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Friday, April 24, 2009

In Romania, bribery is a health problem

Alina Lungu, 30, says she did everything necessary to ensure a healthy pregnancy in Romania: She ate organic food, swam daily and bribed her gynecologist with an extra €200 in cash, paid in monthly increments of €25 handed over discreetly in white envelopes.
Another bribe of €25, or about $32, went to a nurse to guarantee an epidural. Even the orderly reaped an extra €10 to make sure he didn't drop her from the stretcher.
But on the day of her delivery, she says, her gynecologist never arrived. Twelve hours into labor, she was left alone in her room for an hour. When a doctor appeared, the umbilical cord was wrapped twice around her baby's head and had nearly suffocated him. He was blind and deaf and had suffered severe brain damage.
Now, Alina and her husband, Ionut, despair that if they had paid a larger bribe to the doctor, then Sebastian would perhaps be a healthy baby. "Doctors are so used to getting bribes in Romania that you now have to pay more in order to even get their attention," she said.
Romania, a poor Balkan country of 22 million that joined the European Union two years ago, is struggling to shed a culture of corruption honed during decades of communism - and stretching back beyond that. The European Commission, the EU's executive body, published a damning report Thursday criticizing Romania for backtracking on key judicial changes necessary to fight corruption. Sanctions could follow, including losing some of the €32 billion in EU aid it is due to receive between 2007 and 2013.
Transparency International, the Berlin-based anti-corruption watchdog, last year ranked Romania as the second most corrupt country in the 27-member bloc behind neighboring Bulgaria. Those who have faced corruption allegations have included a former prime minister, more than 1,100 doctors and teachers, 170 police officers and 3 generals, according to Romanian anti-corruption investigators.
While alarm grows in Brussels that the EU's newest entrants are undermining the bloc's rule of law, Romanians complain that everyday graft and bribery blight their lives. One patient here recently offered his doctor a free shopping trip to Dubai. The doctor politely declined.
Dr. Vasile Astarastoae, a biomedical ethicist who is president of the Romanian College of Physicians, representing 47,000 doctors, blamed the black healthcare economy on a pitifully low average monthly wage of €400 for doctors, which he said was forcing them to rely on supplementary income.
"Patients don't want to go to a doctor who is distracted thinking, 'How will I feed my kids or pay the rent?"' Astarastoae said. "So there is a conspiracy between the doctor and the patient to pay a bribe."
"If salaries were higher, then the practice would disappear," he said.
A study conducted by the World Bank for the Romanian Ministry of Health concluded that so-called informal payments amounted to $360 million annually. When an illness requires hospitalization, the Romanian patient typically pays three or four bribes equivalent to three-quarters of a family's monthly income, the study showed.
The Ministry of Health is trying to root out the practice, and recently set up a free phone line for patients to report abuses. Within an hour, it was jammed. Hospital here are plastered with anti-bribery posters. One shows a man hiding a gift behind his back, with the words "You Shouldn't Have" above his head.
The issue gained national attention last month when a 63-year-old man, Mihai Constantinescu, died of a massive heart attack in the waiting room of a hospital in Slatina, in southern Romania, after doctors refused to treat him. Mihaela Ionita, the nurse who wheeled him fruitlessly from room to room, said in an interview she believed he had been refused care "because he appeared poor and could not afford a bribe." The hospital said Constantinescu did not appear to have been an emergency case.
Victor Alistar, director of Transparency International's Romanian branch, said the culture of bribery was a hangover from communism, when Romanians endured long lines just to get basics like eggs and milk and used bribes to acquire scarce products and services.
Physicians lament that bribery is so endemic in the healthcare system that if a doctor refuses a bribe, patients typically become anxious and distraught, believing this to be a sign that their illness is incurable and death is imminent. Doctors then take the bribe to try to allay their anxiety.
Doctors and patients say bribery in the health-care system follows a set of unwritten rules. The cost of bribes depends on the treatment, ranging from €100 for a straightforward appendix-removal operation to up to €5,000 for brain surgery. The suggested bribery prices are passed on by word of mouth, and are publicized on blogs and Internet sites. Alistar said public hospitals routinely exchanged "supplementary payment" lists to ensure they had the same rates.
Dr. Adela Salceanu, a psychiatrist and anti-bribery advocate, said doctors used different and sometimes subtle methods to make it clear they expected a money-laden envelope.
She recalled that one friend, a 42-year-old lawyer, recently broke two legs in a basketball game and was taken to hospital for surgery. When he did not offer money to the orthopedic surgeon on duty, his procedure was postponed for a week; he was finally operated on, but only after paying the doctor an extra €400.
Salceanu lamented that young doctors who refused to accept bribes were routinely chastised or threatened with dismissal by senior colleagues for subverting the black market.
Mugur Ciumageanu, a psychiatrist who has practiced in public hospitals in Bucharest, recalled that when he was a young doctor, he was shocked when the senior physician on the ward took him aside and forbade him to talk with patients for three months. Her explanation, he recalled, was that he was spending more time with patients than she was and, by appearing more caring, was denting her bribery earnings.
Marilena Tiron, 26, a recent graduate of medical school in Bucharest, said the bribery culture among doctors started early because residents were also poorly paid - about €200 a month. She said the issue of bribery did not come up in her optional medical ethics class at the University of Bucharest's Medical School "since the teachers were taking bribes themselves."
Astarastoae, of the Romanian College of Physicians, acknowledged that bribery needed to be rooted out, but he argued that the media exaggerated the practice.
While doctors are god-like figures in most Western countries, respected and handsomely rewarded for years of hard study, Astarastoae said that in Romania, the medical profession was denigrated because workers in factories had been made heroes under communism, while doctors and intellectuals were treated as unproductive "parasites."
Astarastoae, who helped write Romania's code of medical ethics, said that under the code, it was considered unethical to take money or a gift before treatment; after treatment, however, it was at the discretion of the patient if he or she wanted to show appreciation.
He said the college had the power to sanction bribery by revoking the licenses of doctors implicated in a bribe. Few patients, however, are willing to name and shame their doctors for fear they could be shunned by other physicians.
Liviu Manaila, Romania's secretary of state for health, said in an interview that the system of informal payments was depriving doctors of their dignity and needed to be stamped out. While the government's budget is too strained to raise doctor's wages, he proposed revamping Romania's socialized medical system so that patients took on a greater burden of the costs, which could then be translated into higher fees for doctors.
But such proposals are cold comfort for Alina Lungu and 18-month-old Sebastian, who will probably spend his life in a vegetative state.
"The problem is that all this black money absolves doctors of their moral responsibility toward their patients," she said. "It has got to be stopped."

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