Monday, 26 May 2014

Ambulance in the playground: Comparing two bloody children's heads across 30 years of post-socialist health care

Photo courtesy of

The child fell down smoothly. As if in slow motion I could see him leaning ahead behind one of the solid concrete benches, installed in the playground by an unknown genius of child-safety design.  Within a second just enough for me to turn my eyes from my daughter Maia’s unsuccessful attempts to hit a badminton ball with a racket I move my eyes on to him, just to see him raising up from behind the bench crying. Something dropped from his head.

“Look, he broke his head,” I muttered unbelievingly while already getting hold of the crying child. A Hungarian mummy was standing just a meter away, staring helplessly at us with her bright blue eyes. I was right, blood was leaking from under the little boy’s blond hair onto his scarf and t-shirt. That had to be stopped. “Szalfeta(napkin)?,” I turned to the young woman who kept staring at us like paralyzed. She was looking at the blood in panic, and suddenly starting speaking very fast in Hungarian, a language that I am far from understanding well. It did not seem like she understood what I asked for. “Szalfeta,” I repeated, “szalfeta”? It took her another bling to understand: “ah, igen, szalfeta,” she reached quickly into her handbag, “tesek, chak piszkos,” she said apologetically, handing me a neatly folded napkin. Never mind. I pressed the tissue onto where the blood seemed to be coming from, while the boy was screaming his lungs out. I then took his hand and said firmly “It’s OK, Lauri,” then  pressed his own hand onto the improvised bandage. “Hold it on,” I said, while leading him to sit onto the nearby wooden bench, far from the concrete ones. There I called Emese and told her that Lauri had fallen on his head and was bleeding, so she should bring his mom over to the playground and some proper bandage. And she should call an ambulance, I concluded. Emese was thrilled.

Lauri was the son of Seija, Emese’s childhood pen-friend from Finland. The two of them had arrived for a weekend visit to Budapest and were staying over with us at our flat. Lauri spoke no other language but Finnish. But he was a very bright 7-years’ old who was following promptly my instructions issued to my own kids earlier that day – to clean up their room and put their toys in order. So when time came for the usual afternoon playground time, I proposed to take him along and Sheia did not mind. Maia, also 7, was quite happy, as she seemed to be growing fond of Lauri after 2 days of suspicion. After a sudden rain shower in the afternoon the playground was almost empty, and the weather was fresh, so I initiated a badminton game with her while her brothers were digging the deepest-ever tunnel in the sand. Lauri sat down on the concrete benches watching us, then apparently decided to start jumping from one when the accident happened.

Emese and Seija arrived running within a minute or so. Lauri had stopped crying and was holding the tissue tight onto the wood. No blood seemed to be dropping from it any more. When he saw his mother he gave her a bit of crying of course, but she soon realized that the wound was very tiny. Short and strong-built with a mostly motionless face and light grey-blue eyes, which suddenly light up in a big short smile. A mother of five, she had apparently seen a lot, and was quick to tell me how Lauri had a similar accident already at the age of 1. If it were up to her she would probably not even call an ambulance, but Emese had already done so, following the advice of other Hungarian mums and dads around us. Sheia was in possession of an EU health card on her so cost should not be an issue. Some 3 – 4 minutes later a siren was heard and a Volkswagen ambulance car parked straight in front of the playground’s gate, following my intensive waving and gesticulation showing the way into the Vermezo park from the nearby Miko street.

A doctor and a nurse, both male and both in shiny red and yellow emergency suits helped each other applying some iodine substance on the wound. Supposed not to hurt at all, according to them. Then the ambulance transported Lauri, Seija and Emese to the St. Janos Hospital. An hour later they all returned, with Lauri’s wound cleaned and glued, and all in perfect mood, in spite of having queued among tens of other kids who had got hurt in the warm and inviting Budapest May Sunday afternoon. “All in all Hungary’s emergency health care showed a decent face,” Emese concluded later in the evening, after the Finnish guests and our own kids had retreated into their bedrooms.

A good face amidst extremes.

On the day of the European Parliament elections and 10 years after accession to the EU Hungary seems to have preserved the key features of its former socialist universal health care system, and adjusted it to capitalism where possible. The final result appears a bit clumsy and is routinely criticized as not sufficiently reformed – mostly by Hungarians and the mainstream press which reproduces stable “transition” clichés according to which whatever existed during socialism was wrong and supposed to be replaced by some ultimately better free-market alternative. But Hungary today seems like a ‘best of two worlds’ – at least in comparison to two alternative health care models that we have experienced: of Bulgaria and the UK. Although much more abundantly funded, the latter is subject to severe austerity and cost cutting pressure for decades. This results in significant deterioration of first instance patient care, which is essential for prophylactics an early diagnostics. It is simply hard to visit one’s GP or medical practice, and even harder to get any thorough tests or specialized treatment on time. Hospital care is of generally good quality, depending on the particular hospital and region, but cost cutting measures affect it as well.

Although incomparable to the UK at first glance, the story of Bulgaria’s health system over the past 25 years offers a striking example of how bad things can get when similar “market-oriented” austerity driven reforms are implemented indiscriminately without proper strategic planning and in conditions of endemic corruption , corruption and nepotism. Its starting point would be some 30 years back in time, when the country’s then socialist health care was at its best, reaching to each and every citizens through a network of ‘policlinics’ in the towns and ‘health service’ points in the villages, connected to regular hospitals in all regional and most municipal centres, and a range of academic hospitals and research or public health institutes in the capital and major cities. All these were completely owned, run and funded by the state.

Lauri’s case in Budapest of May 2014 reminded me of another quite similar one that took place back in the spring 1984, that I was the primary culprit of. Back then I successfully tore a long whole in my 11 years’ old head by sticking it with full force onto a sharp end of a telephone and phone book tablet made of cast iron. I recall well the surprise and frustration when what felt like a warm rain of blood started pouring down my face and onto the thick carpet at a friend’s sleek apartment. The friend, aged 9 and deadly scared himself, managed to supply me with a cotton handkerchief which I stuck to the pulsating wound on my head, mostly in an attempt to prevent the blood from further staining the apartment. It did not even occur to me to call an ambulance and I gave a run to the district Policlinic whose location I knew all too well from numerous visits with my parents. It took me less than 10 minutes to run there, waiting for my terrified younger brother who was trying to catch up without saying a word. 

The policlinic had a designated section for children with a separate reception, which is where I knew I had to check in first. The most impressive feature of this reception was an automated registry holding hexagonal drum, the size of a small car, which contained hundreds of health record card-books. The receptionist operated it by pressing a button to rotate it to the desired side, from where she could produce my record within seconds. Judging on my condition she then ordered me to run straight up to the third floor where there was a surgeon’s office, among all other medical specialists. Less than 15 minutes later I walked proudly out of the door, with my head stitched and bandaged abundantly, just like the heroes in the then popular TV series glorifying an alleged mass anti-capitalist partisan movement in Bulgaria during the Second World War.

Apart from separate sections for children and pre-natal and new-born care, the facility featured a fully functional chemical laboratory, X-ray cabinet, quarts radiation healing room, and even a dentists’ office, all fully available and fully free of charge. The policlinic was attached to a larger building, where Sofia’s Second City Hospital was situated. As a matter of fact, the picture of socialist-times health care was not all shiny and bright, especially in the country side. Waiting times were long and facilities appeared warn out. And  the culture of privileges that was the most disturbing characteristic of socialism translated into special treatment for different categories of people,  But equipment was functioning, supplies were sufficient, medicines were subsidized or free of charge, medical doctors and other personnel were paid as (un)decently as everyone else and received respect and gratitude.

Most of this is lost today as a result of the ill-planed and badly implemented market reforms of Bulgaria’s post-1990 health care. With a few notable exceptions, such as dentists, gynecologists or heart surgeons, medical specialists are underpaid by the state and forced into a humiliating quest of securing tips, bribes, and often using their state jobs to secure and treat patients privately. Support staff is chronically lacking in state hospitals, and so are basic supplies. Until recently patients were expected to bring sheets, cutlery, and pay in cash for the medical supplies used. A state health fund put in place with the idea to generate the revenue needed for maintain health care and subsidizing medicines has turned into a great source of disappointment. Inefficiency, abuse of funds, profiteering and outright corruption are among the accusations against the fund’s management, often heard in public and mass media. 

An unhealthy and unclear mixture between state support and regulation and expected profit-making hampers the work of hospitals and makes the plight of ordinary patients a living health, in which they receive unreliable and bad quality service, but are constantly required to pay for privately, often under the counter. Emergency health care is unpredictable, with stories of human lives being lost due to late arrival of ambulances of shortage of available hospital beds competing in the news pages with never-ending tensions of emergency surgeons and other specialists, whose payment levels are inadequate for the levels of stress and responsibility endured Subsidized medicines are limited in number and inadequately chosen, shortages of vital medicaments such as insulin are frequent, and a monopoly-driven and over profiteering pharmaceutical industry makes quality health care practically unaffordable for the majority of the population.

In contrast to all this, Hungary seems to have found the middle way, but maintaining an acceptable standards of universally accessible health care, maintaining old formats like district child, natal and prenatal care centers, combined with a relatively better established and competitive market of private health care options. A centralized computerized register of all patients makes access to state-funded health care and subsidized medicines quite straightforward, and emergency aid arrives on time, as in Lauri’s blood and tears playground incident.