Return to Albania
Alan Cameron
country within sight of Italy about
which less is known than the
A interior of America." Edward
Gibbon's comment of 200 years ago still
applies to Albania, Europe's poorest nation.
The country's economic and intellectual
isolation was imposed by Enver Hoxha, its
xenophobic, paranoid, Marxist dictator.
After his death in 1985 minor liberalisation
was attempted, but pressure for change
became unstoppable. Many fled the country
-especially to Italy. Finally, in 1992 the
Democracy party, led by a cardiologist,
established a fragile government.
I had visited Albania as a tourist in 1990
when it was still controlled by the Party of
Labour, but during the trip met some
doctors and wrote about the experience in a
personal view (BMJ 199 1;302:1088). I never
expected to return, but had an opportunity to
revisit in 1994. Changes in the four years
were staggering. Gone were the statues of
Hoxha and the party slogans and the red
flags. Roadside stalls were everywhere,
satellite dishes sprouted from every building,
and huge numbers of ancient cars roared
along the ill kept roads-private cars had
been banned by the regime as bourgeois.
People looked poorer; clearly the move to a
market economy had benefited a few, but the
majority were worse off. Factories were
devastated and land untilled. With the loss of
state authority law and order had broken
down and crime was rampant. Unemploy-
ment was at least 50% and there was an air of
menace in the crowded streets. There may
have been some advantages in the previous
regime; at least everybody was educated,
employed, and fed. Yet despite their
privations people remained optimistic: "At
last we are free" was the comment.
I was there as part of a team and spent two
weeks in the surgical department of a 300
bed hospital. Gaining admittance to the
building was the first hurdle each morning. A
scrum of patients, relatives, and staff would
push at doors kept shut by a burly porter.
Something dropped into his pocket did speed
entry but if the customers would not oblige
he kept the crowd waiting so his light
fingered accomplices could extract contri-
butions which were less voluntary.
Inside the hospital was airy, bright, and
kept clean, but the sinks in the wards and
theatres had no running water. There was
some modern equipment, much of it from
Italy, but some was United States military
surplus. Obviously there were shortages:
lack of sutures and instruments in the
theatre; lack of anaesthetic agents-ether
was the standby but supplies were intermit-
tent-and lack of drugs and dressings on the
wards. I was embarrassed after my first case.
I guessed that we would not change gowns
676
but ripped off my gloves without thinking, which were disturbing. Under Hoxha there
whereupon the senior surgeon picked them were few divisions in society: everyone was
up for reuse. Quite complex surgery was paid the same and lived in the same sized flats
done-for example, splenectomy for thalas- provided by the state. Because there was
saemia, craniotomy for trauma, and internal nothing to buy and nowhere to go they had no
fixation for fracture. I was impressed by the need of extra income. With the advent of the
surgeons' skill for when I tried to operate it market money becomes vital, and because
was like being a student again: the scissors salaries have remained the same doctors have
would not cut, the forceps crossed, the clips had to sell their services. Under the old
did not grip, and the needle holders were in system patients went to the polyclinic to be
name only. referred to hospital. Now, a sidewalk
The surgeons were welcoming and keen to consultation for cash is needed and easily
share experiences. What emerged was the fixed because everybody knows the doctors. I
remarkable difference in practice. accompanied the orthopaedic surgeon taking
home an 87 year old who had survived a
fractured femur. The surgeon was last to
"Because salaries have leave and as he did so the patient handed over
the fee. Such practice has its dangers. I was
remained the same doctors told of a surgeon who operated on a
have had to sell their gangster's child for a fat fee, only to have his
own child kidnapped for a somewhat larger
services. " ransom.
The influx of European and Arab volun-
tary workers and missionaries has brought
There were seven general surgeons. problems. Westerners in particular are
Around 15 elective operations were done perceived as rich and therefore fair game for
weekly, with the same number of emer- extortion. As with other countries in the
gencies. There was surprise at my 15 cases former Eastern bloc, freedom has brought
each week, but even more surprise at my the evils of capitalism and a culture where
waiting times; in Albania it was two weeks for gangsterism can flourish. I talked to some
a hernia. Although all the surgeons were depressed aid workers who complained that
consultants, there was a clear hierarchy with aid was disappearing into unofficial channels
a director telling the others exactly which and the police were not only powerless but
cases were to be done and by whom. occasionally actively helping the process. In
Operations were also hierarchical: the chief the hospital I caused hysterical laughter by
would clip a vessel, the first assistant tie it, inquiring who stole the equipment? "Every-
the second cut the suture, while the third one," was the reply, "the porters, the nurses,
retracted. At the end of each case the entire the patients, and the doctors." Aid agencies
group would go off to the hospital coffee bar themselves came in for criticism. I was told of
for a discussion with the patient's relatives. large items of x ray equipment donated from
Once a week there was a joint ward round abroad clearly marked in the home country as
where each patient was presented to the "not suitable for repair."
chief. The seven surgeons were helped by Perhaps my lasting impression is of how
only two anaesthetists; the patient walked decent individuals can be corrupted by a
into the theatre, climbed on to the table, was political ideology. In communist Albania the
tied down, and then anaesthetised either with state came first and individuals last. As a
ether or intravenously by the doctor, who result the rights of the individual patient are
then handed over to a nurse. There was no lost, and kindness and compassion are
monitoring of pulse or blood pressure. absent. Explanation is unnecessary because
By our standards there was gross medical the doctor knows best and even postoperative
overstaffing; at one stage there were more analgesia is neglected. Now under the free
paediatricians than children in the wards. market medical skills are another saleable
One reason for this was the socialist commodity and patients a source of income.
philosophy of full employment. But It was distressing to see a system so
economic reality was dawning. I met newly ignorant of the autonomy of the patient and I
qualified doctors unable to get a job. The desperately wanted to impart some of the
other reason for overmanning related to the ethics which we all take for granted. Yet far
nature of the work. Until recently there was more distressing is the thought that our
no professional nursing training and nursing ethics are a luxury, afforded to us by peace
was an option taken in high school by less and freedom. I am sure that if I lived under
able girls. Without further training they the same circumstances as the Albanian
worked in hospitals so dressings were surgeons my behaviour would be exactly the
changed and sutures removed by doctors. same.-ALAN CAMERON is a general surgeon in
There were aspects of medical practice Ipswich
BMJ VOLUME 310 1 IMARCH1995