Saturday, October 24, 2009


The doctor’s face was beet red and not just because he was pissed off at my wife. We could hear the soap opera “Crying Maria” blaring in the room behind him, and he wasn’t at all pleased he’d been called out to examine Liina’s hand.

“What?” the doctor barked. This was Haapsalu, 2001, and Liina had been manhandled by some Russian thugs who jumped a queue to get aboard the Haapsalu ferry. Liina had boldly attempted to do the job of the ferry operators, who were too scared to even voice protest, and in exchange for her trouble the thugs held her arm and bent her fingers back over her hand. While Liina cried in pain in protective custody on the ferry’s bridge, the cops were called to arrest the queue-jumpers as they disembarked the ferry. Then we hopped in the car and raced to the hospital.

“What?” the doctor snapped again. Liina’s slow response time was getting in the way of his soap. “What do you want?”

Liina held up her swollen hand and explained.

“Move your hand like this!” the doctor demonstrated.

Liina moved it.

“It’s not broken.”

“Couldn’t we x-ray it?” Her fingers were as big as sausages. “I’d like to know for sure?”

The doctor reached out with surprising speed and seized her hand. He twisted it. Liina writhed in pain. “It’s not broken,” he repeated. “No x-ray is needed. Head aega.”

And that was that. The doctor returned to his television, and we drove on to a Tallinn emergency room where both a sober doctor and an x-ray machine were more easily available.

Say what you will about the Estonian healthcare system—and everyone has a horror story—I believe one thing is undeniable: it gets better every year. The days of drunken doctors (as well as Russian queue-jumping thugs) are mostly behind us thanks to EU standards, a more consumer-focused society, and the growing self-confidence of a citizenry who increasingly realize they’re not lower than grass on the great lawn of bureaucracy. Of course, there are some stubborn holdouts, who still think the business of society is transacted using brute force, favors from friends, and the occasional bottle of brandy, box of chocolates, or live chicken given as a bribe. These people are the Soviet residue, and they’re found mostly in the segments of government and business least touched by market forces. Which, sadly, is sometimes healthcare.

Last week, Liina accompanied her best friend Piret to the obstetrician at her family doctor’s practice. Piret is freshly pregnant and was quite excited to see her baby on the ultrasound machine in all its alien-like splendor. It’s her first child, and so she admits some of her questions may have appeared naïve to the doctor. Still, she didn’t feel she deserved the doctor’s repeated answer of: “That's of no interest to anyone in the developed world.”

When Piret could not spot her child on the ultrasound picture and asked if there was a chance she wasn’t pregnant, the doctor snapped, “Are you blind, woman? It’s right there in front of you.” To spare herself more humiliation, Piret falsely confessed that she could see her child.

“And how much do we owe you?” Liina asked, stepping in for Piret and ending the visit to the Soviet Doctor from Hell. The doctor demanded 995 kroons. When Piret took out her bankcard, the doctor demanded cash and told her to run to an ATM across the street. To spare them from seeing the doctor’s face twice, Liina produced the cash and the doctor snatched it from her hand as she shooed them out of the office. No respect. Not even a receipt.

When Liina recounted the story to me later that night I couldn’t help but recall our doctor from Haapsalu. “You think that doctor could have a sister in Tallinn?” I asked. Liina said she was afraid that doctor might have sisters in a lot of places.

Before returning to Estonia in 2000, Liina and I lived in the United States where I worked several years as an adjunct faculty member at a university. Adjunct faculty in America are the bottom feeders on the university food chain, and so the health insurance policy I was able to afford was little more than a guard against catastrophe—a 250-dollar monthly premium got me a five-thousand-dollar deductible policy to cover against major illness. Liina, who traveled frequently to Estonia, anyway, was able to use traveler’s insurance. This was quite cheap, but its downside was that it forced her to visit the American emergency room for any matter, large or small. The one time she did need a doctor—a shard of glass in her palm—we waited six hours to see the physician. The doctor was professional, though if he’d have allowed me access to the anesthetic, I could have done the job myself, and Liina would have been out the door in a mere fifteen minutes. And I might have been grateful enough to treat some of the other patients in the waiting room, many of them poverty cases, nutty hypochondriacs, or people suffering side effects of America’s greatest epidemic: obesity. With calisthenics I would have cured half and killed half, but the job would have been done, and the doctors would have been freed to treat people whose jelly-donut-eating lifestyles didn’t invite illness. But rules are rules, and while I might have been able to pass myself off as a doctor in Haapsalu, I wasn’t welcome to practice medicine in America.

Fortunately, Liina and I were both healthy and so were able to view the American healthcare disaster with detached amusement. We met plenty of the middle class who so staunchly defend their rotting system due to a hyped-up fear of socialism, a people so petrified of government at any level that not only were they unwilling to consider the single-payer system functioning so well a few miles north in Canada, but they were happy to entrust their system to insurance- and pharmaceutical companies and their lobbyists who clearly weren’t motivated to act in the patients’ best interest. At 100 billion USD per year, it's arguably the world's most expensive and least efficient system.

We also met the underclass, those who rely on the emergency room as their primary caregiver and to whom preventative care is at best a dream and at worst a foreign concept. Mostly, our American experience taught us this: America is not for the meek, and it’s no place to be poor.

For most medical treatments, give me Estonia. Yes, the Soviet-era hospitals in their constant state of decay are rather depressing, and the constant buzz of the fluorescent lighting is probably the cause of more depression than winter darkness. And true, I wouldn’t want to have an organ transplant here, and I wouldn’t want to trust an Estonian doctor to diagnose trypanosomiasis, buruli ulcers, or Cushing’s disease, and it’s a fact the American system is tops in the world when it comes to beating cancer. But if I’m able to keep myself fundamentally healthy and only garden-variety illnesses visit me, I’ll take Estonia any day.

And that goes double for emergency treatment. Last spring, during a routine do-it-yourself project, Liina dropped a shelf on my face and I had to visit the emergency room. Since I wasn’t dying (just bleeding from my forehead), I had the presence of mind to put a stopwatch on the visit. Forty-three minutes in and out. And very pleasant doctors and nurses.

I’ve since been once more to the emergency room (Keskhaigla) for my back, and I can’t praise enough the doctors and nurses there. They’ve got their problems, too—the emergency room is full of people who refuse to see their family doctors for one reason or another—but you don’t wait six hours to see a doctor and you’re spared the humiliating financial triage performed by a curt American administrator.

My Estonian family doctors have always been excellent, too, though I admit I have the advantage of some professor friends at Tartu University’s medical school who have recommended physicians to ensure I don’t end up in the hands of doctors like Piret’s. And so far, I’ve used only state doctors, stubbornly believing that I truly ought to get something in return for a thirty-something percent social tax.

I’m pleased to report that Piret found a new physician and she started over. Thanks to an obstetrician and a team of medical pros who seem to love their jobs, it was a wonderful experience for her, and she’s more excited than ever about having a baby. She had to pay six-hundred kroons to a private clinic for another initial visit, but she didn’t get yelled at, and the doctor helped her see her baby on the ultrasound screen. She even got a receipt.

In a country which so desperately needs babies, this isn’t only a victory for Piret. It’s a victory for us all.

Read it in Postimees ("Tervishoid- ja õud") here.

Dept. of Shameless Commerce: Give Vello's book for Christmas (in English) this year. (A refreshing alternative to the usual gifts of Kihnu Island sweaters or bottles of Vana Tallinn.) Available in English from here.

Inherit the Family: Marrying into Eastern Europe