My first visit to Kosova

Lindita Çoku, MD December 31, 2009 Boston, MA, USA

The first week of November 2009 I visited Prishtina as the President of Albanian American Medical Society (AAMS)*. I was as well invited by Prishtina University School of Medicine, Cardiovascular Surgery Department and Prime ministry office of Kosova to lecture as visiting professor. The purpose of this visit was to promote professional networking among Albanian American healthcare

professionals in USA and their fellow colleagues in Kosova and to offer technical assistance to public academic medical institutions in Kosova. During my stay I had the opportunity to meet with many doctors, medical students, patients and dignitaries from the government and the Ministry of Health and assess firsthand the state of medicine and that of the healthcare system in the capital of Kosova. The same day of my arrival I met with a group of leading figures in the health care and political field which included Dr. Shaip Muja, General Surgeon by training and current political advisor to the prime minister, Dr. Valbon Gashi, Vascular Surgeon in the main hospital of Prishtina and Dr. Bekim Dula, Cardiac Surgeon trained in Italy and working at San Donato Hospital in Milan. From my conversation with them, I realized the desperate and dysfunctional state of the healthcare system in the newest country of the world. My expectations were different, but I had yet to see the reality in person. The next day I was taken to Qendra Klinike Universitare e Kosoves (QKUK) (University Medical Center of Kosova), the main referral center of Kosova. The QKUK facilities were very dilapidated and outdated but most importantly, unmaintained let alone the lack of technology. The pedestrian streets inside the hospital were chaotic, congested with traffic and without any supervision or traffic regulation. The tour started from the fifth floor, in which the cardiac surgery department that was undergoing construction was located (see pictures below). From the beginning of the tour I wondered where the doctors operated in case of cardiac emergencies, but very soon I realized that such place did not exist. The institution was not attempting to expedite the construction process of this floor and designate a temporary operating room in another surgical specialty on standby status for such emergency situations. Very few adult cases were referred to Albania where the expertise was not very much trusted and the majority of them to Macedonia and Turkey from where the outcomes had been very satisfactory.

Kosovar patients had to pay €5K out of their pocket to cover the cost of the cardiac surgery only without accounting other expenses which were not subsidized at least partially by the state. The bill for

the cost of surgery that the Kosovar government normally pays is €10K per patient, if they were to receive medical assistance abroad through the Ministry of Health in countries like Italy. However, if these patients were operated in Kosova, the medical cost would be reduced four fold to €2.5K. According to Dr. Bekim Dula, one hundred children are awaiting to have open heart surgery (the list was provided to me). Very few of them make it to USA through “Gift of Life” humanitarian program or in Italy to the San Donato Hospital of Milan. Last September, AAMS donated $500 for the airline ticket of Indrit Zhushi, the four year old boy from the outskirts of Prishtina who had his congenital heart defect repaired at Children’s Hospital Boston. Indrit is one of a dozen Albanian children helped by the “Gift of Life” program in USA to receive surgical intervention across the ocean. At San Donato Hospital Dr. Bekim Dula had fundraised €2M for this project through and was willing to start the program in Prishtina without any delay. Additionally, the government has pledged € 700K, but the support of Ministry of Health is yet to be seen. Furthermore, some Italian physicians had undertaken a few missions to help on site this medical center in cardiac surgery, but as an Albanian saying goes, “the house can not be maintained the whole time with borrowed flour”. At the entrance of QKUK we found an Albanian man who was asking for help in finding a goverment doctor to perform the operation to his daughter: “I am a 15 years old kosovar girl, E.J. Brothers and sisters, for God’s Sake, whoever can help for my heart surgery. God help me”. He could not afford paying out from his pocket as per his concern. We did direct him to get his daughter registered to the Ministry of Health database of patients that were listed for the same issue.

Furthermore, the university center was also lacking expertise in the oncology field. Despite of the new colorful facade of the radiation oncology building, the facility was found to have major insulating defects. I inquired where cancer patients were treated in the absence of an available treatment center, but did not receive a clear answer. Down the road I noticed a construction site. I was informed that this was a “private” cardiac clinic, built inside the hospital premises with permission from the government, although the law explicitly states that “a private clinic/hospital cannot be built closer than 1.5 km from the public medical centers”. This clinic however, was situated within walking distance from and inside the yard of the public medical center. Another surprising discrepancy was that of the issuing of medical licenses to qualified physicians and the absence of job contracts. I was also told that the Albanian cardiac surgeon that has been working for the past 20 years in Germany and is the owner of this project has license to

work in Kosova. I was informed that the majority of physicians in QKUK were working without any approved licenses from the Ministry of Health, or a job contract. Under such circumstances, the physicians did not have guaranteed job security and could be easily discharged at any time. On the other hand, because the physicians were not bound by a legal agreement, they could leave the job whenever they wished or for reasons of malpractice without any consequences. This situation seemed ubiquitous in many other wards and sections of the medical center that I was able to visit. The best thing I found was the dedication of the nurses and physicians working under miserable conditions and making the best out of them. The second day of my stay Dr. Bekim Dula accompanied me during an important meeting with the Minister of Health, Dr. Alush Gashi. I introduced AAMS with a brief presentation stating our mission and patriotic interest to help within our capabilities the healthcare service in Kosova. I also raised the issue of the physician licenses and the lack of their employment contract.

AAMS gifted an American Flag to the Prishtina University School of Medicine In the following days I met with the Dean of Prishtina University Medical School (see picture above), Dr. Gani Bajraktari, a cardiologist, the vice dean and a few other physicians including Dr. Bekim Dula. I was informed that the hospital was having a shortage of inexpensive medications like lasix (furosemide) without mentioning supplies and technology. His concerns and focus was on improving the attendance of medical students in lectures and classes, inspecting the quality of lectures given by professors and working in improvement of the curriculum of the medical school. I offered our willingness to help in this aspect, especially through Dr. Philip Çaushaj who has assisted The Medical Institute – Plovdiv in Bulgaria to improve their curriculum and has a long standing experience in medical education.

Notice the overused/sterilized and tape fixed bovie catheter in the hand of vascular surgeon performing creation of an A-V Fistula in a patient with long standing kidney failure.

After this meeting I was invited to attend a vascular case in QKUK (see pictures above) with two talented surgeons, Dr. Henrieta Zherka and Dr. Valbon Gashi. The case required general anesthesia, special suture and prosthetic materials in order to repair the artery that was obstructed from atherosclerotic process. The patient was a male in the late 60’s and had multiple co-morbidities including diabetes, kidney failure, severe arterial vascular disease.

This kind of procedure according to American medical protocols is usually performed under general anesthesia, but in this case was done with spinal anesthesia which after one hour weaned off. There was not any medication available to sedate him and to locally control his pain. The thread of the stitches was not of the right size and had expired, but that was all that was available. The gortex graft used to tailor the patch was a leftover from cases done in hospitals of Western Europe that had donated them to QKUK. Such grafts were kept in the container of formalin. Instrument sets were missing, surgeons utilized anything that was placed in the tray from the talented scrub nurses. Vessel loops were a dream and there was no such thing like glove size; the scrub nurse would provide the surgeons with whatever glove size was available. All the gloves were missing the cord that holds them in place at the forearm level as they were cut to be used as vessel loops, another example of their ingenious creativity. I closed the wound, an emotionally difficult process which was accompanied in every needle stick by a scream from the patient. After leaving the operating room, the patient was transported in his floor bypassing the recovery room, while his entire family was waiting anxiously in the hallway. At least family care and love was so abundant and in a way replaced the shortage of medical supplies.

The fifth day I presented at Telemedicine Center of Kosova as visiting professor the lecture on “Robotic CABG Surgery at Boston University Medical Center Program.” The attendance exceeded my expectation and there were many medical students present among many attending physicians who asked bright questions about the use of robotics in cardiac surgery. This educational center itself was providing the cutting edge technology and was fully sponsored from USAID a few years ago (see pictures below). The lectures were attended simultaneously via satellite system from other regional public medical centers and offered a distribution of education in national level.

This day I was invited to visit the houses of two surgeons and their private clinics, which met the American standards of healthcare. In the evening of the same day I invited on behalf of AAMS approximately thirty physicians from QKUK whom I had the opportunity to meet during my stay in Prishtina (see pictures below). The group was mostly comprised of surgeons from vascular, thoracic and general surgery specialties, including anesthesia. These physicians felt that this unique meeting was the best professional event they ever attended in their country.

The AAMS purpose of this gathering was to encourage networking of physicians among each other in QKUK and facilitate teamwork in such difficult conditions. They realized that after such dinner they felt more solidarized with each other that the relationships could improve to a better harmony of the medical staff for the best of patient care in Kosova. I felt so encouraged by the positive response because all physicians I had met earlier were affected by the failing medical system in Kosova and their morale was low. The team work spirit was absent; most of them worked after hospital hours in private clinics or their “ordinance” in order to boost their monthly salary of € 240 (see pictures below). Some of them were contemplating of leaving the country to start a brand new life in Western Europe, the last thing Kosova needs. However, all surgeons I met with were utilizing the latest literature from prestigious American and European journals and could perform moderate to difficult level of surgical procedures, but needed assistance with very complex cases.

On the last day in Prishtina I had the great honor of meeting with the President of Kosova, Mr. Fatmir Sejdiu (picture pending). I openly expressed my concerns about the medical system in Kosova and I was asked to submit to his advisor my written recommendations for improvement of the situation, as enlisted below: In order to achieve fast and tangible solutions the government should focus on the following short-term goals: 1.) Reinforce rules and regulations for maintaining hygiene protocols, provide continuous running water, soap and clean medical facilities, for the decrease and prevention of rate of infections. 2.) Reestablish the security system of healthcare personnel and government institutions in order to provide a safe working and service environment. 3.) Reinforce traffic rules and regulations on the premises of the medical centers. 4.) Increase the wages of all levels healthcare employees in order to meet the region standards. 5.) Promote volunteer services of students within public healthcare institutions with prospects of future training and/or employment. 6.) Reopen/reestablish the ambulatory healthcare centers in an effort to improve primary care services and filter those cases which should be seen in tertiary care centers (decreases costs). 7.) Slowly introduce to patients and their families the system of self pay (partial or total) with short or long term payment options. 8.) Establish a mandatory two-year community service for newly graduated physicians as part of their practical training. 9.) Consolidate the existing training programs, open new ones for all specialties at QKUK and establish brotherhood collaborations with other well run regional programs such as the University Hospitals of Tirana, Albania. 10.) Forge official ties with and seek assistance from regional and international organizations that can offer humanitarian, technical and professional assistance to Kosova’s public health system. 11.) Protect the figure of physicians and healthcare employees bypassing legislature that strengthens their job security through legal employment contracts and award accreditation through professional licenses to qualified physicians and healthcare workers. *AAMS is a professional, humanitarian and nonprofit organization under section 501(c) (3) of the United States IRS tax code. It is organized to contribute exclusively to the Albanian-American medical community and immigrant patients in United States of America as well as to maintain strong educational

bonds with academic healthcare institutions in Albanian-populated territories of Balkan Peninsula. Please visit www.albamedsociety.org for further information.

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