While hundreds of Moldavians rely on dialysis and wait for a chance to live the brain death potential donors are disconnected from life support and entombed with their organs. This might be caused by negligence and indifference in opposition with the medical institutions’ or dialysis centres’ obligation to enroll renal impairment persons on Dialysis Patients Registrar and subsequently on the waiting list for kidney transplant.
Constantin was one of the long-term renal insufficiency patients who spent almost 30 years in dialysis centres. He was a subject of a kidney transplant many years ago and unfortunately the medical surgery did not save him from the painful dialysis procedure. Due to the complicated medical procedure his bones were very fragile. He had one amputated leg and he broke the other one just before his death. The disease had weakened him so much and eventually he committed suicide.
According to his family Constantin was confined to cover constantly 75 km using public transportation from his home town of Căușeni to Chișinău for dialysis. It didn’t matter whether was raining, windy, heat or freezing. He had to go.
Arrogance and ignorance
Almost 500 patients with chronical renal failure live in Republic of Moldova. They depend on dialysis for the rest of their lives. Only the fortunate ones can improve the quality of their health through a kidney transplant. The 500 figure is increasing every year and the experts are highlighting this general trend is not applying only to Moldova.
Igor Codreanu head of the National Transplant Agency said many patients usually caught pneumonia while waiting for public transportation in the freezing air and very often these complications are fatal. “If travel through Romania one will probably see vehicles imprinted with a Dialysis signs. These automobiles transport patients. They are taken from home and carried to dialysis whereas in Moldova the patients are coming to this medical procedure by public transportation three times a week. Some travels hundreds of kilometers and the National Medical Insurance Company – NMIC reimburse the tickets.”
More than half of the 500 patients are treated in the Chișinău dialysis centres and come here twice or three times a week depending on their illness severity. The others are scheduled for treatment in Bălți, Cahul and Comrat centres where they go by public transportation, using their own cars or even hitch-hiking. Besides the painful journeys the patients must also endure the doctors’ and nurses’ arrogance and ignorance. Very often there are no medicines or medical consumables. The dialysis equipment is old and the rooms recalls the Soviet times. Codreanu believe the population is very apathetic, has no initiative and is very inhibited. “Due to the poverty and poor health people became unhappy. Moreover they watch TV and see everything is bad. Here people are trained to survive not to enjoy life”.
All the Moldavian ministers of Health promised to change the status quo when appointed. They pledged to open new dialysis centres; to rehabilitate old ones; to hire doctors; to offer transportation and conditions „as in Europe” for patients. Yet, the things changes very slow and many sick persons don’t live enought to beneficiate of this promised modern transformations.
A difficult life
Constantin the man in his 60s who committed suicide was not able to cope with the illnes and the system humiliation. He pull out his fistula - the surgically created vein used to remove and return blood during hemodialysis - while on hospital bed. For years he came from Căușeni to Chișinău and his wife took care of him until his last moments like he was a child. “One evening we came back from dialysis. Was on January 31st. We stepped out from the taxi and I opened the building door. When turned around I saw him lying down in the street. He slipped and felt but I didn’t call for the ambulance as it was after 11.00 p.m. and thought he would be good. Later I wrapped his leg in cold bandages, yet he felt sick the whole night. In the morning I called the ambulance and we went to Emergency Room”.
This was the beginning of the end. One-legged Constantin just fractured his other leg. From the Emergency Room he was transferred to another until he mentally yield. „He was kept on a stretcher in the Emergency Room for a long time. They didn’t want to hospitalize him and we were sent to the Republican Hospital to dialysis department. There refused to hospitalized him as the dialysis department was closed and we went home. While in the Republican Hospital doctors made an X-ray of his leg and said the bone is not broken. We were told there is nothing to be done and go to BB-Dializă. Meanwhile his condition worsened because no hospital accepted us. He was mentally down”. His entire life Constantin came to dialysis by public transportation or hitch-hiking.
Not a single dialysis centre offers such transportation to its patients. Even the modern dialysis centre as Chișinău based BB-Dializă do offer such specific automobiles only under special circumstances. Boris Sasu the chief of Holy Trinity Hospital’s Nephrology and Hemodialysis Unit says he has two patients coming from Orhei and Florești. „NMIC reimburse the two-way ticket. A year ago there was an ambulance to take them to dialysis but the present budget does not allowed it anymore. Patients comes with their own means of transportation”. The situation in the District of Cahul is not different. The Hemodialysis Unit here take care of 46 people based in the southern part of Moldova. I spoke to Elena who was in a middle of her dialysis procedure. „I come by bus here. Idid a similar procedure for one year in Italy when I lived there. I felt much better. Here I see a different attitudine in medical personnel”.
BB-Hämodialyse Handelsgesellschaft mbH is a German consortium which won the public tender to develop the Moldavian hemodialysis units. It also owns BB- Dializă a private dialysis centre located in the Chișinău, the country capital city, inside the state-owned Republican Hospital. The German consortium is not compelled by contract to offer transportation for the patients. „According to the signed contract between the Ministry of Health and BB-Hämodialyse the German partner must either provide transportation for the patients outside Chișinău or to reimburse the transportation ticket”.
However, when the public tender for this contract was announced in 2013 the former minister of Health said the winning company must provide the patients both proper conditions for dialysis with modern equipment and transportation. „The contract specifications provides compulsory terms regarding the patients transportation and food supply”. Under these terms the German company was assigned to modernize the Republican Hospital, Mother and Child Institute, Emergency Hospital, and Holy Trinity Hospital hemodialysis units in the capital. Moreover, according to the same document BB-Hämodialyse was required to do the same for other three districtual hospitals and to establish five new units in other districts. Three years passed since the contract was signed and these dialysis units struggle to survive under inimaginable conditions with out-to-date equipments.
Dmitri Onufreiciuc the BB Dializă manager said the company is planning to open two modern dialysis unit in Bălți and Cahul in the next two years and based on future necessities other units would be open in other municipalities. “These two centres will provide all the patients’ needs. We cannot open similar centres in other districts because it is not financially worthy. We will open dialysis centres in high-priority areas in terms of number of patients.” Dumitru Mastak the head of the Emergency Medicine Institute Hemodialysis Unit believe the unit he works in must have been part of the BB-Dializă structure. The unit has 16 working dialysis gears and uses four because the other 12 are kept for emergency cases only.
According to the contract provisions BB-Hämodialyse Handelsgesellschaft mbH invested 2,3 million euros in Chișinău dialysis centre so far. The same amount is to be invested in Bălți and Cahul future planned centres and the German company must finish the modernization works within a year upon receiving the appropriate locations offered by the Ministry of Health. There are no certain deadlines to renovate the dialysis centres countrywide and the process could last for many years say Ministry of Health officials. A government decision from August 2013 stated the potential winning company for this contract must renovate seven centres and establish five new across Moldova as well as renewing all the dialysis equipment.
BB-Hämodialyse and Ministry od Health broke this governmental decision by changing the contract terms shows a recent Ministry of Economy report sent to Parliament. It probes that BB- Hämodialyse had a planned investment of 15 million euros to develop three dialysis centres within one year and yet only the Republican Hospital centre had been renovated. Regarding the other two centres the contract had been modified indicate the report as it was re-negotiated and additional agreements were added.
BB-Dializă SRL also signed contracts for six districtual centres signed with local municipalities which administrate the hospitals. In two cases the contracts with BB-Dializă has been terminated by local officials due the company’s failure to honour the contractual terms. Ministry of Health avoid to answer the questions regarding the violation of governmental decision and explained that opening three new centres will provide a quality dialysis service to patients. On the other hand, BB-Dializă managers assured the number of the centres will grow if there is a need.
Bureacracy cut lives
A significant issue in Moldova health system is lack of specialized doctors. In Cahul centre only one medic specialized in nephrology take care of people while three omore are needed. Lilia Postolache the head of Hemodialysis Unit is the only doctor here who watches over the renal failure patients. She must work a19 hours shift to cope with the situation. „The working day start at 3.00 a.m. and end at 10 -11 p.m. This situation last from June 2011 when I start working here. I am used with it but I spent more time in the hospital than home”. The situation is similar in Comrat. According to a ministerial ordinance the hospitals’ managers where hemodialysis units exists must record all the patients with renal insufficiency in a registry before they start the treatment. The managers must also give each patient’s medical file to surgeons who perform kidney transplant thus the patient is added on the waiting list.
A National Transplant Agency – NTA official said organs are lost on the way because the transplant list is empty due to disrespect the ministerial ordinance by hospitals managers with hemodialysis units. Doctors seem fail to remember to fill the registry with renal failure patients’ names and send it further to the waiting list decision-makers. Therefore sometimes kidney donors exists but there aro no receivers.
ÎIn a recent case a patient in death brain the relatives granted permission to donate the kidneys and the liver. The patient had a rare blood type and no potential receivers on the waiting list matched it. As consequence the patient has been buried while three lives could have been saved. The NTA director Igor Codreanu said the each patient’s file is sent to Republican Hospital’s Renal Transplant Clinic where a committee checks whether a patient is a possible subject of a kidney transplant or not. “Then the information is sent to the Agency which put the patient on the waiting list. Dialysis centres across the country do not send us these data by arguing the lack of personnel. We try our best to make them more responsible”.
Currently the waiting list comprises 39 names. According to european standards the list must contain a third of the total number of patients included in a dialysis programme. In Moldova than means 150 out 500 patients. Codreanu added that life quality of a patient with a kidney transplant is far superior than the of a person who is doing dialysis. „What happens in Moldova is that a medic deprive a better life for a patient by not including him on the waiting list”.
The personnel from dialysis centres offered different answers as response for their ignorance. Usually the main argument is that the kidney transplant is contraindicated for the patient. Adrian Tănase the head of the Urology, Dialysis and Renal Transplant said 50% of the patients are subject of dialysis for more than five years. Some are on the waiting list, several went abroad for transplant, and others die because of medical complications. „The potential patient must not have any infection, atherosclerosis of the blood vessels in the pelvis area, viral infection suh hepatythis. Many patients have associated disseases therefore the kidney transplat cannot be performed. There is a risk of rejection the new organ”.
A vicious circle
A recent NTA investigation in dialysis centres shows that potential transplant patients are not included on the waiting list due to doctors. During an investigation at BB-Dializă private centre in Chișinău NTA’s inspectors found that 30 patients were be included on the waiting list. „We started this investigation to increase the number of people on the waiting list. Heads of units are not customed to include those people on and and wait for somebody to remind them”.
Lilia Postolache head of the Cahul Districtual Hospital Hemodialysis Unit said the patients here are included on the dialysis registrar but there are no files for transplant waiting list beacuse majority of patients have contraindications to perform the surgery. „We have now 19 patients under medical investigations to see whether they fit for transplant. Someof them are afriad of surgery. Moreover, almost all of them have both Moldovian and Romanian citizenships and they rather go to Romania for the transplant. Two of them alrdeay did it.”
Ionuț Nistor nephrologist at the C.I. Parhon Hospital in Iași Romania confirmed that Moldavian patients with double citizenships comes for hemodialysis. „As they are also Romanian citizens are subjects to medical insurance according to Romanian legislation”. When asked why the Moldavians choose to Romania for dialysis over Moldova Nistor said the patients might have more confidence in the Romanian medical system.
BB-Dializă is the only centre large enough to accomodate 300 patients. It’s medical head doctor Petru Cepoida describe the waiting list issue as vicious circle. For instance, if a patients start his dialysis in a districtual centre and later transffered to BB-Dializă the doctors in the first centre had the obligation to include the person on the waiting list. „If a person start dialysis in the Holy Trinity Hospital his name is introduced in the database there. When he is transffered to us and is not on the database we cannot acces the computing system in that hospital to add the person”.
„Actually is indifference” argue NTA’s director Codreanu. „We expect upon Agency’s investigation the number of patients on the waiting list to at least double”. NTA’s inspectors found that at least 63 people were excluded from the list and discovered many wrongdoings.
Republic of Moldova allocate about 13.000 euro annually for a patient who is subject of dialysis while the costs for a person who performed a kidney transplant is only 4.500 euros. The Obligatory Medical Assistance Insurance Fund finances all the costs from the medical insurance every Moldavian citizen pays. BB-Dializă received 2,6 million euro in 2016 and a dialysis session costs 96 euros in compliance with the Ministry of Health approved fee. In 2017 the approved amount for hemodialysis procedures in the whole country is 5,9 million euros. More than half goes to BB-Dializă whose manager Dmitri Onufreiciuc said in the next two years new centres will be inaugurated in Bălți and Cahul. By contrast, the annual budget for people with a kidney transplant medication is 650.000 euro.
The Government have recently approved a new National Transplant Programme for the 2017 – 2021a nd NTA aim to increase the number of transplant to 60 per cent by the end of 202. That means every week a kidney transplant would be performed but this is achievable if the dialysis system is updated, if there would be enough doctors and if the patients would be included on the transplant waiting list according to the law. Until then the patients must find their own way to save themselves or to go abroad for a transplant procedure as NTA data shows 82 Moldavians performed this surgery overseas, mainly in Italy. Thirty-one transplants - 22 kidneys and 9 liver- were performed in Moldova last year with seventeen more compared to 2015 and by March 2017 six kidney and four liver transplants were performed.
This article was developed within the “Overcoming media’s stereotypes through cross border co-operation” coordinated by the Romanian Centre for Investigative Journalism and supported by The Black Sea Trust for Regional Cooperation – A Project of the German Marshall Fund.