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UREMIA INVESTIGATION, 8(2), 139-145 (1984-85)
ESSAYS
Renal Medicine and Renal Patients at the Seventh I.K.A. Hospital of Athens
Eugene 6. Gallagher, Ph.D. Department of Behavioral Science University of Kentucky Medical Center Lexington, Kentucky 40536-0086
ABSTRACT
Clinical nephrologists are generally aware that bringing chronic renal treat- ment to all patients who need it is both an economic and a medical challenge. On the medical side, there is the task of giving the most appropriate form of treatment to the individual patient and, so far as it lies within the power of the physician and his staff, of supporting and motivating the patient to maintain a reasonably satisfying and productive life despite the stress of illness and treat- ment. On the economic side? there are a number of issues concerning the gener- ation of funds for treatment. the utilization of various categories of medical and nonmedical personnel, and the geographic deployment of treatment resources of varying levels of expertise and intensig. For example, the hospital facilities for diabetic dialysis patients who can anticipate periodic complications are more extensive than the more limited back-up facilities needed fo r well-stabilized “healthy” patients who are managing domiciliary dialysis.
These questions have an international aspect, as the nephrology professionals and health administrators in many nations seek to expand their treatment pro- grams for chronic treatment of renal failure. Despite thr variety of approaches to the financing of medical care and despite important cross-national variations in the organization of medicine and its specialties, one can see that similar themes recur concerning renal medicine, the relationships of renal patients to their doctors, and the economics of treatment.
It is from this standpoint that I present an account of renal medicine in Greece, based on contact with the renal staff in a public Athens hospital and upon a survey of public policy concerning the expansion of renal treatment in Greece. As a nation with a more modest level of economic development and per capita annual income than the United States and the West European countries, Greece is nevertheless making a respectable showing in the realm of renal treat- ment.
Copyright 1985 hy Marcel Dehlcr Inc 139 0740- 135 3/84 10802-013 9$3.50/0
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140 Gal lagher
THE SEVENTH I.K.A. RENAL SERVICE
The Seventh I.K.A. Hospital is located in a working-class district which lies 4 miles north of the center of Athens. Dr. Valsamakis Hadjicon- stantinou is Medical Director of the Renal Medi- cine and Dialysis Unit of the hospital. The inpatient section of this unit has 35 beds of the total 200 in the hospital. The outpatient dialysis clinic of the unit has 10 dialyzers. With two shifts daily, it serves 40 patients. An expansion to 20 dialyzer stations, serving 65 patients, will take place shortly; ultimately 8 i patients will be served.
Dr. Hadjiconstantinou greeted me warmly and in fluent English. I explained to him that I was a medical sociologist with a long-standing interest in psychosocial aspects of dialysis-that I wanted to learn about the sociomedical back- ground of his patients and how they coped with stresses of the “dialysis life”-also about admin- istrative and financial aspects of treatment. Most obligingly, he put himself at my investigative disposal for the next 5 hr, during which time 1 obtained a full picture of his clinic. What I learned there was consistent with other informa- tion I had acquired concerning the treatment of chronic renal failure in Greece.
THE MEDICAL DIRECTOR’S BACKGROUND
Chronic hemodialysis began in Greece in 1968; Dr. Hadjiconstantinou has figured promi- nently in its development since the beginning. He recalled the time when, as a young nephrolo- gist at a major teaching hospital in Athens, he and the senior nephrologist urged the hospital ad- ministrators to start a chronic hemodialysis serv- ice. The administrators understood little of
dialysis and would have had no interest except for the lure which the two nephrologists placed before them: An Italian biomedical corporation had offered to lend two dialyzers to the hospital for 1 year. The administrators did not refuse this offer. As Dr. Hadjiconstantinou and his col- league anticipated, the hospital purchased the di- alyzers when the year was up, rather than discontinue dialysis with those patients already receiving i t .
Dr. Hadjiconstantinou numbers among his nephrologist friends several University of Athens (his own medical school) graduates who later mi- grated to the United States and Canada and who are now well-known in renal medicine there. Dr. Hadjiconstantinou himself recently spent 1% years with the renal unit at Guy’s Hospital in London. He is acquainted with leading British nephrologists and familiar with the treatment of chronic renal failure under the British National Health Service (he feels that British home di- alysis is superbly organized and quite effective, but the virtual denial of treatment to older pa- tients is an unfortunate consequence of limited British resources). He has also been an active member of the European Dialysis and Transplant Association, the International Society of Nephrology, and the Hellenic Society of Nephrology. He was a member of the Organiz- ing Committee of the Eighth International Con- gress of Nephrology held in Athens in 1981.
THE PHYSICAL SETTING
Dr. Hadjiconstantinou conducted me from his consulting office to the adjacent dialysis clinic. Here were housed the 10 dialyzers in current op- eration, along with cupboards of supplies. Pa- tients on the 5-hr morning shift were seated in dialysis chairs beside their machines along three sides of the room. Five nurses were in evidence
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Renal Medicine in Greece 141
as well as other members of the medical team. Like many other dialysis settings, the clinic gave the impression of a busy, purposeful enterprise but one which nevertheless maintained a relaxed social and professional atmosphere. Most of the staff and patients had been participants in the clinic for months or years; they were well-known to each other in the quasi-familial ambience which tends to arise in chronic dialysis settings
It was a hot summer day and the clinic had no air-conditioning. Several large standing fans stirred the air. Breezes entered through the open windows along one side of the room. That side of the room was part of an outside wall of the hospital which faced toward the back of apart- ment houses across a courtyard. The hospital opened onto the residential crowdedness and bustle of metropolitan Athens; one looked from the dialysis room over to the cluttered apartment balconies stacked one above the other.
(1-3).
THREE PATIENTS
My orientation to the dialysis facilities in- cluded interviews with several patients, during which Dr. Hadjiconstantinou served as my inter- preter. After he described each patient’s clinical status, I directed questions to the patient con- cerning his or her sociomedical situation.
I will present brief sketches of three patients, each of which reveals important facts about chronic renal failure treatment in Greece.
George Aimilianos is a 45-year-old married male patient, on hemodialysis since his very rapid renal failure in 1979. Although he is well- adjusted to dialysis routine, he hopes to receive a graft eventually. Relatively little transplantation is done in Greece. George has been in touch with the transplant division at Vanderbilt Univer- sity in Tennessee regarding transplantation there. Dr. Hadjiconstantinou told me that a number of Greek patients have received transplants at Van- derbilt; renal personnel of Greek background in that institution have established an informal “Greek connection. ”
If a physicians’ committee deems George suit- able (according to both medical and social cri- teria) for transplantation, he will be sent to the United States at the Greek government’s ex-
pense. The committee is composed of transplant surgeons, immunologists, and nephrologists. Dr. Hadjiconstantinou prepares a dossier on each transplant-eligible patient for committee review. Almost all patients whom he has proposed have been approved.
George has maintained full-time employment with little interruption since first starting dialysis. He works for Olympic Airlines, the domestic and international airline in Greece. Before renal failure, he was a luggage handler at the airport; since then, he has been shifted to nonstrenuous administrative work. Another concession to his illness is that he is permitted to leave work early on dialysis days. His home is close to Ellinikou Airport (Athens International), which lies about 9 miles southeast of the center of Athens.
George’s household consists of himself and his wife. His wife has steady work in a small dress factory. Their daughter was with them until her recent marriage. George said that, at 17, his daughter was almost too young for marriage but, feeling that his own future is clouded by his medical condition, he has carried out his paternal duty by seeing to it that she was suitably “mar- ried off.”
I asked Dr. Hadjiconstantinou: How compliant is George with dietary restrictions‘? The doctor turned to the patient and translated my question to him. From the chuckles between them and the doctor’s tone of playful admonishment, I gathered that George has his weak moments. Dr. Hadjiconstantinou said to me: “We quarrel about this-he is very fond of octopus.” At 4-5 g of protein per ounce, octopus has approximately the same high protein content as chicken or sirloin steak. Seafood abounds in the Greek diet-oc- topus and squid are great favorites. Whatever George’s dietary indiscretions-and I gathered that they were only occasional-he at least ran true to national form.
The second patient with whom I became ac- quainted is Fotini Doumouliaka, a 16-year-old fe- male patient in her first year of high school. Dr. Hadjiconstantinou referred to her family as “dis- torted.” Fotini’s parents are divorced. Her father, with whom she lives, is alcoholic. According to Dr. Hadjiconstantinou, her father is very strict with her; for example, he would never permit her to go to school dances, even if she wanted to.
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142 Gallagher
Fotini’s medical difficulty started when she was 4 years old, with persistent low-grade fever of unknown origin. When she was 8, she began to have hematuria and joint pains. Her renal function declined rapidly within the past year. Dr. Hadjiconstantinou and his colleagues, who have been her doctors for the past 2 years, de- cided 7 months ago that the time had come for her to commence dialysis, with fistula access. On dialysis, Fotini started to feel better. Dr. Hadjiconstantinou regards her as “fully rehabili- tated.” Her school attendance is regular and she gets high grades. She has school in the after- noons and dialysis three mornings a week. She spends the first few hours of each dialysis ses- sion studying but finds it difficult to concentrate after that. Like many other dialysis patients, she feels that the time she spends on the machine is largely wasted.
In response to my questions, Fotini said that she has enough energy to do the things she wants to do (Dr. Hadjiconstantinou told me that her hemotocrit is 23-25). She has a residual urine output of 500 ml/day and can be corre- spondingly generous with herself in liquid in- take. She is slated to receive a transplant eventually. Her mother has offered to donate but histocompatibility has not been determined as yet.
The third patient is Anthony Bouras, a 32- year-old married male. He lives with his wife and their 5-year-old son. He has been on dialysis for 4 years, using the same fistula which was originally installed. His medical difficulties started suddenly with a backache and fatigue when he was 2 5 . X-rays showed that he had small, contracted kidneys. He progressed into re- nal failure over the next 3 years. Although no biopsy has been done, it is assumed that he has some form of glomerulonephritis.
Anthony’s economic situation typifies that of many Greek dialysis patients. Before his illness, he worked as a taxi driver and construction la- borer, earning about $436 (U.S. equivalent) monthly. Since his illness, he has relied on a government disability pension of $250/month, augmented by a $50/month food supplement al- lowance, plus an annual vacation allowance of $180. Because of the disability allowance he is not supposed to have employment. However he
does hold a part-time job as a bookkeeper in a travel agency (family income is further increased by his wife, who works as a hotel maid). If re- quired to, he would give up his job rather than jeopardize his government allotments. Although he could probably perform nonstrenuous, full- time work and earn more than the total (about $327/month) of his allotments, he strongly pre- fers the government support because it is more dependable.
Anthony is a candidate for a transplant. His parents have offered to donate but he has de- clined their offer. He has been in touch with a transplant unit in Toronto, Canada. Unless a suit- able transplant kidney can be located in Greece, he will be sent there. His stays there will proba- bly be of 4-8 weeks’ duration. While there he would be visited by cousins who have migrated to that city.
THE DOCTOR-PATIENT NEXUS
The relationship between patients and physi- cians in chronic dialysis treatment units tends to be personalized and affectively toned, rather than formal and affectively neutral. This tendency has been noted by observers in a number of different dialysis sites, even in large medical centers ( 4 3 . It was abundantly evident in the interac- tion between Dr. Hadjiconstantinou, his assistant physicians, and the patients. Perhaps the dialysis nurses, being in closer sustained contact with the patients than Dr. Hadjiconstantinou, knew them better as individuals, but he showed considerable familiarity with the family and economic circum- stances of each patient as well as his or her medical history. Dr. Hadjiconstantinou took a quasi-paternal pride in those whom he felt were doing particularly well, such as Fotini, and he expressed “parental” chagrin at several patients who were lax in their diet. His recommended allowance concerning fresh fruit-available vir- tually year-round in Greece-is relatively gener- ous: one piece of fruit per meal. But some patients always take the biggest peach or apple they can find. They follow his rule literally but violate its spirit, and so they get too much po- tassium. He said that he does not like to give detailed instructions to patients or argue with
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Renal Medicine in Greece 143
them; he expects them to use common sense and to act in their own best interest. There have been no fatal cases of hyperkalemia, although several patients have required emergency overnight di- alysis for that reason.
As with renal physicians elsewhere, Dr. Had- jiconstantinou’s role involves contact with gov- ernment administrators and fiscal authorities. While he is well aware of the high cost of dialysis and in full sympathy with policies de- signed to effect economies, he is reluctant to impose these policies rigorously on individual patients. For example, patients are reimbursed for their transportation costs in getting to and from treatment. Few of his patients have their own autos, so they must use public transport- bus, subway, or taxi. It would cost less if they traveled by bus or subway. Many, however, take taxis for convenience since they are reimbursed for that. Dr. Hadjiconstantinou noted that during a recent taxi strike, all the taxi riders were forced to use bus and subway, which brought them to the hospital with no particular difficulty.
Even more revealing of his nonjudgmental stance was the following account: Dr. Hadjicon- stantinou reported that some patients who are friendly with taxi drivers procure from them bogus receipts for taxi rides. These patients then ride the less-expensive mass transit and pocket reimbursement for the more-expensive taxi fares. Dr. Hadjiconstantinou said, “It is not right, but these are mostly poor people, and I am a doctor, not a policeman.”
Occasionally, Dr. Hadjiconstantinou and his assistants help patients in arranging their living conditions. For example, arrangements were made for a 53-year-old bachelor patient to live in a small room in the hospital and to do hospital maintenance work when his physical condition permits. This patient was born and lived on a remote island until he developed renal failure 4 years ago. He has a severe congenital deformity of the spine and had lived in a state of social isolation on the island, perhaps because of his deformity. Although he goes back occasionally to visit relatives, he enjoys his life in the hospi- tal, which is a generally more stimulating and accepting environment than his native habitat. Dr. Hadjiconstantinou believes that the past 4 years have been the best years of the patient’s
life. If so, it is the ironical result of the patient’s misfortune in suffering renal failure and his sub- sequent good fortune in acquiring a resourceful, concerned physician to deal with it.
DIALYSIS-TRANSPLANT IN GREECE
Currently there are 56 dialysis units in Greece. The Athens-Piraeus metropolitan area, with one- third the total population of the nation, has 28; Salonika, the second largest city, has five. The geographical distribution of the 56 units is a problem, particularly for patients who live in rural m a s and on the more remote Greek is- lands. It would be out of the question, Dr. Had- jiconstantinou said, to provide dialysis service on many of the islands, since they presently lack basic medical facilities. Some effort is being made, however. Crete already has two dialysis units; Rhodes, the largest of the Dodecanese group, has one. Soon a four-station unit will be started in Lesbos, in the eastern Aegean Sea close to the Turkish coast; a physician and two nurses to operate it are currently being trained by Dr. Hadjiconstantinou and his staff.
There are no financial obstacles in Greece to obtaining treatment for chronic renal failure. As in the United States, it is categorized as a serious disabling illness, which makes the patient eligi- ble to receive direct treatment services, or pay- ment for such services, from I.K.A. or from other state insurance companies. Employed per- sons in the population, and their dependents, also have financial coverage for treatment in the private sector through one or another of 73 sick- ness funds (6). However, even though renal fail- ure patients are entitled to receive treatment, there is no certainty that they will in fact be referred to specialized renal facilities. Although Greece has more physicians per 1000 persons than the United States, they are highly concen- trated in the cities (7). Specialist care has an even higher urban concentration. An American survey of living conditions in foreign countries states, concerning Greece: “. . . living standards are relatively high . . . however, the quality of medical care outside the three major cities is not adequate”@).
Whatever the case may be in regard to other
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forms of advanced medical treatment, the Greek record in regard to renal medicine is relatively strong. During my visit, Dr. Hadjiconstantinou pulled from a shelf in his office Volume 18 of the serial reports of the European Dialysis and Transplant Association. He showed me a graph which compared, among European nations, the number of dialysis-and-transplant patients per million population in each nation, with that na- tion’s annual income per capita. This graph could be regarded as measuring a nation’s renal performance in relation to its financial capacity. On this graph, Great Britain stood exactly in the middle. Its performance was precisely average in relation to its income. Greece is a poorer coun- try, but it had approximately the same level of performance as Great Britain. On this basis, one could say that the national “renal effort” is stronger in Greece than in Great Britain.
These considerations led me to ask Dr. Had- jiconstantinou whether there were any policy re- strictions on dialysis availability. He said no, adding that it would be against the Greek tem- perament to ration treatment or to establish a measure on individual lives. I wondered about possible age limitations. We looked over the case files for the 40 patients currently on dialysis in his clinic and found that the three oldest were born in 1910, 1914, and 1917. Dr. Hadjiconstan- tinou said that age is not an excluding factor, nor concurrent illnesses. Terminal illness is the only basis, he said, on which a renal failure patient would not be offered treatment; if a patient is already dying, he said, why prolong the ordeal?
Dr. Hadjiconstantinou estimated that, to date, there have been 3000 dialysis patients in Greece, of whom 1500 are current patients.
Turning to transplantation, Dr. Hadjiconstan- tinou said that the total transplant effort in Greece is not extensive although, in its small scale, it has a considerable history. The first transplant was performed in 1968 with an un- matched cadaveric graft. That patient reverted to dialysis 7 years later and survived another 3 years. Since then, there have been some 600 transplant patients (including many sent abroad), of whom 250 have currently functioning grafts.
Most patients with transplants obtained in Greece have live-related grafts. Dr . Hadjicons- tantinou expressed his personal reservations about live donation; he feels that, despite im-
provements in graft retention, the uncertainties are too great to justify the use of a healthy person’s kidney.
Regarding cadaveric grafts, Dr. Hadjiconstan- tinou said that Greece has a law on the books which facilitates donation, but the professional interest necessary to promote it does not yet exist. He noted that Athens has a 500-bed casu- alty hospital from which many kidneys could be retrieved, if surgeons and other specialists really wanted to help transplantation. General surgeons, he said, are too busy with appendectomies and hysterectomies; urologists are fully occupied with their own kinds of surgery. It will not come about, he said, until surgeons can be hired spe- cifically for transplantation-not only to perform the grafts but also to establish a network of cooperation between the public and physicians of various specialties who deal with potential do- nors and their relatives.
Dr. Hadjiconstantinou estimated that more than 100 Greek patients have been sent at public expense to the United States, Canada, and Eu- rope for transplants within the past 5 years. This is obviously very expensive for the Greek gov- ernment. One way to economize is to keep in Greece the patient who is on an active waiting list abroad until the call comes, instead of having him or her first go abroad and then wait. Lead time can be very short; a Greek patient can reach an American transplant site within less than 24 hr after notification is received of a compatible cadaver kidney. Sometimes, however, postopera- tive complications and rejection episodes require the patient to remain abroad for a long time; one such patient remained for 6 months in the United States and then died there.
He said that the main emphasis from the gov- ernment currently is on expanding treatment mo- dalities, especially hemodialysis, to meet the needs of all chronic renal failure patients. There are no policies, official or unofficial, concerning rehabilitation, home dialysis, transplantation; nor are there distinct strategies for spreading re- sources or achieving economies. In a general way, however, renal professionals are cost-con- scious and they try to convey this attitude to patients.
Dr. Hadjiconstantinou has in the past sup- ported two patients in attempts at home dialysis. One patient was an Australian antigen patient;
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Renal Medicine in Greece 145
for him to dialyze at home would have spared the clinic the responsibility of isolation precau- tions. The other patient wanted to make the at- tempt because a wealthy shipowner had given him a dialyzer. Neither attempt lasted long. Both patients felt unsafe at home; they wanted a nurse from the clinic there by their side. From a staff- ing standpoint, it was simpler for these patients to return to the clinic for dialysis.
In regard to the rehabilitation of his patients, Dr. Hadjiconstantinou estimated that almost all his female patients cany out some domestic ac- tivities and that at least half his male patients work either part-time or full-time, whether of- ficially or “illegally.” The opportunity for both female and male patients to engage in gainful work is greatly favored by the nature of the Greek economy. In metropolitan Athens and other urban areas, there are many family busi- nesses and residential workshops-restaurants, neighborhood groceries, auto repair establish- ments, dress-making shops-which can absorb the work of ill family members on a flexible basis, allowing “time off” for treatment and pe- riods of incapacity, and matching the capacity of the ill worker with selected tasks that need to be done.
EPILOGUE
After I left the clinic, I immersed myself in other investigations concerning the organization and delivery of medical care in Greece. I learned that the current government, headed by Prime Minister Andreas Papandreou, has ambitious plans to start a National Health Service which would emphasize basic medical care, to be deliv- ered by full-time career physicians at geographi- cally distributed health centers (9). The projected Health Service would extend basic care into medically underserved rural and maritime areas. In the already well-resourced urban areas, it would also offer competition to the private prac- titioners, both generalists and specialists, whose services are paid for mainly by the sickness funds.
The impact of this plan upon renal medicine is uncertain. In any event, it will take a decade or more to implement the plan even if the Pa- pandreou regime retains its mandate. For the
present, a gradual expansion of renal facilities is already underway, an expansion which will maintain the existing “tilt” toward clinic hemo- dialysis, away from transplantation and other di- alysis modalities. (There, however, are at present about 100 CAPD patients in Greece, mainly resi- dents of the Greek islands and remote rural areas.) Within the smaller world of the Seventh I.K.A. Hospital, I felt that patients had a good technical level of care and, equally valuable, a sense of personal concern which Dr. Hadjicon- stantinou and his staff projected to them.
Dr. Hadjiconstantinou’s statement that he is “a doctor, not a policeman,” impressed me. Proba- bly many other renal physicians would agree with him. They care most about giving compe- tent, conscientious medical care and they value good relationships with patients. While they are also cognizant of the need to hold down the cost of treatment, they are reluctant to act as the stem agents of fiscal or administrative policy with their own patients. Dr. Hadjiconstantinou’s situa- tion well exemplifies the many-sidedness of the renal physician’s role and the uncomfortable con- flicts of responsibility which it leads to.
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REFERENCES
Chyatte S: On Borrowed Time4iving with Hemodialy- sis, Oradell. N.J. Medical Economics Company Book Division, 1979. Gallagher EB and Morelock M: A dialysis-transplant program and its growing pains. Med Care 12,(6):520, 1974. Foster FG and McKegney FF’: Small group dynamics and survival on chronic hemodialysis. Int J Psych 8(2):105, 1977. Fox RC and Swazey J P The Courage to F a i l 4 Social View of Organ Tranplants and Dialysis, 2nd ed. Chi- cago, University of Chicago Press, 1978. Czaczkes JW and De-Nour AK: Chronic Hemodialysis as a Way of Life, New York, BrunnedMazel Publishers, 1978. World Health Organization: Country reviews and statis- tics: In: Health Services in Europe, Vol 2 , 3rd ed. Copenhagen, 1981, p 81. US Bureau of the Census: Table 1550 in Comparative international statistics: In: Statisricul Abstracts of the United States. 100th ed. Washington, DC. US Govern- ment Printing Office, 1979, p 893. US Congress: Country Reports on Human Rights Prac- tices for 1982. Washington, DC, 1983, p 920. Greek Embassy to the United States: Greece-The Weel In Review. Washington, DC, August 16, 1983, p 1 .
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