Black Sea Countries Health Systems

Gary Podolsky MD

Objectives :

1. To discuss the Health Care Systems of several countries we will be visiting as part of our Black Sea Cruise
2. Introduce and discuss specific problems unique to the countries.
3. Prepare our conference attendees for sights and opportunities of medical importance that they may wish to visit.

Ukraine

Ukraine translated roughly as "borderland" is now no longer "the Ukraine" part or USSR, Austria-Hungary, and Poland but is now its own distinct country. It is the second largest country in Europe, after Russia with 48 million citizens.

It has borders with Moldavia, Romania (Southwest); Hungary, Slovakia, Poland (West); Belarus (North); Russia (East); and with the Seas of Azov and the Black Sea.

Ukraine has existed as a distinct ethnolinguisitic area for over a thousand years but has been invaded and ruled by many groups, which has fragmented its identity.

An Abbreviated History

The history of Ukraine is fairly complex and some facts are still disputed but this simple sketch abbreviates the main points. Please see the references for more a detailed scholarly review as these represent the best available books in English.

Kyiv Rus

The Kyivan Rus culture was established on the Dneiper River for trade with the Black Sea with influence from the Varangians, a Scandinavian group. This was very prosperous. This state declined as rival princes fought each other for succession.

The Mongol Golden Horde

Tatar invasion further diminished autonomy as parts of Ukraine became under outside control.

Lithuanian Rule

The Lithuanians drove out the Mongols and began to govern Western Ukraine. Later the Lithuanians declined and this territory passed into Polish Control. Under Polish landlords a severe feudal society developed. Serfs were so under control they needed permission to marry and were not permitted to leave their villages.

Diaspora

Many Western Ukrainians migrated around 1900 to Britain, USA, Brazil, and Canada during the "Diaspora" period. Many of these settlers came to Manitoba accounting for this large segment of Ukrainians from the same immigration wave. For varying political reasons this avenue of immigration was stopped.

Western Ukraine later became part of the Austrian-Hungary Empire then Austria-Hungary with strong Polish influence in this territory.

Communist Rule

Russian control (Tsarist, Bolshevik, and Communist) influenced Eastern Ukraine at different times.

During World War II Ukraine incurred heavy damages and mass executions under Nazi occupation. The Western part became part of Lenin's USSR.

Rada Government

In 1917 Ukraine was briefly independent but this was a very short-lived government.

A Carpathian Ukraine also declared its independence but this only lasted months.

Under Stalin the Ukraine was subjected to a man made famine and suppression of freedoms.

The Chernobyl incident poisoned the immediate surroundings. It has led to increased rates of cancer for those living close. Kyiv is 100 km south but was not directly affected although Soviet officials dispersed radioactive soils and products to areas outside of Chernobyl.

In 1991, the Soviet Union fell and Ukraine became independent. It had huge debts to Russia and there was an increase in crime.

In December 2001the Orange Revolution allowed a clear departure from Communist Influence.

Much of the world does not understand Ukraine because much of the information communicated was second hand through Russia and heavily screened. Ukrainians have always occupied their land with a specific language and culture that had been denied and suppressed by their conquerors (the Mongol Golden Hoard were an exception as they did not interfere with the lands they controlled). Ukrainian society today also has Polish and Russian influences but must be viewed as a separate culture.

Odesa (Odessa), a city organized by Catherine the Great had been set up as a Free Trade Port and has always been cosmopolitan with many languages and ethnic groups freely meeting.

Crimea

This area traditionally had not been part of Ukraine but was placed as part of Ukraine by the USSR and has remained such after 1991. Stalin to Siberia displaced the original Tartar population, with some now returning to make up only 10% of the population.

Note that many Ukrainians may have families with mixed parentage so that one household could have more than one language or ethnicity making such demographics difficult to interpret.

*Many Jews have emigrated to Israel in recent years and their proportion is declining. In the past they were victims of pogroms (purposeful exterminations by peasant rebellions and occupying forces).

Since 2005, President Yuschenko has allowed freedom to speak one's own language although Ukrainian is the official language.

Figure 1 St Sophia Cathedral in Kyiv (Kiev)

Health Care Beliefs

Modern and acute sick care is practiced.

The population understands preventative medicine but smoking and alcohol abuse by young and middle aged people is present. Hard manual labour in rural areas and stress because of economic problems has caused illness.

Recently healers and those with "extrasensory perception" have expanded their influence.

Health Care Practices

There is a state system of health care prevention with hospitals and specialty facilities (paediatrics, oncology, maternity, etc.). Polyclinics are run with an emergency physician screening patients for same day referral to a specialist in a polyclinic setting.

Doctors will visit patients at home in ambulances after hours.

Sanatoriums and Health Resorts (General Health Resorts, Children's Sanatoriums) are popular. Balneological hospitals exist where patients are treated with mineral water, silt and salt.

Recently many smaller hospitals have been closed.

Major Illnesses

Cardiovascular 847 deaths/100,000

Malignant Disease 193deaths/100,000

Traumatic Deaths 147/100,000

Infectious Diseases 22 deaths/100,000

Tuberculosis 17 deaths/100,000

Thyroid disease from Iodine deficiency in the soil and water is common in Western Ukraine. It is estimated that HIV is present in 0.96% of adults aged 15-49yrs. Fifty percent of Ukrainian sex workers are estimated to have HIV and syphilis.

Health Team Relations

Doctors are dominant to Nurses who carry out orders.

Physicians earn about 50 US dollars per month but are supplemented with small gifts from patients. Doctors working for Pharmaceutical companies will earn substantially more (600$/month).

Hospital Care

The state will fund only some medication, so patients must pay for most medications, bandages and supplies. Relative's supply home cooked food. Hospital food is of poor quality.

Dominance Patterns

Under the Constitution of Ukrainian men and women have equal rights. Women occupy 75% of the Health care jobs. In 1999 and 2000 a woman was Minister of Health.

Other Norms during Physical Examinations

Direct eye contact is appropriate. There are no restrictions regarding touch in medical examinations.

Urban patients are usually on time but rural ones are less concerned with time.

With regards to pain reactions people accept analgesics for pain. The government funds narcotics for cancer patients.

Birth Rates

Most families have 2 children with the first hopefully a boy and the second a girl although this is not a huge concern. Births are assisted by doctors and midwifes in hospital.

Post delivery babies and mothers are in different wards.

Twenty % of mothers breast-feed and most start bottle-feeding several weeks or months after breast-feeding ceases.

During pregnancy and breastfeeding women do not smoke, drink alcohol, or eat chocolate or citrus fruit and avoid taking medications unless necessary.

Death Rites

Death is accepted as inevitable. If a death occurs in hospital an autopsy is performed. If death at home occurs, at home family members are usually present. There is no hospice system.

Food Practices

Main meals are breakfast (until 9 am), lunch (1pm-2pm) and dinner (after7pm).

Child Rearing

Children are reared by their families to be disciplined and obedient. From aged 1-6 they attend kindergarten where teachers attend them from 8 or 9 to 5 or 6. These teachers read books, tell fairy tales, organize games and take children for outdoor walks. These kindergartens have decreased because of economic crises.

National Immunizations

BCG birth, 7 and 14 years

DTP at 3 and 18 months and 3,6, and 14 years

Measles 1 and 6 years

Td 11, 14, and 18 years.

The varicella vaccine is also given.

During soviet rule diptheria had been discontinued with a subsequent later increase in the disease. Travellers to Ukraine and USSR are advised to be up to date on diptheria immunization

Tick Borne Encephalitis is not very common and has not been reported in Southern Ukraine but does exist in the Northwest.

Pollution

It is estimated to be 3.2 times greater than in Europe and 21% of all diseases may be in some part related to environmental pollution with another 13% from drinking water.

Berries and mushrooms picked in Chernobyl should not be consumed. There are also concerns about eating fish from the Dneiper River in Kyiv.

Since 1991 the population has not increased.

The mortality rate exceeds the birth rate by 300,000 each year and life expectancy is now 60 from 70 years in 1991.

Radiation

The Chernobyl disaster has left the immediate area unliveable. People living nearby were afflicted by increased cancer rates and there is still concern from eating berries or mushrooms grown in that area and sold in Kyiv.

Bulgaria (Republic of Bulgaria)

Bulgaria is bordered by the Black sea, Romania, Turkey, Greece, Serbia, and Macedonia and has 8 million citizens.

Health Care Beliefs:

Acute Sick Care

Preventative medicine is not extensively practiced.

Only 16% of the population has ever been offered preventative interventions.

A small proportion still believes illnesses can be cured by magic.

Psychotherapy is not valued.

Reform in Health Care is under way. Patients pay their general practitioner but free care is given to children and unemployed. The government covers some hospital visits for free.

Bulgarians often self medicate and consult their family first, only seeing a doctor as a last resort.

Religious people will consult a priest and may use alternative medicine: meditation, massage therapy, herbal medicine, therapeutic touch, biofeedback and homeopathy.

Individuals themselves gather medicinal herbs.

Nutritional supplements and antioxidants are very expensive.

Diseases

The Roma subpopulation has a greater rate of STDs, syphilis, gastroenteritis, tuberculosis and Hepatitis B than Bulgarians.

South East Bulgaria has a lot of Iodine deficiency thyroid illnesses.

North West Bulgaria has a high incidence of nephritis and other kidney diseases.

Circulatory illnesses (stroke, myocardial infarction) affect 21.3% of the population.

Asthmas and bronchitis have doubled in the last 4 years among children.

HIV prevalence among young adults is estimated at 0.01%.

The ratio of doctors to patients is 1:296 but there are a great deal of sick people and the system is overloaded. Patients if dissatisfied may change physicians every 6 months.

Families stay with patients in hospital and supply food and linen.

Practices

Eye contact is expected and a light handshake is expected on parting and greeting.

Punctuality is maintained for work but not for clinic appointments.

Pain reactions

Some Bulgarians are very stoic while others are dramatic. Older patients with chronic pain may have feelings of discouragement and helplessness.

Birth Rites

All births occur in hospitals with high-risk women being confined to home. There are no childbirth classes and families and husbands do not attend births. Mothers and babies stay in hospital for 4-5 days and babies are brought to their mother for feedings 5 times daily. Breastfeeding is widespread and encouraged.

Child Rearing Practices:

Children may sleep with parents until age 10.

Parents wish for children to be quiet and obedient although with both parents working children may display more delinquent behavior. Physical discipline is not accepted and parents instruct by suggestions, explanations and advice.

Adulthood is defined at 18 years. At preset there is a large-scale discussion of the rights and privileges of under 18 year olds after several were crushed in a celebration. Those under 16yrs are prohibited to consume alcohol or go to a club without identification and parental consent.

Death rites

Individuals may donate organs. This is valued as a great gift although families who object may overrule the wishes of the deceased.

Other

Large meals are eaten at midday and evening.

The head motions for yes (nod) and no (shake) are reversed in Bulgaria.

Greece (Hellenic Republic)

Greece is surrounded by the Mediterranean Sea and encompasses 2000 islands. Its neighbours are Albania, Macedonia, Bulgaria, and Turkey.

Recently there are more Pakistani and Bulgarian Speakers

Health Care Beliefs

Health care focuses on acute care with religious elements.

Many Greeks believe that God grants health and allows illness for a reason. This supports the belief that illnesses may be cured by atonement.

Other beliefs are: that certain foods, amulets, prayers, avoiding the evil eye and wine prevent illness.

Having blue prayer beads and a cross also is thought to facilitate cures.

Remedies of herbs made into elixirs, ointments, beverages and plasters are used.

Figure 2 Representatives of Body parts symbolizing illnesses. These are burnt in an offering in Church in a sympathetic magic gesture. For sale in Lesbos

Mental illnesses were stigmatised 30 years ago but are now better accepted.

Biomedical views of illness are gradually replacing magical-religious beliefs.

Religious beliefs may also influence the way patients are treated. Doctors may withhold diagnoses of serious illnesses from patients to avoid anxiety but inform their families first (similar to Bing Crosby in "Bells of St Mary's'). Cancer is sometimes not named and is instead called "the disease" or "bad illness". Patients frequently do pilgrimages to Holy sites. Over the counter use of vitamins and antibiotics is widespread.

Common health problems like diabetes, hypertension and obesity are due to the increased adoption of a Western style diet in the last 30 years.

HIV prevalence is estimated to be 0.16% in young adults.

Healthcare is doctor centred with nurses being subservient and the concept of a Health care team is not developed.

Longer visiting hours in hospital allow families to provide for patients.

Families tend to be patriarchal and to include close extended families. Most Greeks would not institutionalise their older relatives.

Direct eye contact is appropriate. People tend to stand closer together in conversations. Patients prefer same nurses to be the same sex as themselves.

For health care appointments expect a delay of 5-10 minutes and for social occasions a delay of 30 minutes.

Expression of pain and emotions is encouraged although some people remain stoic.

Birth Rites

Doctors in hospital deliver births. 77% of mothers start to breast-feed and this drops to 47% by the first month, 23% by 3 months and 5% at 6 months.

Children are reared in their parent's bedroom for their first 40 days. Childrearing is permissive with no spanking. Mothers are responsible for discipline.

Death Rites

People who are dying may be sequestered from the outside world, and dying at home is preferred. Family and friends travel great distances to visit sick or dying relatives.

Food practices:

Greeks eat 3 meals a day with a light breakfast, lunch at 3pm and dinner between 8 and 9. Fasting occurs on religious days.

The traditional Mediterranean diet consists of grains, vegetables and fruit and is low in saturated fat. Most dietary fat is from olive oil. Traditionally alcohol intake is moderate at meals and celebrations.

Russia (Russian Federation)

Health Care beliefs involve acute sick care, and preventative medicine is beginning to be implemented.

Cigarette ads now have a statement from the Health Minister stating they are unhealthy.

Fear of mental illness is common and schizophrenia is the most frequently diagnosed mental illness (this does not mean that it is necessarily more common in Russia).

Previously, USSR psychiatric approaches were punitive to patients. Psychotherapy is beginning to develop.

Out patient clinics in cities are free but medications are not. Private clinics have emerged but are very expensive.

Alternative healers, including ESP practitioners have become popular.

Specific Diseases:

Tick borne encephalitis has occurred in Siberia and n the North. Hepatitis B is high in Siberia. Other reports of Tularaemia, West Nile virus, Crimean Congo Hemorrhagic fever are being reported.

The main causes of death include cardiovascular (58%), malignancies (18%), traumas and poisonings (13%) and alcohol related (9%).

HIV prevalence is estimated at 0.018% although this is suspected to be an underestimate due to low reporting.

Alcohol consumption with binge drinking has increased in recent years.

Health Team relations

Doctors are dominant to nurses but patients' trust of both is dubious. Families do not stay in hospital but frequently visit to bring food.

Men dominate politics and business while women are often schoolteachers and health care professionals.

Eye contact is not avoided.

Punctuality is not well maintained and appointments made may be broken without a problem. The expression of pain is acceptable for women and children but men are expected to be stoic ("Moscow does not believe in tears").

Birth Rates

Births occur in maternity hospitals are attended by midwives under the supervision of doctors. Mother and child stay in separate wards for 5 days. Newer wards, which put them together, are being introduced. Breast-feeding is common within the first 6 months.

Children are raised permissively and the mother is responsible for discipline. Parents are often concerned with their children's performance and achievements.

Death

Deaths are viewed as tragedies and families, friends and co-workers attend funerals.

Romania

Romania borders the Black Sea, Hungary, Moldova, Yugoslavia, Bulgaria and Ukraine and has 22 million citizens.

Romanian is a Latin based romance language.

Health Care Beliefs

Acute sick care is practiced with emphasis on health promotion practices.

Prenatal and childcare are stressed.

Under communism many public health lectures were given which improved understanding in the general populace.

Rurally, religious healers promote health by using their "bioenergy" to fight disease. Gypsy women (ghicitoare) or fortune-tellers also heal, but Roma people also use mainstream healthcare.

Western medicine co-exists with holistic and folk medicine. Romanians trust and seek out doctors for their illnesses. Employers and employees, through salary deductions pay for national Healthcare.

Private clinics exist. Hospitalisation is free but medication is not.

Health Problems

Major diseases include: cardiovascular diseases, hypertension, viral hepatitis and cancer.

Malnutrition occurs among AIDS patients. The prevalence of HIV is 0.02%.

Industrial pollution also influences health significantly.

Health Team

Doctors are in authority with nurses being subordinate. Doctors work in Public clinics and then may go to work in a Private clinic later in that same day.

Families are expected to stay with hospitalised patients and to provide food and assist with basic hygiene, although nurses and cleaning staff assist. Friends are strongly expected to visit.

Gender equity is a new concept and women do not yet have equal involvement in decision-making processes.

Eye contact is appropriate and a sign of honesty.

Birth

Romanian women deliver in hospital, usually without local anaesthesia. Families will look after the expectant mother and offer her the best quality of food. Because of imperfect sanitation conditions women may be pre-treated against possible infections, which may be acquired from their stay in hospital. Usually mothers go home after 2-3 days. New mothers will rely on an experienced older woman (usually the mother-in-law) for her first 2 weeks. Breastfeeding is encouraged. Women do not breastfeed in public.

Abortions and contraceptives are legal.

Children

A child being raised is not specifically strict or permissive. Children may have many caregivers, while their parents work, including grandparents.

Education is free and compulsory between 7-14 and most children stay in school after.

The education of girls is considered important so that they will not be subjected to family slavery.

Drug addiction is a growing problem.

Death Rites

Friends and relatives try to attend the dying. Mourning is prolonged with meals offered to the dead on the day of burial, at 40 days later and at 6 and 12 months after which mourning is completed.

The Orange Revolution

Recently Romania has had their own Orange revolution, which preceded Ukraine's. Free elections occurred in 2004, decreasing the Communist party's influence.

Romania is expected to join the European Union in 2007.

New positive initiatives such as the Headquarters for the Fight against Human Trafficking are based in Bucharest (in Cecesceau's House of the People) and will serve to improve conditions.

Figure 3 House of the People

Turkey (Republic of)

Turkey is situated in South-eastern Europe and is bordered by the Black and Aegean Seas.

Health Care Beliefs

Health care beliefs involve acute sick care with little in the way of health care prevention. People accept care passively, but may postpone elective treatments during Ramadan or when fasting. Beliefs include the biomedical as well as alternative and magical-religious.

Use of herbal tea, chiropractors, and folk medicine is common. The evil eye is believed to cause childhood illnesses.

Patients do not question doctors (who are mostly men). Doctors have absolute authority. Consent forms are not used much. Information is shared freely with families and medical decisions are made with families.

Dialogue between doctors and nurses, who are mostly women is weak.

Specific Diseases

Beta thalassemia is present and endemic goitre is prevalent in the Black sea area. Hepatitis A and Tuberculosis are more common.

HIV is estimated at 0.01 % among young adults.

Families are expected to help with patients in personal and therapeutic care. A member of the family usually stays 24 hours with the patient.

Dominance Pattern

Males make major decisions although women may make medical decisions. Parents are expected to be looked after by their family in their old age.

Eye Contact

Direct eye contact with authority figures is felt to be disrespectful. In interacting with patients doctors generally do no touch in greetings, although a pat on the back may be used as a sign of support. Socially a kiss on both cheeks and a handshake is customary for greetings.

Pain may be considered a part of life and might not be discussed or openly expressed.

Birth Rites

Most births (81%) are attended by a Health professional and happen inside a Health institution (80% urban and 60% rural). Deliveries may be done in a prone or kneeling position.

Families and fathers are not present during deliveries. After birth family and neighbours help the new mother for 40 days. Ninety-five percent of women breastfeed usually for 12 months, although only 14% exclusively breastfeed.

The mother is the primary caregiver for children but is assisted by the paternal grandmother. Discipline is strict. Children play with same sex playmates.

Mothers may sometimes fasten an evil eye pin to their child's clothing to protect them.

Figure 4 The Blue Mosque

Appendix Special Disease noted in the Black Sea Area:

Tick Borne Encephalitis

A virus related to the yellow fever, dengue fever and Japanese encephalitis viruses causes tick Borne Encephalitis. It is transmitted by several species of ticks living in Central and Eastern Europe and parts of Asia. Tick activity starts when soil temperature rises to 5-70 degrees C in March or April and ends in the fall. In Mediterranean countries ticks are more active during November-January.

Ticks are worse in wet summers and mild winters. The risk of infection from specific tick bites ranges from 1:200-1:900. People at highest risk of being bitten include agriculture/forestry workers, hikers/ outdoorsmen and collectors of berries and mushrooms. These ticks attach to humans at hair-covered portions of the scalp, ears, arms, knee joints, and hands and feet.

Diagnosis: Is by serology. 1gM Elisa on serum (acute) Confirmation of infection requires acute and convalescent serum.

Infection

Incubation occurs after 2-28 days with biphasic symptoms.

1st Stage (viremia): fever, headache, myalgia and leuko and thrombocytopenia for 1-8 days. The Latency stage then occurs lasting 1-33 days before the 2nd stage.

2nd Stage Up to 25% of cases develops meningitis, meningo-encephalitis, and transmyelitits. The Case fatality rate is 1-5%. Paresis in the acute stage occurs in (3-23%) and usually involves shoulder or hemiparesis and may sometimes involve cranial nerve pulses.

Mild disease (55%) meningeal/encephalitis.

Moderate (37%) moderate meningeal symptoms.

Severe (8%) severe encephalitis. Treatment is supportive only.

Long tern sequelae: Prolonged hospital stay. After 50 days- 40% are still on sick leave. 40% of patients had chronic residual symptoms, which include neuropsychiatric symptoms (memory loss, stress intolerance, decreased concentration), balance, dysphagia, hearing, headache, and paresis. Negative prognostic factors include middle to high age and the severity of the acute phase.

Patient afflicted with Tick Bourne Encephalitis s tend to follow 3 clinical causes:

•  Full recovery in 3 months.

•  Prolonged clinical return with neuropsychiatric and neurological problems.

•  Residual paresis. In epidemic areas, TBE is one of the most important causes of viral CNS infections. Case fatality and severe effects are still very low (0.5-5%).

Tick Bourne Encephalitis Vaccine

•  Common used in Austria/Germany/Balkan.

•  Indicated for long-term residents.

•  Short-term travelers? May consider if significant exposure.

•  Recommended for endemic areas in the Alps

•  People receive 90%protection after the 2nd dose.

•  Vaccine is not available in North America (may be special ordered though).

On speaking with several Neurologists at the Eastern European Neurologist Association TBE is not a major cause if concern in Odessa and Southern Ukraine. It is more reported in Northern Ukraine and Eastern Europe.

Crimean -Congo Hemorrhagic Fever

This occurs in Africa, Asia, and the Middle East. It is common in many animals but rare, yet serious in people. It is caused by a virus transmitted by infected ticks or by direct contact with infected animal body fluids. There is no vaccine. Risk to travellers in low. Symptoms start after an incubation period of 1-3 days. Non-specific symptoms include fever, dizziness, headache, neck stiffness; aches, abdominal pain, diarrhea, nausea, sore eyes and photophobia. Generalized bleeding can develop. Diagnosis is confirmed with a blood test. Treatment is supportive only.

References :

Cultural Health Assessment 3 rd Ed Carolyn Ericson D'Avanzo Elaine Geissler Mosby 2003 ISBN 0-323-01858-0 (This book gives an objective Nursing perspective on all countries. It offers good sociological insights and is very descriptive)

Romania and Moldova Lonely Planet 2005 Steve Kokker, Catheryn Kemp 2005

The Russian Way - aspects of behaviour, attitudes of the Russian 2 nd Ed. Zita Dabars McGraw Hill 2004

Essential Bulgaria 3rd Ed. David Ash Essential Guides

Ukraine The Bradt Travel Guide Andrew Evans Bradt 2004

Kiev The Bradt Travel Guide Andrew Evans Bradt 2004 (Both of these are concise and give the best tourist advice on Ukraine)

Culture Shock! Ukraine Meredith Dalton Graphic Arts Center Pub Co ISBN: 1558684204 (This book is highly recommended for those working or planning a short stay)

A History of Ukraine Paul Robert Magocsi University of Washington Press (December 1, 1996) 784 pages ISBN: 0295975806 (This large book gives an encyclopaedic history of Ukraine and helps readers understand why simple answers are not easy to come by in describing Ukrainian History)

Ukraine by Orest Subtelny University of Toronto Press; 3rd edition ISBN: 0802083900 (Also a very authoritative read)