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British Medical Journal, 30 May, 6 June, and  13 June 1992

Letters from Poland

This is the first of three articles examining health issues in Poland
By Karin Chopin, medical student, Bristol University
22 Montague Hill, Kingdown, Bristol BS2 8ND

British Medical Journal
Volume 304, 30 MAY 1992
pp 1429 - 1432
BMJ web page

Too many advisers, not enough aid
by Karin Chopin

"The minister says you will be able to explain more easily to the English when you have seen something of our country. He would welcome the opportunity, moreover, to see for once his country - through a foreigner's eyes. Would madam be interested in accompanying our itinerant minister on his travels while she is here?" Word had obviously reached the Polish deputy minister of health that someone writing for the BMJ was in town. I had arrived in Poland in the autumn of last year to see how the new regime was addressing the country's poor health record. Having just spent a fairly fruitless week being ushered politely from office to office, listening to a lot of rhetoric about the proposed Polish health reforms, I was most definitely interested in travels with this minister.

The quixotic and controversial deputy minister of health, government sanitary inspector, and chief environmental health officer, Zbigniew Halat MD is engaged in a personal crusade to shake the health service out of the spiritual atrophy induced by 45 years of communism. Hard working, self reliant, aggressive, and abrasively masculine, this man of Promethean energies put me in mind of a nineteenth century northern mill owner. While he attended a seemingly endless succession of meetings and conferences in horrendously smoke filled rooms all over the country I was at liberty to sit in and listen, or privileged to roam free throughout hospitals, talking to patients and staff, or honoured as a foreign guest in schools, academic institutions, and factories. Over the next three months I was shown such a picture of Poland that I felt I had been to the horizon and back. Miraculously, door after door opened before me. I was profoundly touched by the warm acceptance and generosity with which I was received everywhere I visited, deeply appreciated after the struggle of Poland' s paradoxical public boorishness. For all the traumas of their recent past, the Poles have retained their legendary hospitality, sense of humour, and capacity for enjoyment.


British Medical Journal
Volume 304, 6 JUNE 1992
pp 1495 - 1497
BMJ web page

Pollution most foul

by Karin Chopin

In 1848 Rudolf Virchow published his Report on the Typhus Epidemic in what today is Upper Silesia. His report detailed the oppression of the Polish speaking inhabitants by the Prussian landowners and bureaucracy, which he saw as the source of their and illness. Subsequently, in poverty, starvation, l879, he noted that matters in Upper Silesia had hardly improved since his previous report. In June 1990 Professor Irena Norska-Borowka, head of the neonatal pathology clinic of the Sileslan Medical Academy, Zabrze, published an account of health in Upper Silesia. She wrote of "increasingly high rates of infant mortality and child morbidity in the Upper Silesian Mining Basin, a high percentage of mentally and physically handicapped children ... socioeconomic factors such as poverty, smoking, alcohol, and drug abuse, and previous abortions ... hard physical work, and stressful urban conditions." It comes as a shock to find things so little changed since Virchow's time.

As facts come to light after 45 years of communist obfuscation, Silesia is emerging as the most ecologically disturbed part of Europe with the poorest health record of any industrialised community in the developed world. It would seem that a century and a half of industrial so called "development" has apparently had little impact on the wretched life of that province - if anything, it has created a new source of ills. Last November I travelled to Upper Silesia to see for myself. It was not a part of the country my host, the itinerant Polish deputy mister of health, Dr Zbigniew Halat, visited too often if he could help it. "When Poland faces a tricky international football fixture," he had said to me when I told him I was going there for three weeks, "the odds are that it will be played in Katowice: if the surroundings do not incapacitate the opposition with depression, the oxygen free atmosphere usually takes a few yards off their pace."

The Polish side of the "black triangle" Upper Silesia is the industrial base of an otherwise agricultural country. It consists of an almost continuously built up conurbation of about a dozen towns. Two million inhabitants make this the most densely populated part of Poland (population 38 million). It lies along one side of the infamous "black triangle," where Polish, Czech, and eastern German heavy industry creates desolation that does not respect borders. The air is sulphurous here. The snow is acid snow. The lakes and rivers still look alive. Not so the forests: whole tracts of once glorious birch and pine stand naked, stripped of their foliage, or stunted, resembling the skeletal survivors of a nuclear storm. The region has attracted worldwide attention since the beginning of the glasnost era because of the horrendous pollution from its outdated factories. It has been officially classified as an environmental disaster area by the Polish Academy of Sciences and represents an impressive example of the environment's influence on health and the results of unregulated industrial development and official neglect.

For 40 years the acceptable level of pollution was that amount the foundries, steel mills, chemical plants, and coal mines, etc, needed to emit to meet production quotas. The principal source of this pollution is Poland's dirty brown coal, which yields  benzo(a)pyrene, one of the deadliest of carcinogens. The district is dominated by mining: Upper Silesia boasts 98% of Poland's coal production; 23% of the country's electrical energy is produced here, 52% of its raw steel, and 100% of its zinc, lead, and silver. Levels of heavy metals in soil and river sludge are alarmingly high around metallurgical plants. Sulphur dioxide outputs per head from this part of Poland (along with neighbouring parts of eastern Germany and Czechoslovakia) are the world's highest (table). Because untreated industrial and communal sewage are released in surface waters there is no water of first class purity that is, no drinking water. One fifth of the food commercially grown here is polluted to the point of being unfit to eat. Rates of sick leave and industrial diseases are much higher than the national average. Accommodation is often situated alarmingly close to plants. There is a significant and rapidly worsening unemployment problem due, firstly to the collapse of the Russian market and, secondly, to the forced closure of some of the least economically viable plants or worst offenders in the pollution stakes. Cigarette smoking undoubtedly increases the health damage done by air pollution. In Poland in 1988, 72% of men and 57% of women in their early 30s smoked, compared with 33% of men and 30% of women in that age group in Britain (source: Katowice Sanitary Epidemiological Station, Upper Silesia).

A serious problem

The capital of Poland's black country is Katowice, and presiding over the sanitary epidemiological station there is the formidable Teodora Karczmarowa, who, once reassured that I had not come in pursuit of sensation, was most forthcoming, and, indeed, saw the BMJ's interest in the situation in Upper Silesia as evidence that other people are taking the yellow flags as seriously as she does. "Any research into, or exposure of, links between Soviet industrial tyranny and disease was deemed seditious under the communist regime and therefore banned," she explained. "Although studies so far show only correlations and do not establish causation, they do indicate a marked effect of environmental degradation on the health of the population. We can't wait for irrefutable proof that people are falling sick and dying as a result of the devastation of the environment. There is no time to wait until the economic battles in this country have been won." Two years ago the old regime would not even admit that there was a serious problem, and now there are laws controlling the disposal of waste and air pollution, while further emission levels are being drawn up and with them criteria for the environmental assessment of new projects.

Tired and angry

Democracy in eastern Europe has a hundred faces; this one was sad and silent. And somewhat sceptical about visiting foreigners, too. I had waited a long time to meet Professor Mieczyslaw Chorazy, head of the department of tumour biology at the Institute of Oncology in Gliwice, Upper Silesia. "Dr Livingstone, I presume?" he greeted me with a sardonic smile. "Another foreigner come to civilise the natives." I assured him I had come to do no such thing. The prophetic vision of a kingdom of justice on earth, which was called Marxism, brought not only intolerable bestiality, suffering, and practical failure to hundreds of millions of men and women, but, according to Professor Chorazy and his associates, also seems to have left its mark on the genetic code of the population of Upper Silesia. ''I have had the greatest difficulty in getting any of my material published until recently," he told me, and went on to elaborate the details of his research. Since 1984 he and his team have been analysing organic material from airborne pollutants collected on fibreglass filters in 27 locations throughout Upper Silesia. "Our evidence leads us to believe that people living in the area have very distinct signs of damaged genetic material. The epidemiology of the situation has not yet been published but significant correlations between clusters exist. We have unique human genetic material in our hands here, and we want to get other people interested - for example in DNA repair, individual susceptibility , how particular genes are affected, etc. We would like to organise a tissue bank from this material so that others can have access to our unique material in Silesia."

Professor Chorazy is a tired and angry man. In common with many of the other health professionals I met in Poland, he too complained that well meaning international organisations came over with good intentions but on different wavelengths from the Poles. "All they bring in their baggage is ideology. Just look out of the window and see for yourself where ideology has got us these past 45 years....What is the point in sending us 17 highly sophisticated pH meters (as his department had recently received) when (a) there are not enough people here trained in using them and (b) we don't need your sophisticated pH meters to tell us how filthy our rivers are anyway. OK, our methods of measurement may not be quite as exact as yours, but our rivers are pure poison anyway - if we're a couple of units out of this way or that, what difference will it make in the long run? I fully appreciate the importance of accurate baseline measurements, but we simply cannot in our circumstances, afford the luxury of establishing exactly how lethal our waters are. If the World Health Organisation or World Bank is going to spend money on us, let the money be spent doing something about our problems, not forever measuring them, for God's sake!"

"And where does it get us when they tell us that Poland comes second only to Russia on just about every European table of dangerous emissions? Should we close down all our factories and live unemployed, in the dark? Or redirect traffic out of our towns? What on to do? The existing road network in these towns does not even come close to supporting the local and transit traffic. Better spend that foreign aid on building a bypass for Gliwice, instead of pH meters for my laboratories. . . . And the number of visits I've had from Western ecological organisations! I keep on telling them that you cannot apply First World ecological philosophy to a Third World country such as Poland!" he expostulated.

Sepia coloured cities

Mr Tadeusz Frackiewicz, a retired mining engineer, and his wife, Lucyna, professor of sociology at the Silesian Academy of Economic Sciences, had kindly offered to spend a day showing he me how people live in Upper Silesia. Walking the streets of Silesian cities, one cannot help but notice that many of the people appear tired and prematurely aged, their health destroyed by the foul air they must breathe and a diet of greasy sausage and cigarettes. The women invariably look older than they really are. They are often poorly dressed and overweight. For me, they are the most beautiful in the world because I know what is behind the serious worried faces; behind a pale pink lipstick that doesn't exactly go with the colour of their eyes, or hair, or dress; behind the bad teeth, the smell of their sweat in a tram. Their beauty should not be compared with beauty that comes from the West. Their image, fashion, and make up should be judged by different criteria, with knowledge of the context, and, therefore, with appreciation; They deserve more respect than they get, simply because just being a woman - not to mention a beauty - is a constant battle against the way the whole system works.

We called in to see a family living in an apartment out of whose windows I stared across a busy dual carriageway straight into the open furnaces of Huta Kosciuszko ferro-alloy works. There was a satellite dish perched on their balcony. Indeed, a striking feature of the landscape in Upper Silesia is the number of satellite dishes around: "Junk food for the mind," Professor Frackiewicz said contemptuously. Driving around, here and there short stretches of road would drop a few feet, half a tenement block stood derelict due to subsidence, while people still lived in the half that had been spared. Like the English, the Poles love their gardens, and everywhere we saw allotments and backyards exploited to the maximum, with all manner of fowl pecking optimistically at any remaining patch of bare earth. But the vegetables apparently come up runty, the flowers looked sorry for themselves, and the much rows of lettuces are reported to absorb as much as 200 mg of lead/kg (source: Katowice Sanitary Epidemiological Station, Upper Silesia).

In the town of Chorzow, I stopped to take a photograph and an old woman leaned out of a window and eyed me suspiciously, but I managed eventually to coax a smile out of her, and she invited us into her two room house. Onions to be put by for the winter covered her kitchen floor. There was a large cow lying on bare earth in the room next door. She remarked on the absence of a wedding ring on my hand and we talked about the excess of batchelors in her small town, about the men drinking too much. She proffered a meal of boiled potatoes, pickles, and a most unappetising looking sliver of pork fat. Now and again her house shivered as a heavy truck passed on the road outside - probably yet another piece of Soviet military machinery going back home eastwards, further wrecking the terrible Polish roads. "Good riddance!" (a polite translation) she shouted out of the window each time one passed.

The pathos inspired by this highly industrialised region is also at part due to the ubiquitous erosion of its cities. Shabbiness and the colour of sepia are their common denominator. About 70 km common to the east of Katowice lies the beautiful renaissance city of Krakow, Poland's ancient capital. We spent the afternoon there. The very city itself appears as if covered with a sepia coloured film - as if it were fading away, crumbling at the edges, disappearing. I saw angels without wings, caryatids without breasts, horses with broken legs, and gargoyles without noses, their hideous features eaten away by the acid rain - a city slowly decaying. Professor Frackiewicz explained: "To say it's the poor quality paint under socialism is correct, but it is not enough. To say it's soft coal exploitation and air pollution, bad gasoline and bad cars, or lack of money - that again would be correct. But it is not the whole story. All the reasons (and probably many more) are not enough to explain the decrepitude. Our cities have been killed by decades of indifference, by the conviction that somebody else - the government, the party, those "above" is in charge of them. Not the people. How could it have been the people if they were not in charge of their own lives? Maybe now, after the political changes in eastern Europe, the people will have a chance to repossess their cities, reprivatise them, treat them as if they are not merely places they are sentenced to be in or which they only pass through.

A monolith does not come undone overnight, and I had not come to Silesia: expecting happiness and light, but as I neared the end of my stay I wondered how long it would take for that part of the world to shake off its melancholia. On the road back to Warsaw I even wondered how long it would take to me to shake off.

British Medical Journal
Volume 304, 13 JUNE 1992
pp 1557 - 1560
BMJ web page

Post-totalitarian medicine

by Karin Chopin

There is no way of knowing what democracy will end up looking like in Poland but here are some glimpses of it now.

Ania, a 45 year old obstetrician I met on my travels with the itinerant Polish deputy - minister of health, Zbigniew Halat MD, invited me to her home to meet a group of people involved in various aspects of health care. Sitting round her kitchen table, they unfolded their lives for me.

Temptations of corruption

The young psychiatrist: "People have so much initiative in this country. This is our capital - but it must be exploited appropriately." The head of a public health laboratory. "Our records aren't that good, I'll admit, but who are the World Bank, the World Health Organisation, or the Americans to come preaching to us? Rather a life in a Gdansk housing estate than a life in the Bronx. . . . And as for Sweden, people there are so bored that they all want to commit suicide."

The matron in charge of a nursing home: "We experienced the second world war and ever since, like most of the people in eastern Europe, I think, we behave as if it never ended. Maybe this is why .I an1 never really surprised that even 45 years afterwards there is still a lack of medicines, bandages, syringes. . . ." ,

"If the new laws permitting private clinics are not encouraged, one can safely predict that our citizens will continue to resort to the time honoured Polish custom of illegal payoffs - bribing doctors and nurses," the ward sister said. The corruption of the medical services in Poland is an undeniable social fact - "It's so much easier to bribe women doctors than men doctors," a friend from Warsaw once admitted. "How much more natural to give presents to a lady."

"We don't want to be like this," a  young doctor protested, "but it is the system that forces us to. We are state employees, but the state is bankrupt and tells us to go and earn privately. You start out with noble intentions but then you find yourself having to succumb to the temptations of corruption just to survive." (Doctors currently earn 72% of the average national wage.) The newly appointed Polish minister of health, Dr Marian Miskiewicz, acknowledges that doctors , accept bribes, especially in surgery, orthopaedics, and obstetrics, but he does not agree it is a common practice. A Polish sociologist elaborated: "The trouble is that the health care system, basically designed in the early '50s, remains a highly centralised and rigid structure. The more rigid the structure and functions of a given institution, the more likely is a split between formal and informal structures."

The hospital manager: "Do you know that ambulances are called out four times more frequently in Poland than in the developed countries of western Europe?" (The minister of health had recently publicly deplored the disgracefully wasteful deployment of ambulances in Poland.) "A woman has a temperature and cannot be bothered to go down to the clinic, so she calls an ambulance. And then we don't have enough petrol to send out for the chap who's having a heart attack." Here I could not help interjecting: "But people in the West think of you also as a developed country." "What do you mean, 'developed'?" one of the company retorted in the fashionably self deprecating manner of he postcommunist era. "We're lagging at least 20 years behind you. Don't you realise that in the past decades our principal slogan was building communism, our main priority defence . . . an issue such as personal health was about number 193 on our list of national priorities."

I mention the young man I had seen on the way there, crouched in the doorway, covered with only a blanket to protect him from the falling snow. "I have AIDS, please help me," said his sign. "It is only a miracle that there are not more beggars, what with more than half of the working population living at the edge of poverty," explained Father Rornan Indrzejczyk, pastor to the medical profession in Warsaw."

And then, in the midst of all this, our anti-choice nationalist government is threatening our right to abortion and telling us to multiply, to given birth to more Poles!" Ania, our host, was enraged by officials in the Ministry of Health, who refuse to disseminate any birth control information, and accused them, the Chamber of Physicians, and the gynaecology establishment of being "criminals" for allowing abortions to proliferate by opposing birth control programmes. "They should be serving time," she said, "for the harm they're doing to women's health. And apart from anything else, abortion is a costly method if used as a primary resource of contraception as it is in Poland." She is involved in a passionate crusade to lower the nation's appalling abortion rate. "Do you really want to know why so many of our doctors oppose birth control? In this country much shame is still attached to abortion, and our doctors oppose birth control because they make so much money out of private abortions (many women apparently choose this alternative to ensure proper anaesthaesia and anonymity). We've been brought up to look on abortion as a necessary evil, and on birth control devices as harmful and unreliable. . . . We are so backward that half our condoms break upon first use."

There were, inevitably, some negative comparisons with the West, which tended to centre on Westerners' "sad over-individualism." "Our sense of community is fast declining, but you're still far more solitary and lonely than we are. ... Over here if you fell sick in the street you'd immediately be taken into someone's house; over there, no one would know the difference if you died. And you put all your old people into homes for the elderly, which would be unthinkable to us, even if we had many such homes. Old age is celebrated in our country, rather than regretted." But someone else countered this: "Our family ties are sometimes too strong, and our living conditions kill all privacy - I could do with a little bit of loneliness sometimes, maybe even some of your Western alienation."

Health care reforms

"You are a fortunate young woman," Dr Andrzej Wojtczak, the distinguished professor of public health medicine at the Medical Postgraduate Centre in Warsaw, told me. "Foreigners usually only meet a very select bunch of English speaking people in our country. Do not be sparing in your criticism; you have seen so much. The trouble here is that knowing and accepting have become the same thing, and it takes an external voice to shake us. The politician cannot be pessimistic - even if a good dose of introspective gloom might be the only precursor to radical change. . . . We know the patient is sick, but sometimes you need to borrow the eyes of a friend to see yourself."

The avuncular Professor Wojtczak was an island of calm in the turbulent waters I had found myself tossed into in Poland. Every couple of weeks I would collapse into one of the comfortable chairs in his office, tea and cakes would immediately appear, and, with infinite patience and kindness the good professor  who, as the principal author of the country's new national health policy, had far more important things to do, would help me get all that I had seen and heard into perspective. He attributed the current predicament of the Polish health service to years of excessive centralisation and bureaucracy; to the high priority put on developing the production of materials and consequent devaluing of health, and of non-manual workers including health workers; and to the informal health care system based on privilege that arose alongside the formal system. "Now add to that the present lack of discipline among civil servants, the arbitrary decision making that goes on at all levels, the country's outdated laws, the continuing corruption of many officials, and the fact that in the past many health statistics were either kept secret or were non-existent or unreliable, and perhaps you can begin to understand why you are finding reporting on our health service such a challenge."

Professor Wojtczak summarised for me the underlying trends of the Polish health care reforms now either in force or under discussion: decentralisation to a local level; increased cost consciousness; a diversification of health care funding sources; a shift of responsibility to the patient; and the re-education of about 40% of doctors to create general practitioners, and the introduction of the concepts of general practice and health promotion into medical education. "The latter will be our most difficult task," he explained, "for the concept of general practice is completely alien here. And since we have very few resources, the government has not got enough money for health promotion. What exists is totally uncoordinated, and anyway, the whole concept is bedevilled by the problem of lack of credibility of the source - politicians have been lying for so long that the general public distrusts them and is not receptive to health education messages. The transition to a more effective and efficient health service will be difficult without a restructuring of the whole socialist legacy," he admitted. "And it will take so long to change habits. For even though the socialist states have fallen apart, many of the old habits haven't. They are still with us, built in like a microchip. . . . Although Poland is currently leading the countries of central and eastern Europe in the field of health reform," he told me proudly, "the faltering progress it has made in this field stands both as an example and a warning for those emerging nations to our east about to undertake the same adventure."

 Need for a change of heart

Sadly, the Polish people are not a healthy lot. Moreover, Poland is experiencing increasing problems meeting the health care needs of its population. The key problems are lack of money, inefficiency in the health service, profound demoralisation among health professionals, and a predominant reliance on public funds for the system's revenue. Since the 1970s the health of the Polish people has deteriorated and the increases in life expectancy achieved during the 1950s and 1960s have actually been reversed (figure). Mortality among men over 30 is now greater than 10 years ago, and 20% fewer men in Poland can expect to live to the age of 65 as compared with men of the same age in the Netherlands or Japan. Infant mortality is higher in Poland than in most European countries; although it declined from 111 deaths/1000 live births in 1950 to 15,9/1000 in 1989 (as compared with the Organisation for Economic Cooperation and Development range of 5,0-14.2), the rate of decline has slowed. The incidence of hepatitis B infection is 10 times greater than the European average. Poland's tuberculosis problem is still the most severe in Europe, and this disease remains the single most common cause of death of infectious aetiology in the country, although the number of deaths from tuberculosis has decreased drastically to 49/100 000 (as compared with 9/100 000 in the United States), The number of disabled people among the working population is increasing: this may be linked to the fact that about 20% of the workforce is exposed to a hazardous working environment. It is differences in lifestyle and harmful health practices such as unhealthy eating habits, smoking (Poland has Europe's highest growth rate in the incidence of lung cancer), excessive drinking, a sedentary way of life, and, to some extent, accidental injury and deaths that are held responsible for this remarkable divergence between eastern and western Europe (data from the Polish Ministry of Health). Although the programme of radical reform launched by the new Polish government to remedy the major ills of Polish society applies equally to the Polish health care system, the government has so far paid little attention to health problems, as it has been mainly concerned with improving the country's desperate economic situation and establishing a new political system. "We have already wasted two years arguing," Dr Miskiewicz admitted bitterly in a recent newspaper interview. In common with most people in the Ministry of Health, he is seized by the urgency to reorient Poland's health policy to address the radically altered epidemiological situation that has emerged in the past two decades. But he concedes that improvement in health care will be a prolonged process, as much a result of a change of heart as of a change of policy. "People have to understand that, although the system has changed for the better, they will get less for some time to come. ... There is no reaching out for simple answers provided by quick fix demagogues... The health care system needs large infusions of funds but money alone will not solve our problems."

The "Polish factor"

Indeed, the formidable problems facing Polish medicine are also those facing Polish society: the solution to the former cannot be achieved without that of the latter. Unfortunately, Solidarity tactics of political revolution remain the only tested method of achieving change. The Poles seem to be having great difficulty in making the necessary management changes to respond to the new opportunities. "At every level, people simply don't know how to take decisions and act upon them," a frustrated Ministry of Health official complained to me. "And if they do, they do so in an entirely disarrayed and arbitrary manner. The totalitarian system did not permit people to develop such skills; they were considered dangerous, because democratic."

Initiatives in the health field, as elsewhere, are stymied at each step by all kinds of bureaucratic, and what the Poles themselves refer to as "characteristically Polish," factors. The bureaucratic situation in the Ministry of Health is indeed so distressing that a visitor can only laugh at the outrageousness of it all; And, unfortunately, Stalinist ghosts still haunt the splendid nineteenth century palace in Warsaw's old town that houses the ministry. Those who helped run the health services into the ground still hold many powerful positions; The Chamber of Physicians (Poland's equivalent of the General Medical Council), for example, is still virtually controlled by members of the former nomenklatura, who may consider they have more to lose than to gain from further changes.

As regards the infamous "Polish factor," every visitor to Poland is, of necessity, referred to the history books for an explanation of the country's current distress. For Poland lies at the crossroads of Europe, and its spirit has been formed and deformed by the cataclysmic pressures of a millenium of continental madness. Centuries of oppression have therefore left the Poles with very little experience of government, negotiation, or leadership, and yet they have a tremendous ability to mobilise in times of crisis. Moreover, they are a highly individualistic people: every Pole has a different opinion on everything, and considers it imperative it be known. Inspiration and panache are held in high esteem; to be correct and dull is considered a horrid misfortune. They possess enormous vision and energy, but these energies often spill over in a disorganised, sometimes even disastrous way. Consequently, meetings, conferences, etc, often dissolve into chaos. As one visiting World Health Organisation consultant remarked to me: "The Poles must be restrained, they have too many ideas." Poland's history is, indeed, extraordinarily unhappy, and that unhappiness seems to permeate its modern day consciousness in a very tangible way. But they really cannot, as is their wont, put so much of what ails their health service down to the fact that Roosevelt sold them down the river at Yalta.

Strong emotions

One winter's day, the Polish deputy minister of health and I drove halfway across Poland to a meeting of chief sanitary inspectors from Poland's 49 provinces. We stopped for lunch in a village 100 miles south of Warsaw, and a hundred years away from 1991. The openings provided by the postcommunist order have turned the streets into a continuous market place, and life into a bit of a nightmare for these pioneers of public health, who are having to battle with the consequences of free enterprise bursting out all over. Unfortunately, Poland has become something of a dumping ground for substandard foreign food imports. Parliament is already overwhelmed and unable to keep up with legislation in this field, while regional public health departments hardly have the resources to keep up with vaccination programmes, let alone keep tabs on entrepreneurial Polish peasants turning out sausages in their back yards and then setting up shop by the road side. After a while the horror stories the sanitary inspectors were telling one another of what had been found inside some of these sausages, jars of pickled mushrooms, etc, and of milk from obviously leukaemic cows finding its way on to shop shelves, began to run together in my head. But their man from Czestochowa, home of Poland's Black Madonna, had a happy story: "Two million pilgrims we had, when the Pope came to visit last June, and not a single outbreak of diarrhoea...... And, what's more, I didn't even have to ban the sale of ice cream."

At cocktails that evening, I was assailed by the Lithuanian minister of health, a burly, genial epidemiologist: ''I am here because we in Lithuania are looking to Poland, our neighbour and ancient ally, for an example for our health service," he told me. "Tomorrow I return to Vilnius." He paused. "Would you do us the honour of coming to write about our health service too? There's plenty of room in my car." I declined regretfully; he was wonderful company at dinner.

The next day found us in Wroclaw, Lower Silesia's historic capital, where I was shown around the maternity wing of a local hospital. A curious feature of the Polish maternity system is that new mothers are forbidden to see their husbands or relatives at anytime during their hospital stay. Ministry of Health officials upheld this custom as an instance of Poland's strict or hygienic precautions in hospitals. Women have little or nothing to say about the conduct of their labour. The treatment is invariably rough, impersonal, crass, as in a production line. But my most vivid impressions of all concern the lack of warmth or personal attention in these maternity wards, in which I never saw a sign of women's practical ot emotional needs being taken into account: no personal effect such as a nightgown or slippers is permitted, no flower or card is allowed to taint Polish maternity wards' supposed "sterility." I seldom saw a smile or heard a happy voice in these institutions.

We continued out journey northwestwards to Zielona Gora, near Poland's border with Germany, where the minister opened Poland's first national conference on sex education (a suitable euphemism, which I now forget, was found for its official title). By coffee time, however, I was bored and sneaked out in search of our driver, who needed little persuasion to take me mushrooming (a favourite national pastime) in the beautiful forests surrounding the town. "Bison, lynx, and boar live here," the minister had told me as we had driven through. "And bears and storks and fish eagles," his driver had added. These two never missed an opportunity to draw their English guest's attention to the wealth of their nation. We filled the car boot with mushrooms and I returned to the conference hall trailing burr-like fragments, half a dozen yellow apples concealed in my ample handbag, just in time to witness the meeting erupt into impassioned chaos. That evening I ventured to ask the minister why Poles did not try to control their feelings in such situations. "What do you mean?" he retorted angrily, as if the idea had been proffered by a robot. "How can we do that? They are our feelings." Thus I learnt that true Slavs suffer their emotions as if they were forces of nature, winds and storms and volcanic eruptions. They cannot imagine tampering with them, for they are the most authentic part of them.

Sick but passionate

"So what is your diagnosis on the Polish health service after three months in our country, Dr Chopin?" the amiable journalist pressed me. "Third or Fourth World health care?" I wished fervently I had nor been so bold as to agree so the interview as her tape recorder whirred menacingly on the table between us. I managed to avoid committing myself by making a feeble joke about the English remaining an underdeveloped nation too - in passion. She liked that.

My tour of the Polish health service had been an extraordinary journey, both professionally and personally. I was profoundly depressed by the shocking vastness of the damage done by 45 years of communism to the health of the Polish people, and to their psyche. Equally, I was enormously inspired by the sense of basic values which survives, impressed by their extraordinary initiative, by their blissful lack of cynicism, so fashionable in the West. And although the Poles are living in an epoch rife with problems and perils, life there is certainly nor boring.

I would like to thank the many people all over Poland who were so helpful to me in researching these articles. I am indebted, in particular, to Professor Andrzej Wojtczak of the Medical Centre for Postgraduate Education, Warsaw; Dr Zbigniew Halat, deputy minister of health, and Mr Piotr Jaworski, his invaluable assistant; to the World Health Organisation team from Copenhagen - Dr Franz Staugaard, Dr Ilie Marcu, Dr Allan Juhl, and Ms Katinka de Vries; and, above all, to my friend Michael Slattery, who encouraged me to undertake this project and who died of an AIDS related illness while I was in Poland.

National Geographic 
Volume 179, No. 6   JUNE 1991
pp. 36 - 63

East Europe's Dark Dawn
The Iron Curtain Rises to Reveal a Land Tarnished by Pollution.
by Jon Thompson, MD

While the world wasn't looking, Eastern Europe's regimes poisoned their environmet in the name of progress. Now new leaders must assess the damage and set priorities for reversing it.

In the fall of 1989 the communist governments in Eastern Europe began to crumble. As the Iron Curtain was torn apart, journalistst - nosing around in Poland, East Germany, Czechoslovakia, Hungary, Romania, and Bulgaria with a newfound freedom - were met by an outpouring of complaints about polluted air, contaminated water, and poisoned soil.

The headlines in the Western press  - "Pollution Chokes East-Block Nations", "Environmental Catastrophe in Eastern Europe" - brought a crowd of questions to my mind: Why all the fuss right now? How bad is it? How did it happen? Is it affecting people's health, and how are the new governments responding?


Now that the Eastern block has opened up, the most outdated, inefficient, and uneconomical factories - often the worst polluters - will simply disappear, and thousands will find themselves out of work. With massive unemployment and backward industry, it will be almost impossible for any governments to make the environment a top priority. 
Because pollution was used by political activists as a stick to beat the ruling communists and because money and jobs are far more important to the man in the street, the pollution issue will likely fade from the headlines. The sewage and sulphur dioxide, however, will still be there. To achieve the standards we take for granted, huge sums of money will have to be spent. But whose money? How will Eastern Europe's struggling economies pay for the necessary  improvements, let alone the clean technologies we are now beginning to expect?

Enormous tasks lie ahead. To tackle them, East and West must join together. But will Eastern Europe's new rulers find the environment as important now as they did when they were in the opposition?

National Geographic 
Volume 179, No. 6   JUNE 1991
pp. 44-45

Pollution's long shadow

From the Baltic to the Black Sea, half a century of runaway industrialization has left a smear of destruction through the heart of Eastern Europe. Under orders from Moscow, factories appeared where only farms and markets had stood. The historic university of Krakow  was "given" the huge Nowa Huta steelworks simply because the Stalinist regime mistrusted the city's intellectual elite. Now the city lies within "the dirty triangle" formed by Poland, Czechoslovakia, and eastern Germany - a region of dense population where pollution controls are often nonexistent". Eastern Europe's network of rivers has become a convenient method of disposal - especially the Danube, recipient of eight nations' waste.

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National Geographic
Volume 179, No. 6   JUNE 1991
pp. 44-45


Already choking on its own waste, Eastern Europe is also the acid rain dumping ground for the West, thanks to winds that bring pollutants from as far as Britain. In Poland more than 600,000 acres of woodland have been damaged; in Czechoslovakia, close to one million acres.

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