Article in the Pozvanete & Novini Newspaper issue of 26-Sep-2003 Translation from Bulgarian:

Original in Bulgarian

Back to chronology

Pozvanete & Novini (Call us & News) Newspaper
issue 230
Varna, 26-Sep-2003, Friday

[Headline on the first page:]
Democracy in action: How and why medics wanted to silence a medium

[Headline throughout p. 8-9:]
If something happens to me, I won't be able to come and say, "Didn’t I tell you?"

Reneta Stoyanova is handing her book, "Chronicle of a Leave Foretold", to a former patient of hers. The novel published in this August describes the hemodialysis patients' problems.

THE CONFLICT: The publication of this interview has its prehistory. Reneta Stoyanova, a former medical nurse in the hemodialysis unit of St. Marina Hospital – Varna, came to the editor’s office. She posed some questions of importance to health care. There cannot be any doubts that the questions Stoyanova raised should be discussed in earnest. That is why, by the iron laws of professionalism, our journalist Iskra Urumova asked the executive director of St. Marina for an appointment and for am exhaustive interview. The respected by us medical leader received Urumova but, to our surprise, in the presence of Prof. Nikolay Penkov, Dr. Maya Kyoseva and Dr. Zhana Georgieva, he refused to comment the words of the health worker Stoyanova. Ivanov pointed out that "all the authorities have already given their opinions on the Stoyanova case." Well, Mr. Ivanov, you are probably not aware of the fact that social interest is not always the same as that of authorities. Indeed, there are lots of examples to show that they often talk at cross purposes. The only God for a decent journalism is true service to social interest. "Pozvanete & Novini" has found that society has the right to know what a long-standing health worker thinks of the work in this HD unit. The editor’s team would lose its self respect and the respect of the social opinion if we tried to cover something that concerns the most valuable human capital: health. Instead of commenting in essence, however, Mr. Medic dared to threaten the journalist Urumova that he would bring a suit against the newspaper if Stoyanova's interview was published. In other words, Mr. Medic dared to impose sort of preemptive censure by mentioning the independent court authorities as a threat. According to Dr. Ivanov and his colleagues enlisted above, Reneta Stoyanova was mentally unstable. Well, Mr. Ivanov, we are not psychiatrists. And, to the best of our knowledge, you are not, either. That is why we appeal to you, instead of "going to a goat for wool" with phrases like "commenting on this theme is irresponsible on the background of the trial of our health workers in Libya and could entail further court claims by foreign citizens", to comment in depth and give a substantial answer, with facts and arguments, to the revealed in the interview with the medical nurse Stoyanova.

[Another headline:]
Reneta Stoyanova:
Bulgarians Were Dialyzed on Infected Machines Because of Foreigners
By the middle of the 90s we lost control over our patients’ testing for hepatitis B, C and AIDS. Patients are admitted not tested for hepatitis and lie on clear HD machines. The results of several nurses were lost in February-March, 2003. For 16 years, I have not seen a document in which it was written that the HD patients belong to a risk group, says the former HD nurse. She worked there from 1-Oct-1987 to 2-Jul-2003.

You say you expect us to help you with a few questions. The first is: do anti-epidemic standards exist in Bulgaria for infectious diseases and, in particular, for hepatitis?
It is not some general standards but virologic standards intended for HD units.
THERE SHOULD EXIST SPECIFIC
standards intended for testing the patients in HD units such as the ones that exist in Europe. These standards clearly say that the HD patients are tested for hepatitis B every other month or every three months. For hepatitis C every six months, for AIDS, every year. They are not a dogma, they
CAN BE MODIFIED
depending on the condition of an HD unit. If high percentage has been ascertained, then it is desirable the testing to get more frequent, checks should be performed to find out the source of infection and to restrict it fast. This has been done for a long time in the HD units around the world but these matters need clarifying in Bulgaria.

Have you seen such standards in your HD unit?
For 16 years I have not seen a document in which it was written that the HD patients belong to a risk group and should be regularly tested for this, this and that. Neither over what time periods should they be tested.
STANDARDS LIKE THESE ARE FOR THE WELL-BEING
both of the patients and the staff who are also exposed to risk.

While you worked there, how often were the patients and the staff tested?
Many years ago, we used to test our patients over every three months for hepatitis B and AIDS. Then we started testing them for hepatitis C as well over three months.

Which years do you mean?
The end of the 80s and beginning of the 90s. I think we lost control by the middle of the 90s.
I CANNOT SAY EVERYTHING,
I can only ask you to try and see the statistics of the unit, how long have the patients not been tested the way they were tested before.

How about the staff?
The staff as well. For example, the last time it happened so that, it was I think in February or in March, that
5 OR 6 NURSES AT A TIME SENT
blood samples for tests of hepatitis B, C and AIDS. We sent them with reference bills from our GPs, as it was required, and then they never returned, the results got lost. We asked our head nurse to do something. She called the lab many times but nothing could be found out. We informed the executive director and on 28 and 29 May, by his order, I suppose, but I cannot tell by whose order
ALL PATIENTS AND STAFF
gave blood samples for hepatitis B, C and AIDS. So far, I do not know what the results are. I do not know even my result, no one ever called me to tell me at least my result. The head nurse said the results would be ready by the end of June because the lab was waiting for some new kits for the tests. Then I left and
FELT UNEASY
to call and ask for my result.

When did you leave?
My last working day was 29 May. Exactly on that day I gave blood for testing. Then I was on a paid leave till the end of June.

What is the risk if tests are not conducted regularly neither on the patients nor on the staff?
Well, you can ask my bosses. For example, when a patient is admitted for hemodialysis, he or she must have been tested in advance so that we could determine on which machine to lie.
THERE ARE THREE TYPES OF MACHINES IN THE UNIT
The so called clear: for people who do not carry the virus of hepatitis or AIDS. Machines devoted to patients infected with hepatitis C and machines isolated for infected with hepatitis B.

How many are the machine altogether?
21. Out of them: 2 for hepatitis B virus carriers, 7 or 8 for hepatitis C. I say 7 or 8 because two inspections were made by the end of May. One wrote 7, the other 8 devoted machines.

Inspections from the Ministry of Health?
One was internal hospital, and the other by the Regional Center of Health.
THESE MACHINES WERE NOT DESIGNATED
in any way so they could not be distinguished from the others. They could only be pointed at: these here are fro hepatitis C. The machines for hepatitis B are in a separate room which is at the beginning of the corridor. It should not be there.
IT SHOULD BE AT THE END OF THE CORRIDOR
and really isolated with a sign on the door "Entrance forbidden". Only for the staff who serve the patients there. But these are details form the epidemiology which is not known here. So, we have 7 or 8 machines for virus carriers of hepatitis C, and on them were also dialyzed patients who were not virus carriers because the machines are not enough. There are too many patients.

So, you have 12 clear machines, yes?
Yes,
BUT LET THE BOSSES SAY
that they have observed the regulations and have dialyzed the patients separately – those infected with hepatitis C only on the machines devoted to them. It would not be easy for them to explain, when the foreigners came, how were all the patients allocated and accommodated.

Before that, I’d like to ask you another question. You said that these machines can only pointed at. Does the staff know which machines from which patients are?
Even the staff cannot tell which the machines are because it was a rule that medically unqualified members of the staff, technicians, should allocate the patients on the machines. They know where each patient will be.

Who takes the decision?
Who controls it, rather? The decision should have been taken by the head of the unit, Dr. Kiril Nenov. The doctor on duty is to control.
AND THERE WAS A CASE ON 25th MARCH
2003, it is written in the register for physicians’ reports, it is read before the doctors every morning. The doctor on night duty wrote that a technician had put a negative patient on a machine dedicated to positive patients. He described that
THAT HAD HAPPENED WITHOUT THE KNOWLEDGE OF THE DOCTOR ON DUTY
No measures were taken on that case.

And did it become clear if that patient got infected?
These things are hard to make clear. First, the patients are not tested. Besides, to see if a patient has been infected, you have to wait about 6 months. But that was not an isolated case. Other patients have shared these machines, too. I had told once that the way our patients are admitted not tested and then use clean machines and
MONTHS HAVE PASSED BEFORE WE IDENTIFY
someone as a virus C carrier, these machines cannot be considered clean any more. I may be wrong, but 2 or 3 months before the foreigners arrived, a new patient was dialyzed for months on such a clean machine. Then he was tested, when he finally brought a reference bill from his GP and
IT TURNED OUT HE HAD BEEN HEPATITIS B POSITIVE.
Perhaps he has carried the virus even before he started dialysis. This machine was then disinfected, as all are between the shifts, and we went on considering it as clean.
ON THAT MACHINE A FOREIGNER WAS ALLOCATED
I cannot tell which foreigner was allocated on which machine because they are not designated. There are some numbers stuck on them but they can easily be removed.

The disinfection of the machines, does it mean that a disinfected machine can be used by people who are not virus carriers?
This is a controversial question in medicine. Some assert a disinfected machine can be used by a negative patient, but
OTHERS SAY THIS IS NOT QUITE SO
because there are inaccessible places on the machine which cannot be disinfected. There is a regulation according to which the virus carriers must be dialyzed on machines devoted to them only. I worked 16 years there and still do not know what regulations there are.
I SEARCHED ANYWHERE TO LEARN
how it is because I worked in information blackout. Everybody still works so. And only because I alerted that I think we had enough problems to resolve: with testing of our patients, with shortage of supplies, because I said we were not ready for medical tourism, I was accused of whatever not.

By whom?
By my direct boss. I cannot prove it; I can only tell you that
I WAS MADE TO LEAVE BECAUSE THEY HUMILIATED ME
insulted me etc.

You mentioned foreign citizens a couple of times. What is it about?
People from Belgium, say, on dialysis there, decide to come on holiday here, at the seaside. This is arranged still while they are there, I suppose, and place is found for them. They are promised they would be dialyzed in Varna while on holiday. And they arrive. The one who promised them brings them, Prof. Nenov. I do not even know what he promised them because he has a private HD unit.

What was the date when the foreigners arrived?
The first and second groups were dialyzed on 22 May, 2003. 16 people were dialyzed, 8 on the morning and another 8 in the evening. That day was Thursday. We had 13 regular Bulgarian patients on Thursdays, and another, I cannot tell exactly how many, in the afternoon. To accommodate among these, say, 20 and something patients of ours 16 more from abroad
IT WAS A GREAT LOAD, AND WE DID SO:
8 foreigners were accommodated in the morning shift which comprised 13 people. This makes 21 overall. We had 19 machines; I do not count the two for hepatitis B. So, we moved two of ours to the afternoon shift
BY ORDER OF THE HEAD OF UNIT
Now we had 11 our patients and 8 foreigners. All stations were full this way. On the 7 machines supposedly devoted to hepatitis C carriers were allocated our patients who were not for those machines
FOREIGNERS WERE ALLOCATED ON 8 CLEAN MACHINES
and on the remaining 4 clean our patients again. There were only our patients in the afternoon, and only foreign in the evening. It is only the first shift, actually, that presents interest. So, the foreigners came on Tuesday, Thursday and Saturday. Six times during two weeks until 3 June.
EACH TIME OUR PATIENTS WERE PUSHED
to the infected machines so that there would be clean machines for the foreigners for we had been told they were clean, that is not infected with hepatitis B, C or AIDS. So, we did our best in serving them. I do not say they got infected here. Far from that! Besides, the incubation period of 6 months has still not passed, though I have heard there are methods on the West to identify the infection much earlier.
I ONLY SAY THERE IS RISK
Both our and guests patients are exposed to certain risk when dialyzed together in such circumstances.

Was there only the group from Belgium? You mentioned something about a group from Israel?
Oh, the Israelis came, too. They were for only one HD session. Perhaps they simply passed by on their way to another town, I suppose. They were dialyzed here on 27 May. The only thing I could do for them was
TO ASK THE EXECUTIVE DIRECTOR
not to allocate them all at a time. I had a talk with him. 13 people had been expected. 12 came, by documents. I cannot tell what documents exactly. I only have a reply from the Regional Police Department; they write 12 citizens from Israel were dialyzed on 27 May. I suppose the director ordered to divide them in two groups because we did not have 13 clean machines. To dialyze 12 or 13 Israelis, this means that
ON 27 MAY NOT A SINGLE BULGARIAN
was dialyzed. They were all moved to other days. This is what we did: our regular patients of Monday came a day earlier, on Sunday. I was then at work
SUNDAY IS A DAY FREE FROM DIALYSIS
So it is in all Bulgarian HD unit, and in the world, too, I suppose.

Why is it so?
This is a holiday. We use it for a thorough cleaning of the unit. There are groups on Monday, Wednesday and Friday. Also on Tuesday, Thursday and Saturday. All the patients are dialyzed three times a week for 4 hours. That Sunday three shifts were dialyzed, our regular patients from Monday. I was night shift on Sunday. Our patients from Tuesday came on Monday, 26 May, a day earlier.
27 MAY WAS A FREE DAY FOR OUR
patients. There were only Belgians and Israelis on that day. I was not at work on 27th.

Was the visit of these foreign groups documented in the hospital?
By 29 May, my last working day, it was not.

Either of the Belgians, or of the Israeli patients?
Either.
NOW THE RPD SAY
it is documented.

When did you alert the authorities and why did you decide to do it?
I sent a letter to the health authorities on 22 May.

Was it a complaint?
I did not entitle. Just to whom it may concern.
I WROTE THERE IS RISK OF INFECTION
for foreign citizens in a Bulgarian hospital. It is not a 100 per cent risk but there is always risk when we do not test our patients. We also have weak points in hygiene which our bosses are unwilling to admit. I wrote about such weak points in hygiene to the executive director.
WE DO NOT HAVE A DISINFECTION ROOM
in practice. For durable supplies. In a small room, a former bathroom, sized 2 to 3 meters, there is a sink and two shelves. It should house about ten 20-liter and 19 5-liter buckets. They should be filled with disinfection solution up to their brims, even their lids should be soaked in disinfectant. In fact
THERE IS NOT ENOUGH SPACE TO PUT THEM
let alone to disinfect them. There should be a large and deep vessel to soak them. We do not have such one. Sometimes we disinfect them, sometimes we do not. These things are hard to prove. But there is experience abroad. People abroad have made checks and proved that even when the disinfection of the machines is perfect
SUCH DURABLE SUPPLIES
can be a source of infection which spreads through sharing durable supplies by the patients. We do not have the opportunity to disinfect them properly, and in the same room we disinfect surgical material, surgical claps, etc. On this sink in the small room, a former bathroom.

What surgical material and clamps?
Plenty of surgical supplies. Small operations are performed in our unit. A catheter is placed in a surgical way to start hemodialysis. Not only needles. It is a small operation: sometimes a short cut on the skin
THESE ARE VERY RESPONSIBLE PROCEDURES
performed by our doctors under local anesthetic. We prepare the supplies for them.

Are they disinfected?
Yes, they are. Disinfected are even catheters which were used. Disinfected are single-use materials, too.

For instance?
These catheters. There goes a whole surgical kit with them. Because there is shortage of them. I am a witness of such practices. It is hard to prove but it was exactly in this way that we reached 80 per cent infected with hepatitis two or three years ago. I cannot tell what is their percentage at the moment because many of the then infected patients
DIED WITHIN 2 YEARS.

Let us come back to the point. You sent a letter to the health authorities on 22 May. When did you send a letter to the police?
On 26 May, after I saw that the foreigners were not recorded in the unit registers. I asked the head nurse, and she said: "My fault, there is not time for everything in this bedlam." I told her: "DO NOT SAY THAT. IF THERE IS A CHECK
we may be blamed for trying to conceal these people. Treatment is illegal if patients are not recorded in the unit registers." We have two unit registers. "And if you missed to record them, why did the nurses also miss to do record them?" I have to tell you that as soon as this story started I withdrew and said
I WOULD NOT PARTICIPATE
in the shifts with the foreigners.

And why are there two unit registers?
This is a regular procedure. One register is to record a patient on admittance in the unit. This register is kept by the head nurse. The other is in the room where dialysis sessions are conducted and each session which is to be performed is recorded in it under individual number. This way
THERE ARE TWO NUMBERS ON THE PATIENT’S SHEET
one is the unit number, and the other is dialysis number. Thus the number of all admitted patients and the number of all conducted HD sessions are accounted. Both numbers are four-digit ones.

What did you write in your complaint to the police and what did you want them to do?
To check as soon as possible, I suggested 27 May as the most convenient day for a check, when there were only foreigners in the unit, to see whether they were recorded in the two unit registers because I personally had witnessed they were not. I also wrote that the
THE STAFF WAS PROMISED MONEY 'BY HAND'

Who promised it?
Our head nurse gave this as information. It was denied later so I cannot tell you anything more.

About the money 'by hand'?
Yes.
THREE TIMES AS MUCH AS WE USUALLY TAKE
for the same amount of work.

What did the police reply?
By the middle of June, the 2^nd Police Station replied in writing that they had made a check and there had not been found out any disorder. That was all. Who made the check, how and what they had checked.

And you sent another complaint after that?
Naturally, that time to the Ministry of Internal Affairs. The case was transferred from there to the Regional Police Department of Varna. I received a reply from them on 17 Sep. This reply is more or less the same. No disorders.
I WITNESSED THAT THE PATIENTS WERE NOT RECORDED
in the unit registers.

And what was the opinion of the health authorities?
They replied in general words that everything was in order. My request to you is to collect some information.
I DO NOT WANT ANYTHING FOR MYSELF
I do not complain at all and I do not seek any revenge on what they did to me. I was an experienced health worker and they made me leave.

You said you had data about the spread of hepatitis C and B in the HD units? Will you tell something? What are these data in your HD unit, as long as there is information?
Why should I give you data on the hepatitis spread after
THERE SHOULD BE AN EPIDEMIOLOGIST
in the hospital and he should give them. There is also an Occupational Medicine Office which deals with work conditions, occupational safety, etc. They should also have such data. I recently read that this office should have given a conclusion about my health condition on my leaving work, and of my epidemiologic status, too.
I DO NOT HAVE TEST RESULTS
for two years, maybe. I think that there is no order in these matters. They should be regulated and controlled.
Do the patients sign a declaration of informed consent?
I have not seen them to sign anything else than a consent about starting dialysis treatment. A declaration that they have been informed about their belonging to a risk group as hemodialysis patients on maintaining treatment
SUCH DECLARATION I HAVE NOT SEEN
as a sample. I do not think they sign such declaration. They probably do not even know that they should be tested, not how often; some of them even do not know they are infected.

How exactly does infection spread?
There are experts who can explain you. I am not an expert. This is a very complicated question. It is fact that all over the world people who have never had blood transmission
BUT ARE ON DIALYSIS, HAVE SOMEHOW BEEN INFECTED
Therefore, it has happened not via blood transmission. Whether it is via the HD machines, or via shared supplies, or some of the infected would bleed and squirt it around. As far as I know, they have already been separated in our unit, the hepatitis C infected have been isolated in the two small rooms. While I was working, however,
THE HEPATITIS C INFECTED PATIENTS AND THOSE NOT INFECTED
were dialyzed in a common big room. The machines were divided into clean and infected, and that was not observed. Besides, it is not unusual for a
PATIENT TO BLEED SUDDENLY
and to squirt up to the ceiling because the puncture needles are thick. The patients are a stable source of infection with blood borne viruses. They bring their own bed sheets, these sheets are often stained with blood, and then they take them home to wash them. I cannot tell how it is now. They may have provided hospital bed linen now, I hope. I told the executive director that the question was not only medical but also financial
I INFORMED HIM THAT THE PATIENTS HAD NOT BEEN RECORDED
in the unit registers. But he, instead of jumping up to tell me: "Let's go straightaway to see what's going on!", he told me: "Do you know your job profile?" I must obey my bosses' orders, my job profile says, but it is not just the same in the Labor Code, as far as I remember. It is not to obey unconditionally.
I MUST OBEY ONLY TO LEGAL ORDERS
and therefore I need not obey an order which says to dialyze the foreign patients but not to record them in the unit registers. In fact, there was no such order. It was oral. If the patients were recorded later, this would mean the registers were copied, my handwriting would not be there; however I was working at that time.
THESE MATTERS SHOULD BE CONTROLLED
by the head of the Regional Center of Health, Dr. Veselin Balkanski, but the inspection performed by his center did not even notice that we did not have a proper disinfection room. The Hygiene Inspectorate had not noticed that before, either. No one ever noticed how the patients were distributed and how
OUR PATIENTS WERE PUSHED ONTO THE INFECTED MACHINES
There are data on the Internet which I gave in writing to the executive director as early as 27 May. They were registered under an incoming number. There I presented statistic tables with data about the percentage of hepatitis C infected in the HD units in various countries. For example, Belgium: 4%, the Netherlands: 3%, Bulgaria: 65%. Moreover, they had tested over 2,000 patients in the West compared with only 60 or 70 from an HD unit in Bulgaria.
PERHAPS WE DO NOT HAVE GOOD STATISTICS
in Bulgaria. I have never claimed anything in my letters. I was only a medical nurse. And as such an incompetent person I could only ask questions, you see? So I turned to the executive director and the other competent authorities and asked them
TO GIVE INFORMATION, TO SAY
how it should be. They said: "Everything is perfect. There is nothing to worry about."

You mentioned in the e-mail to our newspaper that your life is threatened?
If something happened to me, I will not be able to come and tell you: "Didn’t I tell you?" That’s all.

[Text to the two photos in the article:]
1. Reneta Stoyanova is handing her book, "Chronicle of a Leave Foretold", to a former patient of hers. The novel published in this August describes the hemodialysis patients' problems.
2. The health reform has created many problems to our health care system. In the most of the cases it is the patients that suffer.

Irena Zheleva
Iskra Urumova