Friday, April 9, 2010

Health Care Reform

From the perspective of an expat, the current furore in the U.S. over health care reform has a somewhat surreal appearance.  I've lived in lots of countries, all of them democratic (more or less) allies (to one extent or another) of the United States.  All of them had one thing in common:  a public health system intended to provide some level of access to health care.  Sometimes the services on offer stretched the definiton of "health care" like matter being sucked into a black hole, but there was always something.

Albania is no different.  There is universal state-funded health care.  Everyone pays.  Everyone can benefit.  This system was introduced by the communist regime in the 1940s as one element of their plan to drag the country kicking and screaming into the 19th century.  Education, medicine, and electricity were made available to nearly every village in the country, regardless how remote.  Imagine the impact those efforts must have had!  In a village where sunset dictated the end of all productive activity and literacy was virtually unknown, suddenly the pine torch was replaced by electric lights which made it a whole lot easier to learn to read and write. Modern medicine arrived to displace traditional folk cures. 

It's still trying to this day.

Just as the Greeks, Romans, Byzantines, Serbs, Venetians, Turks, Italians, and Germans all learned, you can impose change on Albania fairly easily.  Getting Albanians to accept the change is a whole other tenxhere of grosh.  No matter how much the people seem to have adopted the poltics, science, or religion brought in from foreign lands, they still cling tightly to their cultural heritage. A cautionary tale for today's health care providers, environmentalists, and evangelical missionaries.  Mormons, I'm looking at you!

Really, how can modern medicine win against raki? According to many a gyshja, this fiery distillation can cure so many ailments.  Teething pain?  Upper respiratory infection? Angina?  Just rub a little raki on the area in question and let the healing begin.  You don't necessarily have to rub it on the affected area.  Heart problems call for a dab on the inside of the left wrist. Usually followed with a stiff belt of internal oral application.  Just to be sure, of course! 

"Raki - The cure for, and cause of, most of Albania's  ills."

Influenza also calls for the raki cure, among others.  Nowhere in the world have I seen such a level of concern as flu season approaches.  Right about the end of August the paranoia starts to build and every discussion is laced with apprehension about the coming gripe pandemic.  Heaven forbid you sneeze in late August or early September.  Each "achoo!" is met with concern, advice, admonition for not dressing warmly enough, and the offer of a shot of raki.  It's but a short journey from allergies to alcoholism here!

Cold and flu sometimes requires more drastic intervention.  If the raki isn't working and no amount of wrapping up in endless layers does the trick, you gotta bring out the kupa (cups).  More precisely, glasses.  The patient lies on his stomach, bare back exposed.  A series of small drinking glasses are heated by flaming balls of cotton dipped in rubbing alcohol (or even better, flaming raki!).  The hot glasses are placed strategically on the "patient's" back. While he writhes in agony, the sickness is drawn out.  Once he has enough red circles branded on his back, he's wrapped up, given a shot of raki, and sent to bed.  Another successful operation is done.

Garlic and olive oil have their own curative powers, especially in the company of raki.  Drinking a glass of milk with a heaping teaspoon of baking soda stirred in cures coughs and blood pressure issues.  Mixing lule basani (St. John's Wort) with olive oil (or raki!) is a general cure-all for skin conditions, scalp problems, ulcers, and hemorrhoids.  Rubbing salt and onion on a contusion prevents bruising.  Yogurt and olive oil will calm a bad sunburn and prevent peeling.  Medical treatments sound so much like recipes for marinating  meat I  suspect the doctors and chefs attended the same college!

Not all of the cures fall into the category of ancient homeopathic treatment.  Albanians have embraced modern pharmaceuticals with gusto:  The formal medical system of prescriptions and quality control?  Not so much.  Pharmacies spring up in Tirana almost as fast as electronic gaming bars pompously calling themselves "casinos." 

"It was either this or a casino."

You can buy antibiotics, statins, analgesics, mild narcotics, and just about any other pill, potion, or pomade with no prescription.  Pharmacists will listen to symptoms and offer their solution and Albanians will take them at their word.  "If this helped your cousin get over a headache, then it's going to help me," they reason.  "Anyway, the pharmacist is burre i mire (a good man) so I trust him."  Never mind that he has no medical training and learned everything he knows about drugs from watching dubbed episodes of House and from reading the pamphlets that come with the cheap samples his distributor is pushing on him.  Oh, and he may neglect to tell you his cousin had a headache from falling down the steps which may or may not be relevant to your migrane.

Such blind trust is nowhere to be found when it comes to doctors.  State doctors and nurses are overworked, short of supplies,  and very poorly paid.  The inevitably bribery  that springs from these conditions does nothing to improve the doctor-patient rapport.  The doctor eyes the patient as a sheep to be fleeced.  The patient just wants to get through the process with the malfunctioning organ removed and all the others left intact.  The quality of care you receive depends entirely on who you know, how much you are willing to slip under the table, and how diligently you watch every step of the way.  If you don't demand to see the appendix, how do you know it was really taken out?

Doctors in private practice aren't necessarily any better.  Their facilities are newer and they showcase some of the most modern equipment to be found.  Unfortunately, what is often lacking is the ability to interpret the results of the tests or use those results to come up with a reasonable diagnosis.  The TV show Fiks Fare recently did a segment where their journalist took a jar of "urine" in for private lab testing.  The yellow stuff in the cup was actually a soft drink, but that didn't stop the vast majority from returning the results of the "urine" test complete with data and graphs.  That says something... either about the competence of the lab technicians or the recipe for a certain popular fizzy drink!  Only one lab returned the sample and admitted they didn't know what the hell it was. 

"Is that pronounced 'Ivi' or "Wee Wee'?"
Despite the drawbacks of conditions here, people still have babies, get sick, have surgery, get in accidents, and recover.  The state health clinics provide cheap preventive care even after you factor in the baksheesh.  Children register with a primary care center and they get reminders to come in for vaccinations like clockwork.  Costs of medecine is much lower here than in the U.S. and most of those drugs are subsidised by the national health plan.  A course of antibiotics that would cost $100-300 in the States goes for about $50 here.  Before subsidy.  Dental care?  Cheap.  Doctors still make housecalls and that costs you about $30, including two follow-up visits.  I was chargd $100 for an MRI of my spine and probably paid more because I am a foreigner.  If you did the same thing in the States you'd be out almost a grand. 

So the argument goes on.  Socialized medicine or private care?  Cost versus service availability?  Recission? Medicare donought holes? Pre-existing conditions? Mandates?  Death panels? Bending the cost curve?  Who's right?  What's best?

Who am I to say.  I'm tempted to cast my vote with the school of medical thought that suggests curing colic in babies through the application of hashish, follwed by a stiff shot of raki for the parents!