Greek health system feels the pain of austerity measures
Daniel Dale Staff Reporter
ATHENS—Greece’s government has made deep budget cuts. And now the country’s doctors are cutting people open again.
Proud surgeons, some of them trained in the U.S., are doing large-incision gallbladder removal surgery for no good medical reason in 2012 — because their hospitals don’t have the money to pay for the tools required for the keyhole laparoscopy that is the unquestioned standard in the developed world.
“It’s not the rule — but even if it happens for one patient, it’s too much, and it needs to be discussed,” Dr. Georgios Papadoulos, a 39-year-old urologist at the large Gennimatas public hospital in Athens, said last Thursday. “If we were talking about something like this three years ago, it would be a joke. Now it’s not.
“The problem is, sometimes you need to compromise the treatment. You may say, ‘This is the best way, but I cannot do it, because we do not have what we need.’ ”
Drugs. Needles. Catheters. Gloves. Stents. Heart pumps. Surgical staples. All harder to obtain than at any point in recent history. None needed more urgently than today.
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The country’s budget crisis has triggered a health-care crisis at the same time as a crisis in mental and physical health. Doctors and nurses, working more hours for less pay with fewer supplies, are facing an influx of patients whose problems were caused or worsened by the same austerity program driving seen-it-all medical professionals to frustration, exhaustion and thoughts of emigration.
European Union leaders meet Thursday for a summit in which they will discuss their options for containing the continent’s debt troubles. On the table is a proposal to give European institutions the power to change the budgets of member states. It will surely be noted by critics that the budget changes foisted on Greece by European institutions have massively intensified the country’s social woes.
The rate of suicides and suicide attempts has soared. Hospitals report major spikes in the number of people walking in with ailments related to stress, depression, poor nutrition and drug use. And there is often little the doctors and nurses can do for them even when their cupboards are fully stocked.
Dr. Maria Mela, head of gastroenterology at the cramped, century-old Polykliniki public hospital in Athens’s poor Omonia neighbourhood, said she has seen a marked increase in patients whose issues — chest pain, irritable bowel, dyspepsia — are not being produced by anything that can be found on a gastroenterological test.
“We can help them up to a point,” Mela, 42, said last Wednesday. “At least we exclude all the medical reasons. And then we have to refer. Because they need to sit down and do some sort of psych therapy. They’re coming in with depressionlike symptoms, they’re coming in crying. It’s like — hell.” She grimaced.
Panagiotis Gourtzilidis, a burly 43-year-old plumber with a scruffy beard, sat in the Polykliniki waiting room last Wednesday with a vacant look on his face. He is unemployed. His wife is unemployed. His five children are unemployed. He has diabetes, but the hospital where he used to get his insulin says it can’t fill his prescription. So he goes pharmacy-hopping — until he finds a store that promises to pay him back at some later date if he pays the full $65 up front, instead of the traditional 25 per cent patient.
“I’m facing so many problems, in the future I might have to jump off a building,” Gourtzilidis said.
Greece’s reported suicide rate was the lowest in Europe — 3 per 100,000 residents — in 2009, the year the crisis began. According to the Greek government, it rose about 40 per cent by mid-2011. By all accounts, it has again surged significantly in the year since as the economy has deteriorated further, and as wages and pensions have been cut even more severely. So has the number of attempts.
The modern Gennimatas hospital, which vaguely resembles Toronto’s Sunnybrook, is in the outskirts of the city. Before the crisis, said emergency department nurse Angela Frangouli-Papadaki, it would treat perhaps three people every month who had attempted suicide — jilted lovers, the seriously ill. Now, she said, the ER sometimes sees 20 in the span of a few days, most of them driven to despair by their financial circumstances.
The patchwork mental health system is unequipped to cope. Overwhelmed therapists affiliated with the public health system are turning away all but the most urgent of referrals. Private therapy, like the parallel private health system as a whole, is no longer affordable for most of the middle class. And many Greek therapists, says veteran psychologist Athena Androutsopoulou, have begun to feel that they are only pretending to assist their clients.
“In psychotherapy groups, for this whole year, the No. 1 topic is the crisis,” Androutsopoulou, who holds a PhD from England, said in her sleek white-walled office on Sunday. “Not their symptoms, not their family problems. People are talking in their groups about the crisis. And this is very, very distressing for us. Because we can’t do anything about that. We don’t know how to help them.
“The truth of the matter is, we’d prefer people coming in with all sorts of psychological problems. Which we know how to deal with. What can we do with problems that are real? It’s not in their heads.”
She tells them to think of their parents’ and grandparents’ stories about the Nazi occupation — to remind them that people have survived worse. She urges them to summon positive thoughts. And she has them draw maps of their support networks to remind them that they are not alone.
But in truth, some of them are more alone than ever. Tight-knit Greek extended families, Androutsopoulou said, used to provide the aid that the state did not. “Now,” she said, “when parents and grandparents are having their pensions cut, salaries are decreasing, they cannot play the social support and protection role that they used to.” People who might have managed their mental health issues before the crisis are now attempting suicide, she said; people who might have made a half-hearted attempt are now finishing the job.
Crisis-related mental health issues are hurting even people who believe they are psychologically sound. Overwhelmed by new-found day-to-day challenges like paying the rent, urologist Papadoulos said, some patients now deny obvious warning signs, like blood in their urine, and allow problems to fester for months. When they do eventually come in, he said, they frequently show little interest in taking care of themselves.
“Yesterday, typical case. We had a lady with renal colic. She has four children: 28, 27, 24 and 17 years old. All of them unemployed. She was unemployed. Her husband as well. She came here, whatever we proposed, she quickly agreed with. Did not ask questions. Her attitude was, ‘We are all unemployed, who cares, do whatever you want.’ She had let herself go.”
The president of the union representing Polykliniki’s doctors and nurses, senior nurse Christos Papanastasis, works out of a bare office whose walls are adorned with images of Jesus, Mary and Greek Orthodox saints. One of them, of the patron saint for people with cancer, was a gift from a grateful patient.
Greeks with cancer and other serious illnesses now face a maddening new obstacle to survival. Because the government has been slow to reimburse pharmacies, many of them have shut down. The remaining stores, like the beleaguered hospitals, have little inventory — forcing outpatients like plumber Gourtzilidis to embark on scavenger hunts in search of the pills that keep them alive.
“The patient has to come here or go to another government hospital or to another one or to another one,” said a sighing Polykliniki nurse, Helen Tomprou, 39. “So it’s very difficult sometimes to find the medicines.”
In the port area of Athens last week, dozens of residents lined up outside pharmacies. For the many Greeks suddenly as cash-strapped as Gourtzilidis, even the traditional 25 per cent patient payment poses a dire challenge. One academic study publicized in April suggested that 90 per cent of Greeks are buying less medicine than they did last year.
The “troika” that bailed out the debt-ridden Greek government on stringent conditions — the International Monetary Fund, European Union and European Central Bank — has nonetheless imposed a hike in patient fees. The troika also forced the government to approve $1.4 billion in health cuts in February — over and above cuts of more than $2 billion since 2010 — even though Greece’s public health-care spending as a share of gross domestic product was among the lowest in the developed world in 2009.
“Major weaknesses still need to be addressed to increase the efficiency, cost-effectiveness and equity of the system,” the European Commission said in a March report.
Critics, such as the commission and the IMF, say major reform is long overdue. Greeks have long been forced to pay bribes to doctors, colourfully known as “little envelopes,” for expedited or improved care. Politicians have appointed ill-qualified cronies to top hospital posts. Administrative bureaucracy abounds. Cost-control policies have been nonexistent or ignored, and hospitals have regularly incurred large deficits the government has quietly covered. Over-prescription of medicines, and overreliance on expensive name-brand drugs, has cost the government untold billions.
And yet, for its numerous obvious flaws, the available evidence suggests the precrisis version of the system was “relatively effective” by international standards, in the words of the Organization for Economic Co-operation and Development. Patient outcomes were good. Many Greeks wonder why the troika prescribed shock therapy rather than a new exercise regimen.
“Three years ago, we used to spend money without taking care,” acknowledged Gennimatas interventional radiologist Nikolaos Ptohis, 38. “It was normal, OK. Now, it’s the exact opposite. The hospital says to us, ‘You have to choose between the cheapest things’ — and we fight about this, and say, ‘No, we cannot use the cheapest. Cheapest doesn’t mean it’s the best.’ It’s not good. There should be some criteria when doing something like this.”
Ptohis and many of his highly educated colleagues are thinking about joining the country’s growing brain drain. Their patients can’t go anywhere.
Before Vasiliki Michalopoulou’s husband died this year, his hospital had so few nurses on duty that she had to change him and get his pills herself.
“I did all the nursing,” Michalopoulou, a 65-year-old retired hairdresser, said at Polykliniki last Wednesday. Now “broke,” she attempts to manage a thyroid problem while battling with the government in court over the pension she says she is owed and dealing with a mind she says is betraying her.
She spoke calmly, with bursts of gallows humour, until she looked down at her pension documents. Then she broke into quiet sobs. “Now that I don’t have any money,” she said, dabbing at her eyes with a tissue, “I’ve started going mad.”
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