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Asthma in Timisoara: A Glimpse at the Romanian Medical System

by Richard Seltzer


Originally published in The New York State Journal of Medicine, Volume 89, Number 5, May 1989. Copyright 1989 Medical Society of the State of New York. Posted here with permission. Contact the author at seltzer@samizdat.com


We just returned from a trip to Romania, where our son Bobby played in the World Under 14 Chess Championship as the representative from the U.S. There, unexpectedly, we got a glimpse of the Romanian medical system and became friends with a young Romanian doctor who aspires to become a surgeon.

July 25

The eight tournaments (World Under 10, Under 12, Under 14, and Under 16 Championships for boys and girls) are being held in Timisoara, an industrial city of 300,000 in southwestern Romania, near Yugoslavia and Hungary. Arriving by plane from Frankfut, the land looks flat and fertile -- large fields of corn and wheat are interspersed with stretches of forest. On the ground, it looks like Indiana.

Recent emigres advised us not to drink tap water and not to eat the meat (for fear of hepatitis as well as intestinal disorders). Meat was likely to be stale, poorly refrigerated, and handled without western concern for cleanliness. They told us to bring canned meat, chocolate, and coffee. The said we would not be able to obtain milk.

In a fertile land, next to Yugoslavia, which is now bursting with ripe grapes, plums, and watermelons, fruit is very hard to find here. We are surprised that there are no street vendors in the parks, and the stores have no fruit.

Today, we saw bakeries with idle sales people and no baked goods -- not even bread -- for sale. Fruit and vegetable stores have nothing but cabbage for sale. A milk store had nothing but cobwebs on its shelves. A nearby meat store was empty the first time we passed. Later, we saw lines stretching outside and around the block.

It turns out that for almost everything that is worth buying, you need dollars, not lei, the local currency. The hotel bill has to be paid in dollars. And the shops in the hotel, that sell Romanian-bottled Pepsi Cola (with a strange bitter-sweet taste) and bottled water, only accept western currency.

On the flourishing black market, a dollar is worth 80-90 lei, in contrast to the official 8-9 lei exchange rate. The risks of a foreigner running into trouble with the law are great, and hardly worth the risk.

Because of the underground economy and the relative uselessness of the local currency, Kent cigarettes have become an unofficial medium of exchange. A package of Kents makes an excellent tip. Fortunately, we had heard that before and brought along a couple of cartons.

Outside the hotel, there is very little to be purchased. The department store nextdoor has unappealling, machine-made goods, displayed on dark shelves. Because of a perpetual shortage of electricity, there are no lights on, and the escalators have not operated for years.

At every other street corner, someone huddles up against the wall and opens a canvas bag, and pasersby swarm to buy black market merchandise -- typically cigarettes and foreign goods.

July 30

After breakfast, standing in the lobby by the stairs, I was talking to the mother of Hedinn Steingrimsson from Iceland. Hedinn is sick. He collapsed and had to be taken to the hospital. He's in their room now, resting. She doesn't know if he'll be strong enough to play when the tournament resumes tomorrow.

Darshan Kumaran's father came along. (Darshan is representative from England in the Under 14). I hadn't known that he is a physician. Concerned about Hedinn, he inquired about the symptoms and what the Romanian doctors had done.

Hedinn had had stomach troubles and diarrhea. He had severe headaches and felt very weak. When he fainted, his mother had been afraid it had something to do with the heart. "No," she answered Dr. Kumaran's question, "he never had trouble with the heart before."

They gave him calcium. As a dietician, she understood that was because of the lack of calcium -- no milk in the diet here in Romania.

"How did they give it to him?" Dr. Kumaran asked, with considerable concern. "Tablet or injection?"

"Injection."

"My God, that's dangerous. He's all right now. That's fortunate. No need to worry now. But such an injection could have stopped his heart. It's normal to be weak from diarrhea. There is nothing wrong with his heart. They should never give an injection of calcium in those circumstances."

"But I didn't know."

"If he is sick again, call me. Talk to me. Let me talk to the Romanian doctors."

At lunch, the head of the British delegation told me that seven of their players are sick, with stomach troubles.

July 31

Last night, while we were playing cards in our room, Bobby started sniffling. He had had a slight head cold for days. How could he catch a cold when it's 100 degrees outside and there's no air conditioning? Maybe he's allergic to something, and we shouldn't have opened the window.

About midnight, when the card game ended, Bobby went running up the stairs to the sixth floor with the other kid and came running back. When he returned, he was breathing heavily, coughing and wheezing. We tried to calm him.

He had previously had some asthmatic symptoms associated with bronchitis, most recently a year ago. So we had brought along his Ventolin "inhaler." And on several nights, he had wheezed a bit and taken medicine through that inhaler. Tonight that medicine had no effect.

For an hour and a half, he struggled to find the right position or achieve the right state of mind for the problem to subside. But it was becoming increasingly difficult and painful to breathe. By 1 AM, he was desperate. He needed to see a doctor.

I went to the front desk at the hotel. At first the woman at the desk could not find the doctor who was assigned to the hotel for the chess tournaments. She called another hotel. The doctor there wasn't in. She got the number of another doctor. I asked her to please call Dr. Kumaran. She did not know what room Dr. Kumaran was in and couldn't find his name in the hotel register.

Eventually, she located the doctor assigned to our hotel.

At 1:20, the hotel doctor came to our room. He looked at Bobby, who was leaning over the sink trying to breathe and said, "It seems he breathes fine." I tried to explain in more detail Bobby's history of asthmatic bronchitis. Without examining Bobby, without even getting within three feet of him, the doctor recommended taking him to the hospital for "an injection." He explained that he was "not a doctor for children" and could not "be responsible" for treating Bobby. Bobby had to go to the children's hospital for treatment.

I was reluctant. I wanted to talk to Dr. Kumaran first. I went back to the front desk. For an interminable time, the very patient and helpful woman at the desk scanned the hotel's two handwritten registers and could not find Dr. Kumaran listed. I asked her to call someone else from the English delegation. This person gave her Kumaran's room number -- 511. She dialed his room, and I explained the problem. He did not know me by name (at least not at 2 AM, just woken up). But he did come within five minutes.

Dr. Kumaran agreed that Bobby probably needed a hydrocortisone shot, but said a slower working pill might bring relief in about 45 minutes. We decided to try the pill, which Kumaran fetched from his room. Both doctors left.

For over half an hour, Bobby struggled again to calm down and achieve normal breathing. There was no improvement.

The Romanian doctor returned. We asked him to please call an ambulance. Dr. Kumaran returned and gave additional advice. The ambulance arrived, and I rode with Bobby to the hospital.

The ambulance was called at 3 A.M., and arrived at 3:05. Bobby was under observation in the hospital (about half a mile away) by 3:15.

A team of medical people briefly examined him and asked me questions, with the doctor from the hotel acting as interpreter.

They asked my permission to give Bobby a hydrocortisone shot. (It helped my sanity that Kumaran had already advised that.) They then took him upstairs to another room. There they prepared the injection and gave it to him while I sat and watched.

The white metal table beside me had a slightly open drawer.

While I watch them treat Bobby, a cockroach scampered in and out of that drawer.

There was a blood stain on the sheet Bobby was lying on. At the time, I thought it was there before they put Bobby in the bed -- that fed my fears of unsanitary conditions. Afterwards I realized it was blood from Bobby, when they gave him the injection.

The syringes were not disposable. They appeared to be made of glass and had been used many times. The needle was inserted into the patient's arm and then the glass container with the medicine was screwed onto it.

Along with the hydrocortisone, they gave Bobby something to help him sleep. Very soon, his breathing returned to normal, and he drifted off to sleep.

Every ten minutes or so the head doctor (a woman who spoke no English) returned to listen to his breathing.

The doctor from the hotel stayed.

The first time he had come to our room, back when I wishfully thought that the pill from Dr. Kumaran would do the trick, I had offered him a package of Kent cigarettes as a thank you. He had refused and seemed professionally offended by the gesture. Now I explained that I appreciated his help and simply wanted to thank him. Was there anything, such as books, that I could send him from the U.S. as thanks?

That led to an hour long conversation, during which he enjoyed practicing his English and I got some insight into the Romanian medical profession and came to respect his good intentions and competence.

They attend high school until the age of 20, then take tests for the university. Only about one in eight passes these tests.

University is free, but you can only enter if you pass these tests. If you want to become a doctor, you must attend the university for six years, then have three years of residency, after which you must pass another test. But for several years now that test has not been given; so he is stuck in limbo. After he takes and passes that test, he will have three more years of residency in his specialty (surgery).

His "chief" had the extraordinary good fortune of being able to study at Johns Hopkins on a U.S. fellowship.

Doctors in Romania are paid about 100 lei per day. In U.S. currency, at the official rate, that would amount to $12.50. At the black market rate, it is only $1.25. (Although he didn't say so, this is almost certainly supplemented with black market dealings.)

Foreign medical books are almost impossible to obtain.

Standard texts like The Textbook of Internal Medicine by Harrison and Textbook of Surgery by Schwartz sell for $85 in the U.S. He would have to work about 68 days and save every penny to get enough U.S. currency to buy one such book.

The doctor gave Bobby an assortment of pills -- prednisone, enfilin, calcium and something to help him sleep. Now Bobby cannot eat anything with salt because the salt would interact with the medication. That means he cannot eat the canned meat and crackers that we brought with us. The restaurant in the hotel will prepare special salt-free meals for him.

August 1

Bobby had another bout with asthma this morning. Again he went to the hospital. Again they gave him a hydrocortisone injection (this time, three vials full).

Seeing the children's hospital in the daylight, I could see that the building must date back to before 1900 -- it looked like an old monastery complex in bad repair. Stone, in need of a new cost of whitewash. An exterior wall, also needing a white wash.

Inside, plaster peeling from the walls. Even the upper stories have the look of a basement. To conserve electricity, there are almost no lights on in the halls, very dark at noontime.

They also provided enough enfilin and prednisone pills to last for the rest of our stay. When our supply of calcium pills ran out, we were given calcium in liquid form in glass tubes that could only be opened by cracking the glass (which is very hard to do without getting particles of broken glass in the medicine).

Bobby has played very well while sick. The weaker he is, the more determined he gets. Yesterday, after staying up most of the night with asthma, he made a mistake on move 9 that should have cost him the game. But he played confidently, as if his mistake were a deliberate sacrifice; and his opponent, Eliet from France, proceeded cautiously and didn't find any of several possible winning plans. Bobby got the upper hand, and at move 20, Eliet resigned, in a hopeless position. Then today, even more exhausted from his second bout with asthma, he beat Faybisch from Belgium in 22 moves.

August 2

The cold symptoms have returned and become far worse. Bobby is constantly coughing and sneezing. The doctor has given him penicillin pills, along with the other medication.

Today, he played one of the finest games he has ever played -- not for flashes of brilliance, but rather for firm control of the position -- carefully analyzing his own and his opponent's options many moves in advance, finding the best plan, and executing it well.

By evaluating his opponent's threats precisely and providing no more defnse than necessary, he could gain a tempo or add a piece to the attack. It was like the performance of a race-car driver who lets his vehicle go on two wheels around a difficult turn -- a well-calculated risk that provided a winning advantage.

August 3

Round 9 was a battle of the walking wounded -- Bobby versus Hedinn. Hedinn looked like an Arab, with a wet cloth wrapped turban-style around his head. Bobby was well-armed with handkerchiefs for his runny nose.

They had played last year in Puerto Rico. Bobby had lost then, but theirs was one of the best games in the Under 12 championship tournament.

This year, after a slow start in the first few rounds, both Hedinn and Bobby needed a win to climb back on top. Actually, in a closely-matched tournament like this, it looked like eight points might be enough to tie for first -- so they both needed wins in the last three rounds.

Hedinn, as white, played a line that offered many traps and quickly led away from familiar positions. Underestimating the dangers of this line, Bobby accepted a pawn sacrifice and quickly found himself in a stranglehold position -- unable to castle or develop, while Hedinn relentlessly added pieces to the attack.

It was a painful experience, probably far more painful than his worst attack of asthma.

August 6

In round 10, Bobby beat Zhu from China. And today, in the last round, he was paired with Chatalbashev from Bulgaria. While the game was in progress, I took a walk around the block. When I returned, there was an ambulance at the door. A crowd had gathered near the stairs. They were carrying a child out. I struggled to get closer. No, it wasn't Bobby. It was another player, a young girl.

When we said goodbye to our doctor friend tonight, he told us that two players in the tournaments had had appendicitis and had had to be operated on immediately.

We were quite fortunate that Bobby's was only a minor problem.

August 7

Despite the shortages, we saw no evident discontent, no signs of imminent rebellion. We saw armed guards at the airport, but nowhere else. This was simply a different way of life that people were used to.

In fact, the shortages, the rationing, and the black market that they give rise to are part of the system of government. For instance, each family is rationed just 30 liters of gasoline per month (not enough to fill the tank once) -- the only way to get enough to meet ordinary needs is to resort to the black market.

The same is true for many other essential commodities. There is no milk, so to help their children grow properly and stay healthy, parents have to obtain calcium pills on the black market. So everybody uses the black market, and everyone knows the secret police are everywhere, watching everything -- taking notes and keeping files, but only prosecuting when it suits their purpose, always having enough evidence to put anyone in jail or to intimidate and manipulate whomever they wish.

Machiavelli would have admired this system of government by corruption -- it seems to be very effective. It seems to perpetuate itself and to require only a modicum of central direction and control.

In a nation where everyone feels compromised, guilty and at risk, it must be difficult to generate righteous indignation against the powers that be. Abstract notions of justice and human rights ring false here. An Oliver North might learn to cope here, but a Robespierre would be totally out of place. The survivors are those who can work with and around the bureaucracy, who know when and how to bend and break the rules.


 
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