Bos/Hrv/SrpRomânăБългарскиShqipМакедонскиελληνικά 21 Dec 16

Greeks Take Health into Their Own Hands

Let down by the public health system, some Greeks are sharing pills, skipping medicine or putting their faith in a growing industry of nutritional supplements.

Dimitra Triantafyllou Athens
Vasiliki Katsoula holds one of the many boxes of medication she shares with her parents at their Athens home. Photo: Anna Pantelia.

At first glance, Vasiliki Katsoula and Konstantinos Karaouzas have little in common.

Katsoula is a thickset 48-year-old woman, depressed, out of work and on the brink of poverty in a hardscrabble district of Athens. Karaouzas is a 39-year-old Paralympic swimmer from a well-heeled suburb of the capital, with a sinewy torso and salt-and-pepper beard.

Yet there is one thing they do share – both feel badly let down by Greece’s crumbling healthcare system and are taking their health into their own hands.

Having lost her cleaning job and with it her state health insurance in 2010, Katsoula’s chosen tool is a kitchen knife, with which she chops and rations the medication she and her parents share for hypertension, blood sugar, cholesterol, depression and more.

“I have high blood pressure, but how can I afford to buy the pills?” asks Katsoula in their ramshackle family home in Aspropyrgos, an area of Athens blighted by oil refineries and a reputation for crime and poverty.

Katsoula says the family lives largely off her father’s 900-euro pension, reduced from 1,300 euros by government spending cuts, but spends several hundred euros per month on medicines. “Now we owe my pharmacist 200 euros,” she said.

“I borrow [medication] from my mother. But I have to calculate the dosage for me and adjust it. Sometimes I cut it with a knife. Sometimes I don’t take it at all.”

“My mother and father share the cholesterol pills; my mother takes 10 milligrams and my father 20, so if she runs out, I cut my father’s with a knife to give to her.”

Karaouzas, on the other hand, says he is fed up with the lack of time, resources and expertise for the treatment of disabled people in cash-starved public hospitals and is tired of the chronic over-prescription of antibiotics for his recurring urinary tract infections. Instead, he is putting his faith in nutritional supplements, in his case a combination of extract of aloe vera and collagen, a protein found in human joints.

“It was very good for me, for my skin … and for my joints,” Karaouzas said of aloe vera. “Some aches have receded. It has also helped me a lot with my digestive system.”

Katsoula and Karaouzas represent a growing trend in Greece of self-medication, or more accurately improvisation, after six years of one of the worst economic crises of modern times.

Some Greeks, like Katsoula, find themselves sharing, skipping, substituting and improvising with pills on a daily basis. Others, like Karaouzas, are turning to a growing over-the-counter industry in nutritional supplements that sees an opportunity in the public healthcare crisis.

“Either they improvise, or they don’t take the medicine at all, or they reduce the dosage”

– ‘solidarity clinic’ founder Giorgos Vichas

They have rejected, or feel rejected by, a cash-starved, under-stocked and overwhelmed public health system that saw its funding slashed by 60 per cent between 2010 and 2014.

“Many patients take the wrong medicines either because there are spare ones left over from a family member or because they cannot afford to buy the proper ones,” said Giorgos Vichas, a cardiologist and founder of the Metropolitan Community Clinic, a ‘solidarity clinic’ run by volunteers in Athens that many Greeks turn to for free, donated medicines.

“It’s very often the phenomenon at the solidarity clinic that patients try to make their own combinations of medicine,” Vichas told BIRN. “For uninsured people, this is the norm. Either they improvise, or they don’t take the medicine at all, or they reduce the dosage.”

“Every medicine can be dangerous if not used according to the advice of a doctor.”

Cash-starved

The Greek public health system has been turned on its head since late 2009, when Athens revealed a gaping hole in its public finances and turned in 2010 to its European Union partners and the International Monetary Fund, IMF, for the first of so far three multi-billion-dollar bailouts.

What followed were successive waves of withering spending cuts that set Greece on a downward spiral into depression, drove up unemployment and starved an already dysfunctional and corrupt health system of budget funds.

Waiting times shot up, supplies of medicines and medical equipment dwindled and the number of people left without state health insurance because they were unemployed climbed steeply to an estimated three million, out of a population of roughly 11 million. Uninsured Greeks were denied free or subsidised access to doctors or medication.

Even for those who were insured, the list of medicines that the state subsidises for patients has shrunk, as has the size of the subsidies. The proportion that the patient must pay rose from 12.8 per cent in January 2012 to 29.3 per cent in July 2014, according to a study published in March 2016 by the independent Greek research body Dianeosis. It now stands at 25 per cent.

The rising cost, growing queues and an enduring culture of bribery mean many Greeks are avoiding trips to the doctor. “I don’t want the doctors – they just see money,” said Katsoula.

The results have echoes of Greece’s Balkan neighbours in the former Yugoslavia and ex-Communist Romania and Bulgaria, where turmoil in the 1990s ravaged the health sectors, fuelling the over-prescribing or illegal sale of antibiotics and a growing problem of addiction to tranquilizers and antidepressants.

Legislation in 2014 under a previous government and again under the current leftist Syriza leadership in July 2016 has tried to open up access to the public health system to uninsured Greeks, but doctors and patients complain the creaking and inefficient system is still not working.

According to the Dianeosis study, 67 per cent of those polled said they had difficulty paying for medicines. A majority said they spent up to 10 per cent of their income on medication.

Thirteen per cent either postponed buying medicines prescribed by doctors because of a lack of money, or did not buy them at all. Ten per cent said they took smaller doses than their doctor had prescribed in order to make the medicine last longer.

Some, like the Katsoula family, turn to cheaper, generic substitutes.

After Katsoula’s mother Eleni changed her hypertension pills five times, a doctor advised the family to stop experimenting because it may have contributed to the bleeding that sent Eleni to hospital in April 2016. There, doctors ordered an intestinal endoscopy, but told Eleni she would have to wait at least six months for the next opening.

‘Self-medication continued to rise’

Greek Paralympic swimmer Konstantinos Karaouzas holds a bottle of aloe vera extract that he drinks for pains in his joints. Photo: Anna Pantelia.

Karaouzas, too, has found little joy in the public health system, which repeatedly prescribed him antibiotics for a recurring infection and, he says, has little time or resources for his special needs since a motorcycle accident 16 years ago left him paralysed from the waist down.

Disability associations and watchdogs warn that healthcare cuts have hurt the expertise and resources available for the treatment of disabled people, meaning few are getting the special treatment they need within the public health system.

The National Confederation of Disabled People told BIRN that it frequently received complaints that particular treatments required by disabled people were being cut from the list of those subsidised by the state and the cost of care was creeping up. Budget cuts had driven up waiting times and reduced resources, it said.

“Social welfare for people with disabilities has been almost entirely left to the discretion of their families,” it said.

Athens urologist Christos Fliatouras said doctors were examining disabled people like Karaouzas “without the necessary knowledge”.

“People like him need specialists and not just plain urologists. But in Greece there is a lack of regulations, services and a supporting framework.”

Karaouzas has turned to homeopathy and expensive nutritional supplements such as aloe vera and collagen in the hope they can help keep him healthy and out of hospital.

At a time when other businesses are shutting shops, cutting their losses and laying off workers, studies suggest the market in nutritional supplements is growing.

“Self-medication continued to rise, as public health funds were cut and consumers tried to avoid visiting doctors,” the London-based research company Euromonitor International said in a report on consumer health in Greece released in September.

The loosening of rules on the sale of over-the-counter products and liberalisation of pharmacy ownership – reforms made under pressure from Greece’s international lenders – “are expected to create prosperous ground for demand and value sales in consumer health”, it said.

“The Greek government’s intention to further reduce the public budget on healthcare is set to drive the self-medication trend; hence will create prosperous ground for growth in consumer health in the forecast period.”

Spiros Terzopoulos of Pharma Centre, which sells pharmaceutical products including vitamins and supplements, concurred, telling the Greek ‘Health’ magazine in 2014 that the reform of the market meant new forms of supplements had emerged “to fill many of the healthcare gaps”.

“The major allies in the evolution of food supplements are pharmacists, who see their customers daily facing many different problems and have taken it upon themselves to act as health advisers and to propose the use of many new supplements … proven to provide solutions to small health problems and alleviate major problems,” he was quoted as saying. Terzopoulos could not be reached for comment.

“Self-medication continued to rise, as public health funds were cut and consumers tried to avoid visiting doctors”

- Euromonitor International research company

George Dokios, the general director of the Greek over-the-counter medicine industry association EFEX, was quoted in June by the consumer healthcare website OTCToolbox as saying the over-the-counter market had increased by 31 per cent in value terms between 2010 and 2015, and from five per cent to 12 per cent in terms of a proportion of the total pharmaceutical market.

Online shopping portal Skroutz.gr has reported, in Greek, a 469 per cent rise in sales of food supplements through its website between 2013 and 2014. It said the vitamin and dietary supplements category was among the top five categories of products with the highest growth in online sales.

Greece’s National Organisation for Medicines, EOF, the state body that approves licences for medication, cosmetics and supplements, told BIRN that the number of applications to put nutritional supplement products on the market had roughly doubled between 2012 and 2014.

The EOF said rules on the kind of claims such products can make in their advertisements were, however, “frequently violated”.

Promises

Drinkable collagen, a protein found in the human body, has become particularly visible since entering the market in Greece in 2010, often with promises to alleviate joint pain, osteoporosis, arthritis and more.

Arthritis Research UK says that trials into collagen’s role in treating osteoarthritis give “mixed results”. Studies into its role in treating rheumatoid arthritis “suggest that it doesn’t have a significant effect in reducing pain and joint inflammation”, the group says, though it adds that “this hasn’t been consistently reproduced across trials”.

Giorgos Tsoukaladakis, the former face of the company Collagen Power, told a popular lifestyle show on Greek television in 2014: “It’s a natural anti-anxiety agent. Stress and anxiety has driven everyone crazy. Unemployment has hit every house. There is not a house, not a family that does not have one or two unemployed people.”

Clutching a bottle of the company’s flagship product Collagen Pro-Active, he told the presenter: “It helps improve our psychological wellbeing.” Tsoukaladakis is no longer with Collagen Power.

Greek pop star Giorgios Sampanis has even promoted the product, featuring it four times in a raunchy 2014 music video for the song Mono Ex Epafis (Only By Touch).

The EOF told BIRN that in June 2014 it recommended to the Greek Ministry of Health that Collagen Power be fined 35,000 euros for misleading advertising. Asked whether the fine was actually imposed, an official at the ministry said the complaint was lodged under the previous government and directed this reporter back to the EOF, which referred the reporter back to the ministry.

Collagen Power owner Giorgos Triantafillou declined to be interviewed for this story. BIRN also sent the company detailed questions regarding its advertising and the fine.

The company replied: “We have not been informed of any decision – or any intention – of the EOF to propose to the Ministry of Health a fine. No fine has been imposed on our company”

It confirmed that Tsoukaladakis had left the company and declined to comment on his 2014 statement, saying it had been “detached from the wider context of the discussion”.

An advertisement for drinkable collagen outside a pharmacy in Athens, saying it offers a solution for osteoporosis and arthritis. Photo: Dimitra Triantafyllou.

The EOF told BIRN in an email: “We are in an open communication with the National Council for Radio and Television regarding the advertising of similar products that make health claims.”

At around 50 euros for a bottle of 600 ml, which if taken as per the instructions would last 24 days, drinkable collagen is expensive for many Greeks.

Doctors, nevertheless, are alarmed at the degree to which their patients are putting their faith in nutritional supplements.

BIRN was given a leaked copy of the minutes of an April 2015 meeting of the Athens Medical Association, on condition the names of the doctors quoted were not revealed.

One said: “Many colleagues call the medical association to complain about the advertising of hyaluronic acid and collagen, due to which patients stop following their treatment.”

Another said: “We have to find out to what extent we can intervene as the medical association to stop this story with the advertisement of substances and products through the internet, television, everywhere, with the result that patients drift away and abandon their treatments.”

The EOF told BIRN that fines were frequently imposed for misleading advertising. “But companies do not comply, at least not immediately,” it said.

“The legal framework is insufficient both in terms of the level of fines and the speed necessary to be effective in such cases.”

‘Ransacked’

Ioannis Baskozos, the secretary general of public health in the Greek Ministry of Health, said he favoured a blanket ban on such advertising. But the government’s hands are tied, he told BIRN.

“The obsession of the Troika,” he said, referring to Greece’s trio of international lenders at the EU, the European Commission and the IMF, “is to commercialise medicine.”

Baskozos said the Syriza government planned to hire more doctors, nurses and paramedics, that it had managed a modest increase in healthcare spending and was offering free access to the public health system for uninsured Greeks.

He also said a new public database of waiting lists would eradicate the notorious practice of doctors seeking bribes to help a patient jump the queue, known as ‘fakelaki or ‘little envelope’. The practice has worsened under the austerity cuts as medical workers see their own incomes cut, and is part of a wider problem of corruption and tax evasion that Greece’s lenders have said Athens must tackle as a condition of financial aid.

“This is a revolution in healthcare!” he shouted.

But Vichas, of the solidarity clinic, said that while there had been improvements in providing uninsured Greeks with access to the public health system, long waiting lists and cash-starved hospitals meant many were simply returning to the solidarity clinic.

Some Greeks, Vichas wrote in September on his Facebook profile, are still unable to afford even the state-subsidised medicines, not least because of the difference between the retail price and the amount the subsidy covers, a gap that is getting bigger.

“The public health system has been ransacked,” said Vichas.

He described a situation in which a patient comes to Greece’s National Primary Healthcare Network, the network of frontline community clinics, with shortness of breath.

“I need him to do a triplex and a stress test, but we do not have the necessary machines,” he said. “For an uninsured person, these can only be done at a public hospital where the person will encounter a huge waiting list and end up finding an opening months away. The time in between can be fatal.”

Dimitris Kourouvakalis, a nurse at Ippokration General Hospital in Athens and a senior member of the Pan-Hellenic Federation of Public Hospital Workers (POEDIN), described a typical scene:

“During the on-call days… waiting times can reach 15 hours, while in one of our clinics there is one nurse for 40 patients. From time to time we face huge shortages. We reached a point where we didn’t even have gauzes. Many times my colleagues bought surgical gloves themselves, while sometimes we ask patients to buy their own medicines.”

Anxiety

Vasiliki Katsoula, pictured with her mother Eleni, holds medical bills at their home in the Athens district of Aspropyrgos. Photo: Anna Pantelia.

Rather than brave such hospitals or community clinics, many Greeks simply buy antibiotics under the counter from their pharmacist. According to the European Centre for Disease Prevention and Control, Greece is the EU’s No. 1 consumer of antibiotics outside hospitals – 34.1 daily doses per 1,000 citizens.

Within its Balkan neighbourhood, Romania ranks second with 31.2 daily doses; Croatia is 12th with 21.4 doses, Bulgaria 13th with 21.3 and Slovenia is 25th with 14.2.

Niki Likourgia, a pharmacist in the hillside Athens district of Lycabettus, said cancer patients came to her asking for “medicines for irrelevant conditions, besides their treatment, without consulting their doctor”.

“You cannot possibly imagine how many syrups and antipyretics (to reduce fever) they ask for when their immune system is down. They even yell at you when you tell them that if they do not speak to their doctor you’re not going to give them what they ask for,” she said.

Sotirios Tsiodras, associate professor in internal medicine and infectious diseases at the medical school of Athens University, cited research that indicated between 40 and 60 per cent of drugstores sell antibiotics without a prescription.

Tsiodras said that six years of the intense economic crisis, anxiety and the state of public health system had left Greeks clutching for straws.

“That’s the reason for this trend; instead of going and paying a doctor of good reputation, you go and try herbs or a traditional recipe you got from your grandmother, or anything else.”

Dimitra Triantafyllou is a freelance journalist focusing on social issues, health and gender. This article was produced as part of the Balkan Fellowship for Journalistic Excellence, supported by the ERSTE Foundation and Open Society Foundations, in cooperation with the Balkan Investigative Reporting Network.

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