R. Stoynova: Risk in medicine is minimal when standards of good medical practice are observed
On 13-Nov-2003, the newspaper Pozvanete-Novini (Call us-News) published an interview with Mr Balkansk, Director of Regional Center of Health-Varna (p. 8, Investigation) in follow-up to some raised questions of lapses in the anti-epidemiologic standards in the Hemodialysis ward at St. Marina Hospital of Varna. I should like to discuss a couple of points in this interview which, on the background of the Libya trial, impressed me strongly.
In the beginning of the interview, Mr Balkanski asks the rhetorical question, "can we expect that a hospital which is indisputably qualitative does not function well and the standards and anti-epidemiological requirements are not observed? That both our and foreign patients are exposed to risk there?" And gives the answer himself: "There is no logic in it." A little further in the same interview, however, this firm statement of the Director of Regional Center of Health falls into a logical contradiction with his own admission: "After the reform, many things in the health care system, instead of being improved, deteriorated".
It is noteworthy that the pediatric hospital in Bengazi too was rated prestigious and there was no logic in expecting that the standards or anti-epidemiologic requirements were not observed there despite the hardship caused by the embargo. Moreover, even when the AIDS epidemic reached devastating levels, the Libyan health leaders still refused to believe that the problems had been due to the bad hygienic and epidemiologic conditions in the hospital. It was not before international experts were brought to investigate that the truth came out. No act of sabotage had caused the disaster. It was a sheer nosocomial infection due to lack of medical supplies, multiple use of single-use materials, missing virologic tests, ignoring of elementary hygienic rules, etc.
Similar lapses in good medical practices were brought to Mr Balkanski's attention in a letter by the end of May this year with regard to the HD unit at Hospital. More precisely: lack of regular testing for hepatitis and AIDS, mysteriously lost results from tests for hepatitis C of several members of the staff, lack of strict observance of the standards for disinfection of the HD machines, indiscriminate use of the same machines by hepatitis infected and non-infected patients. Moreover, when the foreigners came for holiday dialysis in St Marina Hospital, almost all of our non-infected patients had to occupy the infected machines in order to provide clean machine for the guest-patients from abroad.
RCH-Varna performed an immediate check and found out, quote, "Since 7-May-2003, the patients and the staff's serologic tests for HCV, HBV and HIV have been performed in the Navy Hospital with a referral from the Regional Health Insurance Fund. In view of the high risk of the medical staff's activities it is necessary that specification and optimization be made of the periodic serologic tests for viruses and the relevant vaccinations by the leadership of the clinic." Not a single word about the missing for years virologic tests. Not a single word about the lost results of the staff. Not a single word about the dialyzing of non-infected Bulgarian patients upon infected HD machines because of the foreigners. Even today, six months later, the theme of how our patients were distributed along the machines during the foreigners' visit remains prohibited.
The former minister of health accepted uncritically this "check". Soon afterwards he was freed from post and the new minister, Mr Sl. Bogoev, issued Regulation 13 of 30-Jul-2003, which contains several pages of most detailed medical, technical and other standards for the dialysis centers to comply with, incl. clear virologic standards: testing of all patients and staff for hepatitis B, C and AIDS every six months. This regulation was published in State Gazette, issue 80 of 9-Sep-2003. If the control of its implementation was left in the hands of persons like Mr Balkanski, however, there hardly could be expected any change.
Because Mr Balkanski seems not to have heard of this regulation. After he has had month and a half to prepare for this interview, to the question as to whether there exist any virologic standards for the HD units and what they are like, he replies that such standards probably exist but he does not think he should personally be acquainted with them. He totally relies on his subordinates "who do their work" but he does not appear to have any feedback to them. Asked quite directly if everything in the HD unit in question is in order, he replies with a sense of humor: "You ask whether I can say that everything in the unit is perfect? Well, I cannot say about myself that I am completely perfect."
The prime thesis of the interview is "Medicine is risk. It is always available" There is risk indeed. But it is minimal when the standards of good medical practice are observed. And vice versa – indefensively high then they are not. An example of indefensively high risk is the availability of two medical nurses from the pediatric hospital of Bengazi infected with the virus of AIDS whereas all over the world there are total of 50 AIDS-infected health workers. St. Marina provides even a better example of indefensively high risk: three nurses form the same hospital word infected with the virus of hepatitis B.
As to Mr Balkanski's statement that there have not been any complaints from patients so far, it is not quite correct, either. However, there is a problem in direct connection to the few complains and it is that patients do not receive enough of accessible and comprehensive information. How then could a person complain if s/he can neither see what is wrong nor is informed whom s/he may contact in case of any possible complaints?
In support of this lack-of-information argument comes the interview with the anonymous patient on dialysis in St. Marina, published on the next page of the paper. As it shows, not all patients even know that there are different tests: some for the anemia, others for the end products of metabolism, still others for the viruses of hepatitis and AIDS. The journalist asks him if patients are advised when they should be tested but she does not specify tested for what – for viruses or otherwise. The patient then replies: "Well, we know, no need to tell us. Up to the New Year they told us. We had our tests done every three months". The patient obviously means tests for urea, creatinine and other such indicators for end products of metabolism in the blood. The truth is that even these vital tests are not done on a regular basis any more; they used to be done every three months until recently, indeed.
Last, a few words about patients' complaints. Two or three years ago, when about 80% out of all patients on dialysis in St. Marina proved virus carriers of hepatitis C, there was a collective complaint. The case was rather interesting and the local media took up writing about it but when the leadership of the clinic expelled the most prominent activist the rest went silent forthwith. At that same time, Prof. Dimitar Nenov, the ex-head of clinic, most responsibly explained that there was hepatitis in all HD units, and that it was unavoidable. Prof. Nenov passed it in silence, though, that unavoidable would mean occasional cases while such mass infecting was but a scandal like that in Libya. It is not by chance that virus carriers exceeding 15% already alerts serious concerns in West Europe. By the way, two years later, half of the then virus carriers are not alive. Is it a mere accident?
There was another collective complaint, less than a year ago. It was about the lack of bed linen on the hospital beds. Local newspapers wrote about this, too. Who knows why, even this elementary problem has not been solved up to this day, and the patients still bring their own bed sheets from home. It should be known that sheets stained with infected blood must be sent to special disinfection (the hepatitis virus is very hard to kill, much harder than that of AIDS). These sheets should not be taken back home to wash because this way the infection keeps spreading among general public.
In conclusion, the fact that our health care system faces problems is not frightening. Frightening is when these problems are covered behind falsely optimistic statements. After all, Mr Balkanski is going to prove right when, attempting to explain why he is sparing of words, he says: "I do not dare say something that might turn out not quite the same, tomorrow."
Reneta Stoyanova, ex HD nurse in St. Marina Hospital