As with many other poor countries, you do not need look long to find a drug store - or make it several of them - when in Romania. This situation also comes as a consequence of the fact that drug stores still have the exclusivity over the OTC sale. But the big number of pharmacies and the rather frequent ambulances going up and down the road might make one think the local medical system has its share of efficiency and reliability. Well, that is at least arguable an assumption. But let us have a quick look at the system as it is, let us go on with a few major medical operators and then finish with a March 2015 real life story.
Looked at from the air, the system is rather simple: you have state-owned and private clinics / hospitals. While the state-owned ones cover all medical specializations and are relatively well spread in cities and towns, private clinics are to be found mainly in larger cities, as they cater to a higher income clientele. Nothing new so far.
Let us cast a glance in the public sector first. If in some small town tucked in some distant highlands you notice this 8 floor, eventually centrally-located hospital, do not let appearances fool you. When a friend had a cycling - like in ‘off the bike, head first’ - accident and we rushed her to the nearest hospital (that of Râmnicu Sărat), for some reason we could not make then, they immediately put her on glucose perfusions which could only severe her condition. How come? They did not have anything else and gave her whatever there was. As for the 8 floor building, that is a Communist era relic the size of which has nothing to do with the service provided. Other than that, larger cities and especially county capitals have better stocked county hospitals (Ro. spital județean), but services, especially as far as very specialized and ER ones are concerned, can leave a lot to be desired. The experience I had visiting or taking friends, acquaintances or relatives to various state-run hospitals in Târgu Mureș (the Emergency Rescue Service Centre for Transylvania), Buzău, Cluj, Drobeta-Turnu Severin (the county hospitals) or Bucharest (the university hospital) showed poor or badly maintained endowments past the often refurbished reception hall, a fluctuating quality professional service, an omnipresent rudeness and unclean, appalling overall conditions. Of the trivia sort, if you need a CT or MRI and they happen to have the respective piece of equipment, better bring your own DVD if you want the results as they might or might not have one to share. As for the August 2015 smashed index finger which was wrongly put together (displaced bone and badly arranged flesh included), complete with an incorrect prescription and the ‘sorry, but we do not have a tetanus shot’ at the Târgu Mureș Hospital, that needs no further comment.
In Bucharest and a dozen of other large cities there usually is a handful of big public hospitals with a complete - or nearly complete - range of services. But you will soon notice that the bigger the hospital, the more developed the chaotic and corrupt system inside. While changes are under way in this respect as of 2015, for a good part, the public medical apparatus is still free or only partly paid by the patient with an inefficient, half bankrupt social security system backing it. This situation, cumulated with the low number of doctors per capita in Romania (1.9 doctors per 1,000 people, which ranked Romania 31 out of 33 European countries subject to a 2010 study) and an exodus of good doctors abroad looking for a better pay, led to a considerably higher demand than what the system can give (where it does give anything). And discrepancies as such ended where else but with corruption and bribes. With doctors heavily underpaid compared to their foreign colleagues especially in a domain where continuous research is - or should be - part of routine, as well as with medication stock disruptions in public hospitals, bribes (going all the way to settled amounts for a specific kind of surgery) and expensive gifts, as well as a huge, complicated system of who-knows-who rule the public medical apparatus. This is not to say that everyone is corrupt, but rather that you have a good chance - well above 50% I dare say - to end up with a cul-de-sac scene. Why so? Professor Philip Zimbardo has put it better and simpler than anyone else: it is a matter of a barrel of rotten apples. Put a good apple in it and see what happens.
As for the ‘what’s in a bribe?’ question, that varies, from the RON 50 an old woman pays for her regular doctor check-up and all the way to the thousands of EUR asked - or expected - for a certain, complicated above average surgery. But the doctor is not the only one to be bribed in a public hospital, as one has a good chance of not reaching the doctor at all unless paying his / her way through the assistant and if hospitalized pretty much everyone around expects some sort of payment to serve, from the stretcher-bearer and all the way to the nurse. Furthermore, as hospital food often sees shortages (or very low a quality and quantity), most patients have relatives and friends bringing food supplies together with a wad of money or small gifts for the day’s bribes. Not going to pay may result in not going to see that nurse pretty often, being subsequently pushed towards the end of the line for one’s surgery or simply not reaching a certain doctor due to a lack of available slots, to use the official line. Aside from the bribe issue, the medical system in Romania is possibly the area where the who-knows-who legacy of the Communist regime still exists at its best, as, apart from the natural recommendation a doctor might make for a fellow from a different medical branch, this is heavily about entering a hospital through the back door, not waiting in line, taking others’ places or getting available beds where there officially are none. Back to the doctors, in 2014 there were discovered a few cases of doctors encouraging patients to use their services in private, promoting a whole range of services complete with a detailed price list, while surgery was illegally conducted in a public hospital. Once again, this is not to say all system and all doctors work like that, but that for the most part it is this way, as shocking as it may come. For a sample of what the public medical system is like, refer to the end of the article where I am listing my own, last experience with it (2015).
Now, let us go private. The question naturally arises: do doctors working in the private system attend different schools and courses? For the most part no. And it needs be said that many doctors working in private clinics and hospitals in Romania also work in public ones, or have worked there. ‘Hmm, err, but, then?...’ Patience, my dear Watson. As previously said, it is a matter of barrels. In private hospitals doctors get good wages and expect no bribes, furthermore, with its exceptions, it is true, the private health system is more customer (i.e. patient) - oriented. Where different, are doctors working in the private sector better than those working in public hospitals? There is no general rule, but you have a better chance at least to be guided to a better / more specialized doctor if at a private hospital than at a public one where options are rarely an occurrence. What do you gain by going to a private hospital? Instant care, access to up-to-date equipment, decent treatment and - if needed - hospitalization conditions, the right to choose your doctor (if you have a preference). The price to pay? It is, well, rather obvious: you pay for everything, for every visit to the doctor, for every test you go through. For instance, in most private hospitals and clinics, the average consult costs RON 100-150. Take the tax and the private hospital running costs out, then compare the result to the money the doctor pockets from the old woman in a public hospital and see where you get.
The main difference is that at a public hospital malpractice is hard to address (as one is likely to need go through the Colegiul Medicilor, a doctor professional board) and faults generated by a lack of proper resources (such as low quality test reagents or even malfunctioning, old test equipment) can easily lead to an improper diagnosis and treatment. At the same time, doctors - even when it is about the same doctors working in both systems - in a private hospital are bound by a quite rigorous commercial and professional contract where responsibility is strictly stated, while the equipment and all needed resources are a far cry from whatever the public system may offer. A friend with a severe gastric problem contacting a gastroenterologist which worked in both a private and a public hospital was told the doctor wanted to see him in the public one. From a logical rather than professional point of view, I recommended against it, fearing the low quality of the tests conducted there, as well as the doctor’s weak responsibility while at the public hospital. The reason the doctor wanted to see the patient at the public hospital was the bribe he would pocket right away compared to the fixed wage he got at the private hospital disregarding of the number of patients treated. It might look paranoid from the comfort of an airplane seat, but a quick look through any public hospital as a patient and not a mere give-me-five visitor might tell more than I can do here. However, when all is said and done, it is worth noting that, as private hospitals only cluster in a few larger cities, the more remote you go, the fewer options - if any - you are left with.
Getting back to facts and Bucharest, there are several large public hospitals that come complete with a 24/7 ER service. The Floreasca Clinic Emergency Hospital (16 ER lines 24/7), the University Emergency Hospital (locally known as the ‘Municipal’, 8 ER lines 24/7), the Elias University Emergency Hospital (number of ER lines not specified) or the Dr. Bagdasar-Arseni Emergency Hospital (number of ER lines not specified) are the biggest. They have most medical specializations. ER services go free, based only on your ID card or passport; however, once you are out of ER (and in one particular case the Târgu Mureș orthopedist rushed to have my colleague out as soon as he possibly could, even though his situation was far from stable), you will need go through the typical bureaucracy, slow and paid service of the same public hospital. Therefore a private hospital might arguably be better to start with, so that you have a constant, reliable end-to-end service. As of early 2016, public hospitals went through a scandal, as disinfectants employed in supposedly sterile environments were diluted as much as 10 times by Hexi Pharma, a supply provider involved in nation-wide corruption.
Of the private hospitals and clinics out there, three also have ER services: Regina Maria (5 ER lines 24/7), Medlife (5 ER lines 24/7, with dedicated orthopedic and pediatric hospitals) and Sanador (14 ER lines 24/7); other large private (or private-public conglomerate) operators include the Babeș Treatment and Diagnosis Centre, Medicover and Monza Hospital. As far as ambulances are concerned, remote areas and severe accidents are served by the SMURD, an emergency rescue service complete with its ambulances and helicopters, while regular, nation-wide road emergencies are run by the Ambulanță. They are both reached - together with the fire department and police - by dialing the European emergency number, 112. Private operators providing ER service (see above) have their own ambulance service which goes charged. Two other privately-run operators include the BGS, an ambulance service without a hospital (they will take you to the nearest ER hospital they have a contract with) and the Puls, running a few small clinics and a fleet of ambulances. The latter has the advantage of doing home tests for patients that cannot or would not go to the hospital, but it went through a scandal in May 2016, as its license was suspended following its ambulances being found with expired defibrillator batteries and resuscitation medicine. Note that the list above is not complete, it rather includes the major operators there are without recommending any of them. Well, at least in one particular case, the story below could not have me make recommendations. So, let us hear the story, pops.
Case study
I go to the mountains as usual and, for the first time in some 15 years of trekking and climbing up to over 6000 m.a.s.l., I have a more serious accident. A rather small snow slab breaks under my weight and, while the fall itself is rather short, the front points of my crampons on my right foot catch on a rock or ice stump under the relatively soft snow layer and the impact violently kicks my foot before I go on sliding farther down to a complete arrest. An instant mechanical swell at the ankle level in the boot tells of a broken something. Minutes later, while rubbing the ballooning ankle with snow, I evaluate the situation and, aware of the medical complications that may occur from this, I decide to go down on my own; I am in a remote, quite inaccessible area at around 2200 m.a.s.l. and rescue will be slow (almost certainly involving a night out) if at all an option. I call a friend to come pick me up from the trailhead some 1300 m. below and start on my way down, descent that requires crampon use for a while, then navigating through knee-deep snow and eventually, when down in the forest, following some ski tracks. Nearly 5 hours later - on what would normally take me less than 2 hours to cover - I get to the car and we head straight to Bucharest, to the University Emergency Hospital where we know for sure there is an orthopedist 24/7, as it is Saturday evening. We reach the hospital and, paperwork sorted rather quickly, I walk in the respective office to a sudden cliché from Sartre’s Huis Clos.
Two staff are in the room: one behind a computer, constantly clicking what probably is a version of Solitaire, and the other one at a desk in front, his elbows on this oversized register. The latter asks the usual questions, fills in his book, while the former lazily raises his eyes from the computer only for a second as I remove my boot and, seeing my swollen foot, declares while not interrupting the mouse clicking:
‘I hope you have brought along your pyjamas’
They both have a good laugh and then, after a while, Dr. Laurențiu Mateescu appears, asks a few questions and sends me for an X-ray, for which they call a wheelchair and an assistant that keeps on chewing at his tongue in the absence of a sausage. The transfer to the X-ray room goes along a rather narrow and twisted hallway, while the assistant probably enjoys racing, as he speeds up and takes turns sharply, so that only through last minute, quick movements I manage to stay only with my broken ankle and not add any further broken knee. The hallways talk of what should be but an infamous past: scratched, with subsequent layers of aging, peeling paint and dirt everywhere. We get the X-ray done and head back to the doctor. While waiting for him, shouts come from the hallway and I recognize the assistant that pushed my wheelchair: an old lady with a severe problem is lying on this stretcher bed, her face up. My assistant brought her in but, as he left for a couple of moments, the lady took out RON 10 and handed it to whoever she thought had brought her in, which happened to be another assistant. Now the two argue and my assistant shouts and badly curses at the other one to recover the money that was due to him. The violent argument that is about to turn in a fight goes on while the ER operator fruitlessly asks for an assistant in one of the hospital sections.
The doctor comes and looks at my X-ray, concluding there is nothing broken and it is only about a sprained ankle. He decides a 14 day cast and an anticoagulant will do; of the latter he wrongly prescribes a 0.4 ml. dose instead of a 0.6 ml. dose according to my body weight. He then mentions I can remove the cast and replace it with an ankle brace on Monday when shops open. The consult paper fails to mention the severity of sprained ankle or the type of brace needed; when asked, the doctor mentions: ‘any ankle brace will do’. I am yet to find out there are many kinds of ankle braces and even those for sprained ankles are different, according to the sprain severity that goes from 1 to 3.
On Monday, feeling some unusual burning, I go to a dedicated shop to get the respective brace. While the physiotherapist there tries to cut the cast open so as to remove it and fit her recommendation of an appropriate brace on, the scissors hit one of the several, swollen blisters my foot is nearly entirely covered with: the cast was set too tightly and it was badly tailored so that my foot now looks like the Michelin character. She strongly recommends seeing the doctor about it. Intrigued about the lack of information about the sprained ankle and type of brace, as well as about the badly fixed cast, I decide to have a second opinion and call Dr. Alin Popescu, the sports doctor I have known for a few years but did not want to call on a Saturday. Learning of my condition, he rushes me (like in ‘you go there this very moment’) to Dr. Corina Răileanu at Medlife for an ultrasound test meant to provide a clear image on the sprained ankle situation, and then to an orthopedic consult at Sanador. Dr. Codrin Huszar, the orthopedist there looks at the same X-ray of the University Emergency Hospital and shows me what he clearly sees as a fractured talus. The ultrasound test shows fractured tendons and blood clots in two toe joints due to the impact stress. The doctor wants to see whether there are any complications and I do a CT. The latter confirms the comminuted fracture - it is thankfully stable, nothing is displaced, so fixing it with Titanium screws is not a must, even though healing takes longer without them. Past a couple of weeks of next to daily check-ups while blisters and their scars heal, I am looking at one month in cast followed by another month and a half in a brace, always non weight-bearing, as the talus is one slowly sealing bone; 3 months’ worth of rehabilitation exercise then follow. In the end, take it as a recent experience-generated precaution, but I do not call it a closed business until I send the final CT results to Germany and get the verdict coming from a specialized doctor at the Schön Clinic in Munich; for some reason the fact that they answer specific questions by email within 30 minutes shows a considerably different approach and service. The price to pay? I reckon not much higher than that in a private hospital in Romania - or the equivalent bribes in a public one.
Back to Romania and the case study, questions naturally arise. Did Dr. Mateescu order all necessary investigations (an ultrasound or MRI test, as the X-ray test is irrelevant for soft tissues) so as to see the sprained ankle severity or whether there were any complications to it? Did he see the fracture on the X-ray? Was the staff incompetent or plain careless when badly tailoring and wrongly fixing the cast on? Then, the broken bone aside, as they did not apply any disinfectant before putting the cast on, what would have happened had I not decided to go for the brace, as blisters opened the days to come? Had Dr. Popescu, Dr. Răileanu, respectively Dr. Huszar not come around? Or, for that matter, had I not guarded my knees en route to the X-ray room? As for walking on a comminuted fracture talus 14 days after the accident, that is not a question, but rather an answer all by itself.
A couple of weeks following the accident, a colleague asks me whether I intend to take Dr. Mateescu to court for malpractice. I do not. First, because the doctor and the system he works in have already taken too much of my time. Second, because the doctor is not the only faulty one: I consider just as guilty the obedient patient bribing public hospital staff and hence not only supporting a corrupt, faulty system, but being part of it and helping it grow. Both parties involved in an act of corruption at the base of a malfunctioning system are equally guilty. As for myself, I take it as my mistake to have considered the public hospital as a viable solution to my problem. Case closed.
When all is said and done, while the story above obviously has its share of subjectivity and frustration - generated ado, it also shows the statu quo of the public medical system in Romania. And while this is not to say that any consult at a public hospital in Romania will automatically lead to a similar output, it only shows the risk there is for something like this - or similar to this - to happen. But in the end of the day, chance taking comes as a personal option and effects are but self-borne.
