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October 2008

Clinical Update: Global Vision, Part Five
The Eyes of Eastern Europe
By Denny Smith, Senior Editor

From the slopes of the Balkan Mountains to the shores of the Baltic Sea lies a broad swath of earth historically defined as Eastern Europe, although the borders put forth in that definition have migrated both east and west over the last century. Since the end of the Cold War, countries in Eastern Europe have provided a stage for change both welcome and fearsome, as former partners from the Eastern Bloc disassembled and either floundered or gradually transitioned into affiliation with the European Union. The resulting economic and political shifts have jolted these countries’ infrastructures, including the ways medical care is—and sometimes is not—delivered.

Poland Sees Slow but Steady Change

In the 1990s, when Poland became more independent, many opportunities suddenly presented themselves, said Zbigniew Zagórski, MD, professor and chairman of ophthalmology at the University of Lublin in Poland. And yet things for Poland did not change as fast as they did in some other Eastern Bloc nations, such as Slovenia or the Czech Republic. “Our development was slower because the old health care system was not replaced until 1999, much later than in the Czech Republic, for example. And ours was overseen by the old bureaucracy, which was not accustomed to being impartial. So some eye care centers that were quite good did not get money from the state insurance and others that were not very good got quite a lot of money. The not-so-good centers were using hospitals for surgeries that did not require a hospital, and some were not even performing modern surgeries at all, so you might say they were actually losing money.”

Modernization inching along. Dr. Zagórski is a cornea specialist who established the first eye bank in Poland and pioneered limbal and amniotic membrane transplantation here. He has been very active in the International Council of Ophthalmology. He does see progress in his country, even if it lags behind neighbors. “Ten years ago the Czech Republic was performing 4,000 cataract surgeries per million inhabitants per year, compared with Poland doing only 1,000. Now we are doing about 2,500 a year, but the Czechs are doing 6,000, and almost all of those are done with phacoemulsification. In Poland 30 percent of our cataract extractions are still extracapsular. We need more motivation in our system for good surgeons to perform modern surgeries.”

Few subspecialists and even fewer ODs. In Poland, as in many countries from the former Eastern Bloc, subspecialty ophthalmology has been virtually nonexistent, since eye care was traditionally delivered by comprehensively trained physicians, said Dr. Zagórski. “We have plenty of MDs—nearly 4,000 ophthalmologists for 40,000,000 citizens—but we have almost no ophthalmic subspecialists. We have a few good vitreoretinal surgeons, but not enough.”

Interestingly, perhaps because of the prevalence of comprehensive ophthalmologists, Poland has almost no optometrists. “It’s not been a popular profession our country, as it is in the U.K. or the U.S. It’s just been the way of our system.” So ophthalmologists perform the routine refractive care that is more often delivered by optometrists in Western countries.

Will the current lack of subspecialist surgeons and optometrists be changing in the future? Dr. Zagórski thinks it will. “We are introducing independent insurance companies, which could quickly change the situation of modern, efficient surgery for the better. There are also now two optometry schools, and there are more and more MDs traveling abroad for subspecialty training.”

The uneven development but close proximity of eye care communities in Eastern and Central Europe makes for bright opportunities for professional exchange, and Dr. Zagórski is keen on collaboration between countries. “We have very good cooperative programs with Ukraine, Lithuania and Germany. But I would like even more.”


Hungary Looks to the Future

In 1989, Ferenc P. Kuhn, MD, left his native Hungary for the United States. As Dr. Kuhn jokes about it now, the Iron Curtain fell as his plane took off, so his friends wish he had left the country sooner. Dr. Kuhn remains a professor of ophthalmology at the University of Pecs, which, with roots beginning in 1367, is one of the oldest in Europe. He also maintains a trauma practice in Birmingham, Ala.

Remembering the old ways. “Under communism everything was centralized. Ophthalmologists had some private patients, but you could not do surgery outside the state hospital system. We were really scraping by on meager supplies and rundown facilities. What kept us going was the spirit of the people.”

As in Poland, medicine in Hungary did not nurture specialization. “I was the only one in the country doing vitreoretinal surgery and I had only one vitrectomy probe. It was an old, first-generation vitrector. I literally had to take an hour to assemble it before surgery and another hour to disassemble it. And then it took two days to sterilize it. So realistically, you could only do one surgery in three days. I begged the government to get me another one, but, of course, they didn’t reply.”

One day, Dr. Kuhn recalled, the minister of finance paid his practice a visit and began asking strange questions. It dawned on Dr. Kuhn that earlier in the week he had operated on a young man who had suffered a very bad work-related trauma, and there was no option but to remove the eye. Coincidentally, that young man happened to be the brother of the finance minister, who, in spite of the enucleation, was apparently moved by Dr. Kuhn’s care. “He asked me if there was anything that might have saved his brother’s eye. Of course I lied and said ‘Yes—a new vitrector!’ And that was how things happened—nobody cared about the real need—everything happened through the random personal connection like that, or through membership in the Communist Party, which I never joined.”

Medicine with one foot in the past. In 1989 the whole country changed, but, unfortunately, health care experienced the least of these changes. So it resembles the previous system, including its methods of financing, Dr. Kuhn said. More decision-making freedom and the option to work in private practice are now available for physicians, but the old bureaucracies for administering national health institutions are still largely in place. The best known cardiologist in the country, for example, was able to cut the death rate from heart failure at his hospital by half, Dr. Kuhn said. “But then the government imposed limits on the number of cardiac surgeries performed there, which allowed mortality to double and rebound to original levels. So he was fired. Too few people are making very large decisions like that.”

Health workers are very poorly paid in Hungary, Dr. Kuhn said. “The salary of the average physician is less than that of a clerk in a bank. And nurses, no matter how dedicated, are paid even worse. But people just work extra hours and develop innovative solutions. I personally buy the equipment I need if the government won’t provide it.”

No questions, please. Even the patient/ provider relationship was different under communism, according to Dr. Kuhn. Everyone had access to health care, but the scenario that Western physicians are so accustomed to, one in which a doctor sits down with a patient and openly discusses their diagnosis and the treatment options, did not exist. Instead, Dr. Kuhn said, “The relationship was essentially dictatorial: The doctor simply told the patient what was going to happen and no questions were entertained. There was nothing like informed consent.”

Education? Excellent. Typically of Eastern European cultures, education in Hungary is more demanding and sets higher expectations than what faces most young students in the United States. “Our training is wonderful—very rigorous. Unlike in the U.S., we go directly to medical school from high school, and it’s six full years of nothing but medicine. We have to study, in-depth, areas that we might never use again, but this gives us breadth and depth in every aspect of medicine. So we lack the practice-oriented approach, which is so well applied in the U.S., but our basic education is deeper and wider. Unfortunately, because our training is good but our conditions are not, more and more Hungarian physicians are leaving the country and fewer and fewer young people are becoming physicians.”


Vision Flowers in the Balkans

“On my first mission, in 1991, I traveled to Bulgaria, and that was the first overseas trip I’d ever been on,” recalled Robert W. Butner, MD, assistant professor of ophthalmology at the University of Texas in Houston. Dr. Butner has since been on more than 20 medical teaching missions, visiting not only Bulgaria but Albania, Bosnia-Herzegovina, the Transylvanian province of Romania, Afghanistan and Iraq. Most of that time has been spent in the Balkan countries.

“Before the fall of the Iron Curtain, the Eastern Bloc countries were heavily supported both logistically and ideologically by the Soviet approach to medicine. Then suddenly, there was a desire on the part of the Eastern Europeans, who were already highly proficient in comprehensive ophthalmology, for learning the subspecialty approach favored by ophthalmologists in the West. Retina garnered the most interest because it’s the most exotic and difficult to do and requires interesting techniques. The physicians in Sofia were very nice and very eager to learn new things.”

Pathology meets poverty. Dr. Butner has seen a lot of diabetes in the countries he’s visited, but it has mostly been type 1 diabetes that has genetic underpinnings and does not get properly treated over time, rather than type 2 diabetes, which is increasing in wealthier countries and which might have origins in poor diets and inactivity. An even bigger problem is the lack of basic resources, including pharmacologic supplies. “In places like Romania, just five years ago, there were not even dilating drops available in the hospitals. We’d have to buy them ourselves. Even a local anesthetic was not available unless the patients bought it themselves and brought it to the appointment.”

Dr. Butner noted that the older socialist-style approach to medicine and health care was often not inherently inferior to Western ways. “The Soviets had an entirely different way of examining and treating the retina, for example, and not necessarily bad. Part of the American way of doing things is thinking that cost is no object, which poses its own problems.”

Getting patients away from bullets. Dr. Butner was invited to work in Sarajevo during the Bosnian conflict. In Sarajevo, Bosnian Muslims were surrounded by Bosnian Serbs, but physicians of both ethnicities were treating patients of both ethnicities. “They originally wanted Orbis International to come, but Orbis decided it wasn’t safe even to land there. It turned out that they wanted an outside retina specialist to offer an unbiased opinion regarding which patients with retinal injuries needed to be evacuated, since wounded people got a certain number of evacuee slots on departing planes. Having a local Bosnian physician make those assessments would have raised suspicions that partisan bias was determining who would get the coveted spots.”

Dr. Butner might reasonably have felt as cornered as King Solomon in the situation, but instead he thought the Bosnian physicians had chosen the honorable course by trying to recruit a dispassionate voice into a charged situation. “And a year later, the doctors in Zenica asked me to do the same thing—look at patients and determine who should be treated elsewhere and who should stay in Zenica.”

Dr. Butner saw some very serious trauma. “A lot of the cases were pretty horrible, pretty hopeless, and I had to identify those wounds for which evacuation would accomplish nothing. There might be instances when the mayor’s daughter might present with an injury that was terrible—or trivial—and yet the family, for a variety of reasons, wanted her to leave the country by winning a medical evacuation. In those situations I just had to say that I didn’t think that would be beneficial.”

Don’t shoot the doctor. The war pitted three peoples—Croats, Serbs and Bosnian Muslims—against each other, and it also put Dr. Butner in the crosshairs of resentment. Although he was a neutral visitor, he was familiar with the deep historical grievances perceived by all belligerents. “But an international consensus had determined who needed support, and so I was sent in under U.N. auspices to support the Bosnian Muslims. The Serbs, not surprisingly, lodged a protest with the World Health Organization to say that was unfair and they proposed that I spend 25 percent of my time in a Serbian community. The WHO rejected the complaint, but I would have welcomed the chance to care for Serbs as well.”

A future peeks out of the ruins. Dr. Butner attended a medical conference in Sarajevo again this year, and he was astonished and heartened that all the many demolished buildings had been repaired. He noted with interest that the conference was held in the shiny new quarters of Oslobodjenje, the newspaper that famously managed to publish every day throughout the siege of Sarajevo, with reporters working from bombed-out offices.

The conference brought ethnic Albanian physicians from Kosovo together with Croatian and Serbian physicians. “The first physician I ever worked with in Bosnia, a Serb, had been forced into exile because of his ethnicity. Subsequently another ophthalmologist, a Muslim, became my host. They were both at this conference and both eagerly brought me on tours of the surrounding area. Not surprisingly, they each gave me an entirely different tour—one to the Serbian area and one to the Muslim area.”

Dr. Butner is wistful about the new Bosnia, which had once been an integrated society and is now markedly segregated. “Even speed limit signs are symbolic,” he said, “as the lettering goes from characters in Latin to characters in Cyrillic.”