford the best clinics, hospitals and doctors — live with this dysfunctional system every day.
In fact, this is sort of the guided meditation part of this blog post: I want you to imagine that you are an Albanian. Imagine that you have been taught, both implicitly and explicitly, not to question authority or be outspoken. Imagine that, for a variety of reasons, you don’t research medical symptoms and conditions online when something is wrong with you or a member of your family. Imagine that health/medicine gets virtually no play in the news media. Imagine that 55% of your total medical expenses (the number is the U.S. is 11%) is paid directly out of your own pocket (Albanians don’t use credit cards). And then, as you read what follows, imagine you might respond to these experiences.
Let’s begin with the pharmacy system in Albania, a system that is very different from that in the U.S. and has much more possibility for error. In the U.S. there is a protocol whereby a doctor writes a prescription and the pharmacist must fill the prescription exactly as written, clearly labeled with the prescribed dosage and the doctor’s directions. In cases where the pharmacist is unable to fill the prescription as written he/she must check with the doctor before making a substitution. Similarly, the pharmacist may not prescribe a different dosage than the doctor has recommended. In contrast, pharmacists in Albania have much greater discretion in filling prescriptions and this can lead to disconnects that affect quality of care. For example:
- The second ophthalmologist I saw prescribed drops and an ointment for my eye infection. She wrote the prescription on a piece of paper. The pharmacist kept the paper and wrote the prescribed dosages on the medicine boxes in ballpoint pen. When I returned to the doctor 10 days later with the infection still active, it turned out that the pharmacist had written the wrong dosing for the eye drops and I hadn’t been using the drops often enough each day.
- Later in this saga, the third ophthalmologist prescribed a steroid-based eye-drop that is difficult to get. The pharmacy didn’t have it and substituted a different product. I used the eye-drops according to the doctor’s 15-day protocol and saw very little improvement. When I returned, eye-drops in hand, for a follow-up visit, it turned out that the pharmacist had substituted artificial tears (which have no anti-inflammatory properties whatsoever) for the prescribed medication! In short, I had wasted 2-3 weeks on a therapy that wasn’t even a therapy.
- Another substitution occurred with one of the nasal sprays prescribed by the ear/nose/throat doctor. The pharmacist didn’t have the prescribed medicine and substituted a different spray. Because I had already experienced the eye-drop problem described above, I knew to check to see if the medications had the same active ingredients. It turned out that they didn’t and so I insisted (to Peace Corps) that we get the prescription filled at a different pharmacy. Perhaps the replacement medication would have worked as well but the pharmacist didn’t check to see if the doctor would have supported the substitution.
Now a few anecdotes about my various and sundry doctor visits, keeping in mind however that I want you to consider these from the perspective of what it’s like for Albanians to live with this system:
- When I visited the first ophthalmologist about my eye infection, her first response (even before she looked in my eyes) was to do a complete refraction — meaning she was measuring my prescription. I kept telling her that my prescription was fine, that both my glasses and contacts were new and that I was seeing fine and that I wanted her to examine my eyes. But, she kept insisting that she needed make sure I didn’t need an adjustment to my lenses before she did anything else. When she discovered that my current prescription stops just short of 20/20 for distance (which is intentional) she said that that was the cause of my eye issues. I argued with her and told her that I wanted her to examine my eyes. She said that doing so would involve dilating my pupils and that she didn’t have time to do that and so I would have to “come back next week.”
- It’s not a surprise then, to hear that I quickly ended up seeing a second ophthalmologist at a different hospital. This doctor examined my eyes, told me I had an eye infection and prescribed several types of eye drops and an ointment and told me to come back in a couple of weeks. As noted above, the pharmacist — either by design or through error — wrote a lower dosage for the drops on the box. When I returned to the ophthalmologist two weeks later I told her that the infection was still active and described how I had used the medications. When she learned that I had been under-dosing the eye drops, she began to scold me — actually yell at me — saying, “Why didn’t you follow my instructions? You are wasting my time.” I explained that I had used the dosage the pharmacist had given me, but she continued to yell. For the remainder of the visit she rolled her eyes when I spoke and would no longer make eye contact with me.
- That’s how I ended up at ophthalmologist number three: a doctor who had been educated in Turkey and who was Peace Corps’ preferred doctor except they had been unable to reach him (more on this below) when I first developed the infection. This doctor said that the reason the infection hadn’t gone away was that the previous doctor had prescribed eye drops for a bacterial infection when in fact I had a viral infection. It was at this visit that he prescribed the steroid eye drops that eventually got filled as artificial tears. This is also the doctor who at some point changed his diagnosis from infection to blepharitis without telling me. There are a whole bunch of other things he didn’t tell me and, at each subsequent visit, he would think of one more thing that I should do to manage the blepharitis but that he had neglected to mention.
So that’s the end of the guided meditation. What would you have done if you had been an Albanian living in Albania? Would you have persisted — as I did? Remember that I have free medical care, a natural reflex to research things online and no fears about speaking up. If you were Albanian would you have given up? Perhaps you would have given up until it got much worse. Would you have assumed that it was your fault that you weren’t getting better? Would you have defaulted to some sort of folk remedy thinking that the medicines don’t work? Would you have made the follow-up visits that revealed that you had a chronic condition and that resulted in additional recommendations for treatment?
After I posted this blog entry, an Albanian friend sent me an email with the following story: “Your reflections on medical issues reminded me of the time when my son was about to turn one. He had a bad topical dermatitis and terrible eczema on this face. The doctor yelled at me for being an irresponsible mother having allowed the situation to get to that point and said he was only considering my case out of mercy for the baby — had it been me, he wouldn’t have touched me. And, of course, he was the third doctor I was going to since the previous two had put me through a saga (like that which you clearly explain)! If you are wondering what I did…I simply cried and pitied myself and felt grateful that he finally prescribed the medication that worked.”
In the time since I’ve been in Albania, a number of my fellow Peace Corps volunteers have had to deal with more serious medical issues than chronic eye irritation. One volunteer was in a bike accident and broke his pelvis; another slipped on a wet walkway and broke her ankle in two places; another had an emergency appendectomy just a few days ago. Every one of them has some sort of eventually-funny-but-not-actually-funny story about their encounters with Albanian medical care that is eventually funny because things turn out okay in the end. But, the average Peace Corps volunteer is more practiced at — and has more resources for — working the system than the average Albanian does. It’s sobering for me to realize the converse: how little power most Albanians have over the quality of their medical care.
Ending on a Lighter Note
Finally, here’s a funny story that is less about the Albanian medical system than it is about how business, in general, is conducted in Albania: When the problems with my eyes first cropped up, the Peace Corps doctors tried to get me an appointment with the Turkish ophthalmologist they had used in the past. They made several calls to his clinic but the number wasn’t working and they didn’t know if he had closed his clinic or was out of the country. In Albania, it is common for businesses not to have a land-line — only a mobile phone — and, as a result, one’s ability to reach that business is only as good as the mobile/roaming service of the person carrying the phone. That’s how I ended up with the first two ophthalmologists. A couple of weeks later, as a result of the “you’re wasting my time” yelling incident, the Peace Corps doctors decided to try reaching the Turkish ophthalmologist again — still to no avail. Finally, desperate to find out if his clinic was still in business, the Peace Corps medical assistant went to the neighborhood of the doctor’s clinic and started asking around. Ultimately, she ended up in a bakery near the clinic where they were able to tell her that the doctor was on an extended trip to Turkey but was expected back soon.