Polina CupceaTears roll over Maria Ciobanu’s round and soft face. She has been waiting for the family doctor* to come pay a visit to her but the waiting list is long. “I sent my daughter to the doctor this early morning to ask her to come visit me after she finishes seeing patients at the practice. But she’s not there today. And she only comes once a month… I understand very well that she’s got a lot on, that she’s only one in six villages but who will consult me? I’ll have to wait until May”, the old woman nervously bursts through hiccups. She wipes the tears on her chubby cheeks and then covers her red eyes with her hand. Her belly, as big as a barrel, sways from side to side. Her husband Vasile lying on the bed looks at her powerlessly. He’s also crying.
Wednesday, 22nd of March // The number of patients is growing by the family doctor’s door. Some stand, others are leaning by the walls, a few men have made themselves comfortable on the long tall chairs, rocking the rain boots on their feet. Olga, a tall robust woman wearing a headscarf tied under her chin and flat shoes made out of rugs, waits by the entrance of the practice. Frowning, she pretends to be the responsible guard watching every move from under her bushy eyebrows.
“I willingly came at 7 AM from the other end of the village just so that I am the first here”, boasts the woman to a friend in illness next to her.
By 8AM, Elena Ivanschi makes her entrance on the long and dark corridor of the Health Centre in Baimaclia in the Cantemir county. People jump out of joy and make space for her to walk through.
She is thin, narrow, slightly bent, with deep wrinkles on her face and a wavy hair. She quickly squeezes through the crowd of ill people gathered by the door and inserts the key in the lock. Behind her a woman begs whispering to be consulted first so that she can manage to get to Cantemir the same day. She also came here at 7 AM, “on the first bus” from a neighbouring village. “Come in!”, the medic shouts while she enters the small but tall room filled with the light of a generous sun. Olga grinds her teeth.
A lame man heavily dragging his left leg comes close to a crowd of people to find a spot in the queue. He is the 15th. Almost all of them cough, gasp or bend from pain. The cool and heavily soap cleaned hallway is filled with children’s long sleepy yawns.
Once at the practice, Elena Ivanschi puts on a white coat, rolls her sleeves and sits at the table. She organises the stamp, registry, medical books and prescriptions, arranges her glasses and starts handling the pen. She writes a note for Larisa to go to Chisinau at the Institute of Cardiology because “we don’t have a heart disease doctor at the Clinic in Cantemir”.
When the first patient wants to go, Olga takes her by the arm, pulling her further in the hall way. She immediately enters the practice, telling her over the shoulder, “What did you do there for so long?”, on an ironic, despising tone.
Pleased to be there, the woman sits on the chair and pulls out a stack of papers that she presents to Elena. The medic looks through the test results and explains, as if she were speaking to herself, that some are good but that the patient might need to do some other tests.
– Yes, yes. Write a note to check my liver too. I want to check everything. My only worry is to have enough time to go to the church as well. Here’s a little saint, they give alms today, the woman remembers and takes the cake out of her plastic bag.
Then a five-year old boy comes in. The doctor takes two minutes to examine him and then gives the verdict – bronchitis.
Then she wastes double the time to fill the information in the registries. “There’s a lot of paperwork to be filled. I could consult two more people in this time”, Elena says.
She fills in the registries for every ill person consulted and then writes down the information on a yellowed sheet of paper, in 20 lines. But the old paper gets filled with the names of the patients on the other side too, often reaching 30 patients. “On Monday I consult even up to 40 [persons]. The majority – until noon. Everyone wants to manage to get home. They come from neighbouring villages too”, the doctor quickly explains. On the hallway the discontent and sighs of the ill just don’t cease.
– If she had given us each a pill first thing in the morning, since we first arrived here, we would have all been cured by now, half-jokes Victor, a man past his fifties who came early from Tarancuta, a village ten kilometres away from Baimaclia.
– Terrible problem. Two doctors in 12 villages. You die within days on the corridor, a woman sitting in a corner agrees.
One patient exits and two enter Elena Ivanschi’s practice. But the number of those waiting stays constant. There are still some people who arrived at 7AM but their turn hasn’t yet come. Out of boredom, some play the sentinel along the corridor. A man with his eyes deep in their orbits hits the floor with his boots, swelling their grey and dry cheeks with air.
A two-year old child runs around his mother like a whirligig. Older women have crossed their hands and analyse the posters on the walls. “Health is paramount. A healthy beggar is happier than a rich but ill king. Schopenhauer”, says one of them.
Suddenly the door of the surgery slams strongly and a medical assistant springs out of the practice shouting, “Elena Ivanovna, come to us. We have an emergency!” She comes in and explains the state of the woman in the practice next to them. “They wait until they can’t get to my practice anymore”, says Elena through her teeth. She leaves the patient for whom she started writing the prescription and takes the statoscope off the medical bed.
In the surgery, a woman with a white face pressed under pain cries and breaths heavily. “That’s it, I’m dying today”, she sighs. Elena throws the medical record ostentatiously.
– How long have you been ill for? she asks with a nervous, hoarse voice.
– Two weeks, the woman replies panting.
– And why do you, woman, stay at home?! shouts the doctor.
Helped by the daughter of the ill woman, the doctor takes off the woman’s jumper. She analyses the different parts of the body, asks for details, looks at the white-yellowish vomit in the bucket next to her and calmly smiles to the ill woman:
– You won’t die today but don’t wait at home for so long.
Elena asks the assistant to make an electrocardiogram and goes back to the people waiting for her eagerly on the corridor. The children in the mothers’ arms are nervous. The medic hears their screams and calls the kids in. But instead the lame man appears at the door. Without saying a word, he stares at the doctor. Elena feels the intense gaze on her. She turns her back to him and gently tells him:
– Vanya, have patience, you’re a grown man but the children are screaming.
A mother and her two year old daughter enter the room. While the medic examines her, another assistant bursts in. She says that a child of nine months from the risk group has been waiting for an hour. But Elena keeps consulting the little girl. The kid’s screams pass through the wall. The doctor barely manages to keep calm, saying only, “One second”. Then two twins follow. The medical assistant comes again. Vanya also enters the practice. This time the man begs the doctor to please write all his prescriptions because he can’t keep waiting for all the mothers with children.
The doctor stops. Her confusion reaches a peak. She takes a deep breath and looks at everyone around one by one. A silence like a shroud fell down the practice abounding in March sunlight. For a few moments she faces the window. A crown of hot drops rises on her forehead. She doesn’t know whom to prioritise…
– So, the one with the baby of nine-months – let her feed it first and then come to me, she tells the medical assistant. While you undress the twins, she points to the mother, I write the prescriptions for Vanya.
She falls on her chair and starts writing greedily. The yellowed evidence sheet is turned on the other side. It has reached the 24th line. Her brains boil. “I must measure my blood pressure”, Elena says sighing heavily.
Until lunchtime, Elena Ivanschi doesn’t manage to breathe. Nor does she get the time to go to the toilet. At 1pm sharp, the doctor closes the door to the few patients on the hall way. She falls back into the chair and takes a few breaths. Between her thin lips you can hear her tired voice saying “Finally”.
She is 68 and has spent 45 years among patients. In the past two years, because of the crisis of family doctors in rural Moldova, she has become an arbiter for six villages and 5,000 people, according to the 2004 Census. She spends most time in Baimaclia. In the other villages -Acui, Coștangalia, Țărăncuța, Câșla și Suhat – she follows a rota, twice a month. But it sometimes happens that she gets to each village only once a month. Either because of bank holidays or because of the sheer volume of work in Baimaclia. The locals already know her schedule and, if they’ve got an emergency, they come to Baimaclia because “the illness doesn’t wait”.
She should give each patient 20 minutes but because of the long waiting list she offers a maximum of 10.
– Of course it’s not the best quality. One doctor for 5,000 people. After all this paperwork you’re fed up even if it only took you a few minutes to consult the patients, Elena whispers with a feeble voice.
Her words are confirmed by official reports and statistics. While the norm set by the ministry is of one family doctor per 1,500 people, in reality, the ratio is one to 3,000 or even one to 4,500.
The worst situation is in the counties of Cantemir, Leova, Hâncești, Căușeni and Rezina. The indubitable champion is Cantemir, where only one family doctor looks after approximately 5,000 people.
– This means that, if in the county of Baimaclia there are 12 villages, with a total population of 10,000 people, there should be seven and not two family doctors. There’s Elena Olteanu, who is a boss and has to also write reports and take part in county meetings, and there’s me. If we had at least two more doctors… But all of the weight falls on our shoulders, explains Elena Ivanschi.
And the crisis of family doctors doesn’t just lead to the exhaustion of the medics but also to risks to the beneficiaries. “Filling public medical institutions with a personnel to such a high degree compromises the quality of the medical services offered, increases the exhaustion of family doctors who are forced into a position of getting additional jobs, it increases the level of dissatisfaction of its patients and, finally, puts public health in danger”, warns a report elaborated by the National Centre for Health Management.
Elena Ivanschi says she would give up her job, especially since she has long passed retirement age and finds it hard to work under such conditions. But since no young specialist comes to replace her, she can’t afford to leave her colleague on her own.
“Young specialists need acceptable conditions for work in order to come to villages. I don’t know what will be when I won’t be able to do the work anymore and my boss will be left alone to 12 villages. I don’t even want to imagine”, Elena says, exhausted.
Rodica Scutelnic, the secretary of state of the Ministry of Health, says that the problem of getting young specialists in villages is not just the concern of the ministry but also of local authorities.
– The ministry creates various mechanisms to attract young people in rural areas but local authorities should also contribute to solving this problem. Students on state grants sign that they will work for three years wherever they are needed – that is in villages – after they graduate. But these contracts don’t have any judicial power and it is up to the students what they do.
– Of course, after studying for nine years, no one will want to go to an abandoned village without any conditions to work, says Scutelnic.
Although authorities have homogenised salaries for family doctors disregarding age and work experience, young specialists don’t hurry to take rural areas under siege. In 2016, only 19 young people went on to work as family doctors in rural areas, according to the Ministry of Health. Most – five of them – chose the Ialoveni county, while others preferred Anenii Noi; Rezina, Ștefan Vodă and Cantemir have had two young doctors.
As a result, the official norm of one family doctor per 1,500 people is only respected in the capital, while the average for the rest of the country raises to 2,083 people per doctor, according to the National Centre for Health Management statistics from 2014. It’s a number much higher than the European average, where a doctor usually looks after 1,250 inhabitants, according to the World Health Organisation. The leader at the top is France, with a one to 625 persons ratio, followed by Georgia (1/787) and Belgium (1/895). The Republic of Moldova aligns itself to other Soviet sisters, Uzbekistan (1/2,083) and Armenia (1/2040).
Ala Nemerenco, expert in health politics, says that any problem has a solution, including ensuring rural areas with family doctors: “Until we inject fresh blood, meaning young doctors in the system, we won’t change the status quo. But we can only bring young doctors in the system through well thought and calculated policies. If the state doesn’t start investing in family medicine and applying these policies developed by the World Health Organisation, then in the next five years, we will get to a ratio of one doctor not per 5,000, but per 10,000 or even 17,000 people.”
***
Elena Ivanschi shares her lunch break with her best friend, the pharmacist Maria. Maria already knows Elena’s habits, and when the doctor steps her door, the water for the coffee is already boiled. They go to an annex together and share their packed lunches. Then, while sipping their coffees, they share their most recent sorrows and joys so that they’re back to work by 2pm.
– We can talk about family doctors but we don’t even have specialist doctors in Cantemir. The endocrinologist comes to Leova only on Saturdays, and 70 people queue [to get to him]. There isn’t a cardiologist, a pediatrician, neurologist there, and people have to go to Chisinau, says Elena Ivanschi.
She chose to become a doctor because she wanted to help people and she says one shouldn’t take this path if they don’t love people. “I am nervous for them, especially for children. I rejoice when they have successes, that I can give them life”, confesses Elena. After finishing her general education, she went to the University of Medicine „Nicolae Testemițanu” and then, seven years later, she came back to Baimaclia as a physician.
– Baimaclia was a regional centre during the soviet period. They had a walk-in, a hospital and polyclinic here. And you had to be on guard. I didn’t sleep many nights… I gave a lot of time to this profession, stealing time from my personal life, the doctor recalls.
During her almost half-century long career, Elena Ivanschi went through various reforms, changing from one political regime to the other. Now she finds it hard to praise or criticise someone, she simply uses a sarcastic tag – “All are good”. She says it used to be harder with medical equipment in the Soviet Union. The perfusion pipettes were used multiple times, as were syringes – “we boiled them”. Diagnostics machines were also of low quality. “You used to look at the patient and only employ a phonendoscope. Then you gave a diagnostic. Now, you can have tests done, electrocardiograms. It’s different”, Elena explains.
And if in the olden days the problem was technical, now the family doctor system involves a human resource problem. “Maybe it wouldn’t be so difficult if we had more medics. But like this… there are no doctors, and the ones they have are overworked. Everything lies on our shoulders. Then, the patient had direct access to specialists and didn’t have to wait for so long for a prescription or a note”, Elena recalls.
Returning to the practice after lunch break, the doctor dedicates her afternoon to medical records and registries. The patients who didn’t manage to get a consultation have dispersed, postponing their visit to the doctor for the next day. But sometimes a lost soul opens the door and asks her to check their health. Elena would love for patients to learn how to make appointments so that the number of people leaning on walls decreases.
– They come from villages and wait by the door from 7AM. And then they shout if you don’t manage to consult them when they want. When we’re out traveling, some people make a scene that doctors are not here, she says while transcribing prescriptions in the registry.
By 4PM she starts gathering her stuff. She has to visit a few patients in their homes. The first on the list is a former teacher who has trouble with her blood pressure. Then follows an old woman with the same problem. They both live on the same lane where the doctor grew up. “The house where I grew up is further down from here”, Elena points to the end of the central street, where CS Baimaclia is too.
After she ends her visits, the doctor takes the road to the Town Hall. She leaves the bus stop, the bar and the post office behind; the post office is where she takes her pension and compensation of MDL 100 as a deportation victim. From the post office, she goes straight through her mother-in-law’s garden, which is filled with flowers and vines. With its large windows and crimson gate, Elena Ivanschi’s home lies by the end of the village.
Returned home, after a difficult day full of impatient patients, she doesn’t even feel like eating. “I don’t need anything”. She sits down in front of her TV set and waits for the two daily episodes from the Turkish TV series “Stolen Life”. By 10PM she lies down in bed and immediately falls asleep.
THURSDAY, 6TH APRIL // By 8AM, the car with its inscription “Primary Medical Assistance” stops under the fence of a house in the village of Coștangalia. Next to it there are three prams and a horse cart. The haughty house with large windows hosts the Family Doctors Office and, twice a month, Elena Ivanschi stays there. She gets out of the car and leaves for the three room house.
The hallway, in which rugs lie one on top of the other, is quite narrow for the ten patients who are already waiting. Elena makes her way through them to get to the practice at the end of the hallway where consultations take place. The other two rooms, in which young medical assistants work since the crack of dawn, are distributed on two sides of the corridor and serve as surgeries. The practice doesn’t have any running water, gas or toilet. But it has electricity, a wood stove and a rural tap placed on top of a basin storing dirty water.
– First! And please come fast as I don’t come here everyday and there’s a lot of work left to do, Elena Ivanschi shouts restlessly.
Old Manea makes her way out of the crowded hallway. Shrunk by the years, she shyly sits on a chair in front of the doctor. She has come to renew her prescriptions for medicine for her feet. Elena asks the medical assistant in the room next to them to measure her blood pressure, while she starts writing in the register and introduces the necessary details in the records. The pen creaks in the room where a stove, lace curtains and daffodils on top of a baby scale lie in the sun. A woman dares to enter the practice and quietly asks for a hepatitis test.
– I can’t write your name down for this because they don’t have the necessary chemicals/equipment [reactive in romana] in Chisinau. I’ll let you know. Next, and please quicker, quicker, the doctor says.
The eyes of the woman get as big as a fist and she sighs heavily, “We’re done… If Chisinau doesn’t even have it…” She hasn’t yet finished complaining by the time a mother with a child comes in.
Elena’s face has darkened from work. Only the wrinkles have stayed white. Under her glasses, Elena scans the upset child and tries to fool her with a warm smile:
– Come on, lift your dress and breathe deeply – the stethoscope moves quickly by the girl’s back. Oh, it’s brochitis, again. I’ll write the prescription for subsidised medicine. It’s cheaper. Will you have money to get them? Elena asks and then dives her head in paperwork.
– God, God, but who is gonna buy them for me? Might auntie go to Baimaclia today? the mother asks restlessly.
Aunt Manea follows the scene. Staring at the floor, she waits for the prescriptions with her hands by her chest, as if in prayer. From the other room, the medical assistant reports that the old woman has the blood pressure of “a maiden”. Manea hears that and blushes, sucking her lips. A woman slips into the practice and hesitantly greets Elena with a nod. The doctor gives her three papers, without looking at her:
– Here you are, I’m done with you. You’re free, see you next summer.
Behind her, old Manea, thankful that she has enough blood pressure and bone pills for the next three months. The woman with the little girl with bronchitis also leaves the room, complaining she doesn’t know how to get the medicine today: “We don’t have a bus today to get out of the village…”
The two medical assistants storm out on the hallways. They close one door and open the other. There are many people to consult and little time for them all. One assistant looks after a villager getting perfusion, and the other one examines patients who don’t need a doctor.
– When Mrs Elena is not here, we take care of everything. But we can’t diagnose people or prescribe treatments. But sometimes we do that too, unofficially. We visit patients in the village, give injections, write in medical records. If it’s a tougher case, we call the emergency services or we send them to Baimaclia. That’s how we cope with things here, Tatiana explains, while she takes a woman’s blood pressure.
Many villagers wouldn’t have come to be consulted because it’s Thursday and they’ve got “tons of work” on the hill. But as the doctor only comes to the village twice a month, they couldn’t afford the luxury to miss her. “Otherwise you end up spending a lot of money and time to go to Baimaclia”, a man holding a young child says.
In two hours, Elena Ivanschi has consulted about 20 patients. Most of them are mothers with children and old people, suffering from bronchitis, flue or pancreatitis. “If you only eat beans and sauerkraut, how do you expect not to feel your pancreas?”, the doctor tells a mother getting her snotty children. She warns the parents crowded in the practice not to take their children to kindergarten and instead to treat them at home.
A teacher comes in. She is struck to see so many people but doesn’t hold back. She waits quietly, by a fridge full of medicine, for everyone to go. Elena holds her head with her wrinkled hand, pressing the pen on her patients’ medical personal records. Her fingers hurt from so much writing. Until the cortege of parents goes, a chubby woman appears at the door. She looks for the doctor with a strong look. When she sees her, she smiles slyly and shoots words on her high pitched voice:
– Forgive me, just two minutes, as the sausage car is waiting for me by the gate. Register me for a test!
The medical assistant sees the small and piercing eyes of the shop assistant who tries to skip the queue ahead of the teacher. She asks the teacher why she’s giving her place in the queue. “Her sausage by the gate will go off and smell”, the teacher replies amusedly.
After a few minutes, the practice empties of patients. The only thing left there is the smell of onion and sour sweat. A defying and coarse voice spoil the few moments of quiet in the practice: “I came here to piss her off. She prescribed Voleidol (Validol pills) and got my heart swollen.” A man opens the door and comes in. It’s old Victor from Țărăncuța, who came to Baimaclia for a consultation a few weeks ago. He smiles but not for too long, as he meets the hostile and acute eye of the doctor.
– What are you looking for here? Couldn’t you wait for two days to come to Baimaclia?! See how many people we have here… and no time, Elena scolds him.
– Oh, my woman is tough as well but your poor husband! Victor jokes, winking at the medical assistant.
No one resists and they all start laughing. The atmosphere eases and more jokes and joy follow.
The doctor checks the test results and then asks him to take his shirt off to check his bronchits.
– Do you cough?
– Yes, it breaks inside my chest like a big frog, the man answers, filling and emptying his spine, shining from fat.
– Ok then, I’ll give you seven days of treatment. I’ll prescribe medicine for your heart and cefazoline.
– I said so too, says Victor, winking to the medical assistant, who laughs out loud.
– You’re a doctor now? Elena returns to her thorny tone.
– You learn in time. If these medicines don’t work, I’ll open up a jar of fat and one of samagon (home made raki) and I’ll end the illness, laughs the man.
***
MONDAY, 10th APRIL// It’s one of the two days per month when, according to the timetable, Elena Ivanschi has to visit patients in Acui. But she unexpectedly has a check up from the National Medical Insurance Company, so she has to stay in Baimaclia. “I’ll see what I’ll do. They’ll come to me, or I’ll go there another day”, the doctor says.
When the news gets to Acui, the patients with their faces hardened from work, unfriendly looks and humpbacks, scatter angrily to their own homes. Zinaida, Maria and Vasile’s daughter, is also among them. The woman speeds her step to tell her parents that the doctor isn’t here today. Old people’s faces break of despair and their eyes are left in the void, without blinking. They were sure Elena would come today to look at them. The last time she came was a few months ago. Meanwhile they kept sending their daughter to the doctor to renew prescriptions. The doctor had to decide today whether the treatment stays the same.
– Now what will I do? She hasn’t come to me for three months. I have nothing against her, as I had a daughter who was a medic herself and she explained that there are many patients and few doctors but… who will have a look at me? the old woman speaks with a shivering voice as tears fall on her swollen face, out of the fear that she might have to wait for another month.
Maria opened her meaty thighs on the bed covered with a fluffy blanket, leaving her gigantic round belly fall in between them. Her nostrils increase when she gets mad, covering her chubby cheeks.
She had surgery for hernia made unto her nine times in one year. “That hospital in Cantemir exhausted me”, the old woman complains, pulling her golden earrings down. She points out that the big belly she holds in her hand will one day burst out.
Her husband Vasile keeps fidgeting on the bed. He hears his wife’s unceasing complaints but doesn’t have the strength to even smile. He suffers as well. Of prostate. Tears fall over the man’s dry, tight skin. His wrinkled under-eye circles cover his small and worn eyes. He keeps standing up and sitting back down. He doesn’t resist much like that and starts going out like a snail, leaning on his crutch.
The Ciobanu spouses, who are 82 and 77 years old respectively, carry their old age in bed, filled with medicines. “We only go out to the loo”, Maria says. If their daughter hadn’t moved in with them, they “would have been taken to the cemetery a long time ago”.
Two houses away, Zinaida, the oldest person in the village, lies on the bed, covered in rugs and remembering that she has been feeling pain in her bones ever since she had given birth to her first boy. She hasn’t seen a doctor in 30 years. Not because she wouldn’t need it but she says it’s a waste of time. When she feels ill, she drinks a tube of penicillin and a pill. While it rains, she screams more than she rests.
– I have problems with hernia too. When it comes, I bind it with some towels. I don’t go to surgery because I’m ashamed. It’s as if instead of dying, I go visit the doctors. Why doesn’t death take my days and give them to a young person? the old woman asks while making the cross sign.
In order to fit in the room as small and short as a cardboard box, you have to lean your head not to take the whitewash off the bluish-white ceiling. The neighbour Tanea comes in. She had to be queueing for the doctor as she “comes only once a month” but since the visit got postponed last-minute, the neighbour came to help the old woman wash her dishes and sweep the floors.
She retells how she needs a note for her son to manage to get to the sanatorium. “Now I have to go to Baimaclia, queue for a few days to get this note and then waste 30 MDL on transport costs, and I don’t make that money easily. And if I don’t manage to get through to Elena Ivanovna, what will I do?” the woman asks herself.
Lilea is the only medical assistant at The Health Office in Acui. After sweeping by the front entrance of the institution, making villagers return home with a “Mrs Elena isn’t here today”, she goes back home by noon.
She explains the “business” with medicine in no vivid colours. Firstly, in order to get a prescription from the specialist doctors, you have to queue by Elena Ivanschi’s practice for a few days. Then, you get to the polyclinic in Cantemir and they don’t have all specialists there, so you may need to go to Chisinau. But, in order to get a slot with the doctors from the capital, you waste a few days by the Family Doctors Centre in Cantemir.
– When I feel ill, I go straight to the doctors in Cahul and I pay however much I have to. I could die by the time I get a prescription from the doctor. Weeks pass by. My father had to go through surgery last Friday. He booked to have it at the Republican Hospital in Chisinau [through the Family Doctor Centre in Cantemir]. When he gets to the section, he gets ready for the surgery and when the moment comes, they ask for his family doctor note. He says he doesn’t have it. The doctors didn’t even look at him. Now he has to go back to Baimaclia, to Elena Ivanschi, then to Cantemir, then to Chisinau. Only God knows when he gets the next surgery done, the woman says absent-mindedly.
*In Moldova, the family doctor is the equivalent of a General Practitioner in the UK but they are expected to also pay visits to patients at home and not just see them at the practice.
Photos: Polina Cupcea