Socialized Medicine: Survival of the Fittest

(My mother, who is an avid reader of my blog, is a native of Greece and while a fierce partisan of that country is never-the-less perplexed at the love so many of my readers have for socialized medicine of the kind which is the rule of life over there. I offer this brief description of a typical socialized system in a modern European country.-PB)
“Apoklistiki Nosocoma”

The hottest new career in Greece, a country with socialized health care and my family’s ancestral homeland, is the Apoklistiki Nosocoma, or “Private Nurse.” Because the public hospitals are so understaffed families routinely hire one of these trained nurse to watch over their relative while the low-paid government nurses do whatever it is they do for their small salary, a salary which is just enough to convince them to come to work but not enough to actually get them to do anything.

These private (or “elite” nurses) are brokered through the public hospitals in a tacit admission that the socialized system cannot provide decent medical care to the people.

But that’s how it is when nurses (or anybody else for that matter) are employees of the state and have jobs from which they can be dislodged only by the apocalypse or another Persian invasion. They will certainly not be fired for ignoring the patients. Not only is the pay low but, with the exception of a few zealots, there isn’t exactly a long line of Greeks waiting to work for those wages doing the kind of work that our well-compensated nurses do automatically. There are no incentives to work and no penalties for not working. The results are predictable. Not only are Greek public hospitals understaffed but the staff in ’em are not exactly chugging away efficiently.


Of course, if you want anything done in the Greek public medical system you can always pay extra for it with a well-placed bribe. Maybe a couple of hundred Euros in a fakelaki (envelope) to the general surgeon to put your father at the head of the line for a colectomy. Perhaps some well-placed Euros to the charge nurse to make sure she watches your sister. My mother, who lives in Greece, relates to me that this system of bribery is endemic and almost institutionalized. In a country where doctors who elect to work for the state barely make what a garbageman makes over here, not only are there shortages of trained doctors in the public system but they have very little incentive to make the system work and the fakelaki is necessary and expected.

In our country a homeless wino can be brought in for gastrointestinal bleeding and within 24 hours have everything including a sigmoid colectomy and a kitchen sink thrown at him while he is cared for no differently than the paying customers. No bribe is required and the concept of expecting one is unthinkable. In fact, our system, although expensive, provides such good care to everyone that the VIP and the wino are indistinguishable as patients.

In Greece on the other hand, enjoying as it does the bounty of socialized medicine, there is a three tiered system. In the first tier are the private hospitals which are the equal of anything we have in the United States. Unlike our hospitals however, they are in no way charity institutions and only cater to the wealthy. In the second tier is the public hospital system where those who can afford it bribe doctors and nurses and even hire maids to clean their relative’s otherwise filthy rooms. In the third and bottom tier are the poor who lay in cots in the hallways of the crowded public hospitals relying on their relatives for the basics of life and nursing care.
No relatives, no care. Greek public hospitals provide only the rudiments of services to their patients. The condition of the food service in most of them, for example, would be a scandal in the United States. Patient are fed indifferently from rat and roach-infested kitchens and the concept of nutrition seems to be unknown. It would be a national embarrasment except, in typical European fashion, the Greeks take great pains to criticise the United States while their own post-operative patients slowly starve to death. An ironic state of affairs in an otherwise modern European country.
Even getting admitted to the hospital is a difficult process requiring the ubiquitous fakelaki. We would find it hard to believe accustomed as we are to almost instantaneous access to the full panoply of medical resources but in Greece if you have a life-threatening condition, say colon cancer or PORT-score maximizing pneumonia, and you rely on the socialized system you are probably out of luck and could die before you are admitted. The waiting list for what we consider to be routine medical care is hopelessly long.

And things like hemodialysis or Critical Care? Not if you are elderly or poor. You are going to die, just like Darwin intended, because in Greece as in most socialized countries they do not keep the weak and the helpless alive when they become a burden to the state. That’s the secret of socialized medicine. It’s like Logan’s Run. When your life-clock runs out you are done. Finito. Buh-bye. So sorry. Appreciate the taxes and everything but now it’s time to pay the bazouki player.

What’s my point? Nothing really, except you get what you pay for. Providing the high level of medical care that is expected by the American public is not cheap. Attempts to nationalize, socialize, quasi-socialize, or we-swear-we’re-not-going-to-socialize will do nothing to lower costs unless medical care is strictly and severely rationed. Oh sure, you can get yer’ stinking ineffectual primary care provided by a poorly-trained Nurse Practitioner but when your heart starts to give out or you need a new knee, well, you will see the truth to the adage that free health care is great as long as you don’t need it.

27 thoughts on “Socialized Medicine: Survival of the Fittest

  1. Panda, don’t ignore the suffering that our universal access to every tier of the stadium

    EG, wouldn’t happen in Greece: 10 year old boy falls 40ft out of a tree, isn’t breathing, no CPR on the scene, medics transport, intubated at trauma ward 15 minutes later, GCS of 3 at 72 hours, diffuse axonal injury, and parents are still hoping on day 11 that boy might come back. He is surrounded by neurosurgeons who are trying to do their jobs but can never really describe for such parents a minimally conscious outcome, or an aggressive, semi-deranged adult who needs to be institutionalized, outcome. They are just hoping for a PVS outcome so that they can at least offer life support removal in 30 to 60 days.

    The boy was playing Mozart the night before
    at his recital, thunderous applause; goes to my son’s school. The most confident, capable, good-natured 10-yr-old you ever met. He just liked to climb and wasn’t afraid of heights.

    What a cruelty to those parents that they may never be able to say what would have been
    said in any other country: goodbye, dearest beautiful child, you will never be forgotten…

    In Greece, I suspect there would be a lot
    more shrieking and gnashing, but it would be OVER. And there would be some comfort in those awesome painted churches peopled by
    men of God with beards and long black robes.

    Last year during a concert by such priests on tour from Athens at the local orthodox church, a man fell unconscious in the aisle.
    As all the medically oriented folks among us converged on him, the priests slowed their singing for just a few seconds, then resumed their most awesomely beautiful billowing vibrating work as though nothing were going on. Man did fine, later at intermission the people who had assessed him, all four of us, found we had each had the same, exact thought: what an amazing way to go.

    Death needs to resume a more normal place among the living in our country.

  2. I never thought I’d say this but as a Greek, I am offended by the patronizing tone of your post, the ridiculous stereotypes, and the implication that somehow we Orthodox Christians should ignore a guy who may have been having a witnessed cardiac arrest because of the beautiful singing voice of the priest.

    For your information, those black-robed priests in the those awesome painted churches are actually employees of the goverenment (no separation of church and state you understand) and are almost as corrupt as any other bureaucrat. The Orthodox church is almost dead in Greece and only flourishes in countries where it pays its own way.

    The idea that the typical priest in Greece is some kind of holy man is ridiculous. I’m a good son of the Church but I’m neither blind nor naive enough to believe this.

  3. Singapore spends 1/5 on healthcare compared to the US and has the #1 lowest infant mortality and one of the highest life expectancies in the world. While the us is 40-50 places down the live in both these measures but BY FAR spends the most on healthcare out all nations, including nations like switzerland.

    Greece BTW also has lower infant mortality and higher life expectancy than the US, while spending about 30% of what we do.

    Infant mortality per 1000

    180 United States ??6.37
    181 Korea, South ??6.05
    182 Cuba ??6.04
    183 Faroe Islands ??6.01
    184 Isle of Man ??5.72
    185 Italy ??5.72
    186 New Zealand ??5.67
    187 Taiwan ??5.54
    188 San Marino ??5.53
    189 Greece ??5.34
    190 Monaco ??5.27
    191 Ireland ??5.22
    192 Jersey ??5.08
    193 United Kingdom ??5.01
    194 Gibraltar ??4.98
    195 Portugal ??4.92
    196 Netherlands ??4.88
    197 European Union ??4.80
    198 Luxembourg ??4.68
    199 Canada ??4.63
    200 Guernsey ??4.59
    201 Liechtenstein ??4.58
    202 Australia ??4.57
    203 Belgium ??4.56
    204 Austria ??4.54
    205 Denmark ??4.45
    206 Slovenia ??4.35
    207 Macau ??4.33
    208 Spain ??4.31
    209 Switzerland ??4.28
    210 Germany ??4.08
    211 Andorra ??4.03
    212 Czech Republic ??3.86
    213 Malta ??3.82
    214 Norway ??3.64
    215 Finland ??3.52
    216 France ??3.41
    217 Iceland ??3.27
    218 Hong Kong ??2.94
    219 Japan ??2.80
    220 Sweden ??2.76
    221 Singapore ??2.30

    life expectancy at birth

    Andorra 83.52 2007 est.
    Macau 82.27 2007 est.
    Japan 82.02 2007 est.
    San Marino 81.80 2007 est.
    Singapore 81.80 2007 est.
    Hong Kong 81.68 2007 est.
    Sweden 80.63 2007 est.
    Australia 80.62 2007 est.
    Switzerland 80.62 2007 est.
    France 80.59 2007 est.
    Guernsey 80.53 2007 est.
    Iceland 80.43 2007 est.
    Canada 80.34 2007 est.
    Cayman Islands 80.20 2007 est.
    Italy 79.94 2007 est.
    Gibraltar 79.93 2007 est.
    Monaco 79.82 2007 est.
    Liechtenstein 79.81 2007 est.
    Spain 79.78 2007 est.
    Norway 79.67 2007 est.
    Israel 79.59 2007 est.
    Jersey 79.51 2007 est.
    Faroe Islands 79.49 2007 est.
    Greece 79.38 2007 est.
    Austria 79.21 2007 est.
    Virgin Islands 79.20 2007 est.
    Malta 79.15 2007 est.
    Netherlands 79.11 2007 est.
    Luxembourg 79.03 2007 est.
    Montserrat 79.00 2007 est.
    New Zealand 78.96 2007 est.
    Germany 78.95 2007 est.
    Belgium 78.92 2007 est.
    Guam 78.76 2007 est.
    Saint Pierre and Miquelon 78.76 2007 est.
    European Union 78.70 2007 est.
    United Kingdom 78.70 2007 est.
    Finland 78.66 2007 est.
    Isle of Man 78.64 2007 est.
    Jordan 78.55 2007 est.
    Puerto Rico 78.54 2007 est.
    Bosnia and Herzegovina 78.17 2007 est.
    Bermuda 78.13 2007 est.
    Saint Helena 78.09 2007 est.
    United States 78.00 2007 est.

    per capita healthcare spending

    nited States $5,711 Austria $2,306 Congo, Dem. Rep. of the $14 Pakistan $48
    Norway 3,809 Italy 2,266 Burundi 15 Angola 49
    Switzerland 3,776 Japan 2,244 Ethiopia 20 Eritrea 50
    Luxembourg 3,680 Finland 2,108 Congo 23 Myanmar 51
    Iceland 3,110 Greece 1,997 Madagascar 24 Nigeria 51
    Germany 3,001 Israel 1,911 Comoros 25 Zambia 51
    Canada 2,989 New Zealand 1,893 Tanzania 29 Chad 51
    Netherlands 2,987 Spain 1,853 Niger 30 Sudan 54
    France 2,902 Portugal 1,791 Rwanda 32 Laos 56
    Australia 2,874 Slovenia 1,669 Sierra Leone 34 Côte d’Ivoire 57
    Belgium 2,828 Malta 1,436 Benin 36 Senegal 58
    Denmark 2,762 Czech Republic 1,302 Mali 39 Bhutan 59
    Sweden 2,704 Hungary 1,269 Mozambique 45 Mauritania 59
    Ireland 2,496 Bahamas 1,220 Guinea-Bissau 45 Togo 62
    United Kingdom 2,389 Singapore 1,156

  4. The idea that Greek medical care is superior to American is ridiculous, especially if it is based on statistics that are meaningless. Infant mortality statistics, for example, are calculated differently by country. In Greece, for example, there is no such thing as a NICU, at least not to the level of care that we have in almost every decent-sized city. Over there, a 26-week preemie is expected to die and is not counted in the infant mortality figures. In the United States, we routinely go to the full court press for 24-week preemies and even make heroic attempts for babies as young as 22 weeks (without much success).

    You read what you want into statistics. I’m simply telling you that in the Greek public hospital system, as socialized as you can possibly get, the care is substandard. E.A. Conway, a little charity hospital in the poorest parish in Lousiana, itself the poorest state in the Union, is superior in staffing, capabilities, and access to the best public hospital in Greece.

  5. I’ve pretty much given up on trying to point out that negligable differences in non-standardized statistics that don’t even really measure the quality of the service in question aren’t a good gauge as to what we should do.

  6. Right. As if life expectency translates into good medical care. Do we average all of the inner-city young men who die violent deaths into life expectancy? How about all of those preemies who jack up the infant mortality figures? Do they also bring down the life expectency averages in a statistical double whammy?

    A lot of morbidity and mortality has nothing to do with access to medical care as anybody who has ever treated GM workers, all of whom have terrific health care but still smoke like it’s going out of style, pound down the beers, and spend their evenings eating fried food at the union hall. Those guys turn sixty and every artery turns into cement.

    Man. I have seen the same 600 pound woman five times in the last two months. She gets excellent medical care. In fact, she hogs it, sucking up enough resources to take care of a small Greek village and yet, there she is, oozing out from the bed rails, complaining about chest pain and exertional dyspnea.

  7. so why are we as a country spending so much?

    personal experience: my wife had to go to the ed once in ireland – total cost including all xrays, etc = 60 euros ($80).

    also my mother in law went to the ed with a similar complaint her fee: $2200! No CT, no MRI just a bag of saline, labs and motrin.

    Dont tell me its because we’re “paying for other peoples care” in Ireland there are just as many destitute polish day laborers and drunkards, the only difference is they might actually pay the $80 fee because it is reasonable vs. the ridiculous $2000 here.

    US healthcare is going down the toilet. Pretty soon all that will be left are ppl making money of off elective procedures (opthos, orthopods, plastic surg, derms) and everyone else will work for next to nothing. See what s hapenning to medicare now …

  8. My thought exactly, statisitics don’t define the cultures that produce the statistics.

    Stereotyping has its uses …as an Irishwoman who grew up in various countries in the Mediterranean basin with the happiest memories from a summer spent in a fishing village in Greece, I firmly believe that most people outside of the US reject the notion of keeping the 24 weeker alive, the dead trauma patient alive, etc hence the statisitics.

    Precisely the qualities of cultures where plates are smashed at weddings, funeral processions are seen in the streets, and priests keep singing while the wounded are being tended, do not allow for sense-defying, at times verging on the monstruous, tampering with the dead or dying.

    And by the way, if you’ve never been to an Irish wake, you’re missing out.

    Loud funerals are good. Maybe the only reason the Irish have them is because they hate the English and have some Greek blood.

    And if you heard how beautiful that singing was you wouldn’t care if the priests were corrupt and you’d want them humming through all your codes too, including your own.

  9. We pay a lot because we are subsidizing the highly expensive medical care that people need towards the end of their lives. That’s the point. You get what you pay for. You may not think you will ever need four heart caths and six stents but we sure as hell pay for them for people who do.

    My personal record is a patient with twelve stents and a CABGx3. These expensive procedures have probably extended his life by ten years. What’s a year worth? That’s the question. In Greece, the answer is nothing.

    Primary care is not expensive in the United States if you are willing to pay out of pocket. My internist charges $130 or so for a twenty minute appointment (but is only reimbursed 80 by medicare)which is not unreasonable or unaffordable as long as you don’t go for a cold or because your feet hurt.

  10. Gaye, you only know the tourist Greece. Most Greeks do not break plates, yell “Opa,” or live in little fishing villages. Greece is a modern European country with the good and the bad of every other materialistic, largely secular society. It is not quaint except at the edges of the Greek Islands where only a small fraction of Greeks actually live. Hell, half of them live in Athens, another quarter or so live in Chicago.

  11. Yes, well I was too young to go to weddings when I was in Greece. The plate smashing occurred regularily at the Greek weddings in London I attended in the 80’s, and there were no tourists. Just because Chicago Greeks don’t smash plates doesn’t mean London ones don’t.

    And sadly, there are no more fish in the mediterranean. Another story.

  12. dr. who –

    Access to health care clearly correlates exactly with life expectancy, which is why VA patients are so healthy. Wait…

  13. This is comparing apples to oranges.

    On one side of the pond, we have a much older and well-established homogenous population, culture, religion, and government with a concomitant healthcare system/process.

    On the other side of the pond, we have a much younger heterogeneous population, culture(s), religion(s), a republic government (NOT a democracy) with a concomitant healthcare system/process.

    Talk amongst yourselves.

  14. As you said, the quality of private health care in Greece is about just as good as the quality of private health care in the states. This is due to the flow of money, allowing for supply of whatever is demanded – basic economics. The difference between the States and Greece is that health care is not considered a right in the States, whereas it is in Greece. Sure, in the States, private care is partially subsidized by the government in certain situations. But what about the poor who have no insurance, no money, and are not assisted by any government program (of which there are many in the US)? The best shot they have in the States is to go to the emergency room to try to escape death for a few more days. Any further treatment is often too expensive in this ruthless capitalistic health care system, leaving the patient – a citizen of the US – without care. In Greece, all citizens that attempt to work have governmental health insurance. No citizen, regardless of his/her ability to pay, is left uncared for. Costs in the governmental system are also DRASTICALLY lower than those in the private US (and Greek) system across the board for the exact same procedures. Yes, the services and overall quality in the public system are not as good as those in a private system, but they get the job done for those who can’t afford the best.

    With regard to end of life issues, you are discussing a cultural, rather than economic, subject. Greeks have been around for thousands of years and have learned one or two things from their past – beliefs and culture handed down to each generation of kin. The concept of fighting death in a hospital until the patient breathes his/her last in an enclosed area within a foreign building is a very American concept. End of life in Greece is often considered natural and acceptable when weighed against a diminished quality of life or potential death away from family, friends, and home. This cultural system has allowed greater funds to be transferred to preventive care (as opposed to end of life care), resulting in longer life expectancy and greater public health. Anybody who has lived in both countries will tell you – you don’t have to look at statistics to understand the difference.

  15. The Greek public hospitals are, I repeat, of very low quality and bribery (another Greek insitution that has been honed over the last thousand years)) is a de facto requirement to get anything done. The “fakelakia” are probably not included in the health cost statistics.

    If the public hospitals are so good, why do many prosperous Greeks pay for private hospitals? I also wnat to add that I lived in Greece for many years and because a lot of cash changed hands for most transactions, it is impossible for you to say how much Greeks spend on health care. My mother pays her doctor in cash and I guarantee he doesn’t report this to the government where it will be taxed into extinction (the other price of “free” health care).

    I take exception to your characterization of our health care system as “ruthless and capitalistic.” It may have elements of capitalism in it but to characterize it as ruthless is more of the same propaganda spouted by various media organs to deflect attention from the sorry state of the Greek public health care and your economy in general. No one at any time is ever denied care for any reason, not just emergencies, in any hospital in the United States and the care they receive is indistinguishable from that recieved by the paying customers. This is a fact and it is the private money in our system that allows charity care of this extent.

    I repeat, if you think people only come to the Emergency Department at death’s door then you have never set foot in an Emergency Department. I’d say that only ten percent of the patients I see are true medical emergencies (trauma, shock, etc.). Another large chunk are serious medical problems but not immedietly life-threatening which usually result in admission. The rest are minor complaints.

    It is also no lie that even though the majority of our poor can afford beer, cigarettes, drugs, cell phones, cars, and all manner of luxury items, they will not spend a dime for medical care because they know they can present to any Emergency Department and get treated for free.

    Additionally, out of 300,000,000 Americans, if you don’t count people who can afford insurance but don’t want to buy it, the people who are eligable for government health care but opt out (i.e. too stupid of lazy to enroll), as well as illegal aliens we have about eight million hard corps uninsured, most of whom are probably unreachable by any social services and the likes of which I treat every day of my life. Not bad for a third of a billion people.

    As for preventative care, we have a diverse population from every culture and nation in the world as well as a huge dependency class bred to helplessness and stupidity by what socialism we have. If you think a little primary care is going to make a dent in the large portion of our people who don’t give two nickles for their health, well, you just don’t get out much.

    Your country is going in that direction as well. Greece today is nothing like it was even twenty years ago and you know it. With you Albanian problem, for example, I think you are starting to see some of the same kind of challenges that our country faces but which you previously did not have to worry about.

    Good luck.

  16. By the way, I lived in Greece. You have fat people over there as well as smokers. I recall an ad campaign many years ago which highlighted the epidemic of coronary artery disease.

    Maybe you remember it. There was a fat greek guy sitting at the family table eating his dinner and it looks like it’s going to be an olive oil commerical when the guy stands up, grabs his chest, and keels over. The tag line was, “O paxos micreni to zoe.” (Fat Shortens Life)

    Oh, and the one with the fat kid running. That looked like it was going to be a choclatee drink commercial.

    Additonally, Greeks do die of lung cancer, pancreatitis, diabetes, and the rest. they just don’t get treatment and the deaths go into the “natural causes” column.

    The bottom line is, as you admit, Greece spends less but gets less. This is not a difficult concept. Them little yiayias who die at home after their hips give out would get hip replacements in the states and maybe a few more years of quality life.

  17. Greeks have been around for thousands of years? I didn’t realize their health care was *that* much better!!

    Greeks are around for about the same time we are here in the States. Greek culture can trace its roots back further, but the U.S. traces our heritage back through many diverse cultures, including Greece, as does most of the Western world. Medical care that extends life so long is “progress” not some effect of us not having any history, because the Puritans were all about dying young, but we’ve kinda changed our mind since then.

  18. “Medical care that extends life so long is progress” does not always apply.

    For example, take Alzheimer’s wards. What’s that all about? If you made it a requirement
    to get a driver’s license that you pick one: (1)if you were out of your mind, didn’t recognize anyone, and were a danger to yourself, would you prefer to die at the next available opportunity, or (2)would you want to get every possible treatment to prolong your life, including antibiotics, surgery, feeding tubes, ICU stays and some 28 medications for prevention of heart attack and stroke?

    99.9999% of Americans would pick option 1. And yet option 2 goes on and on…I think the English are right on to refuse ICU stays to demented patients. This kind of “care” is not care. It is feeding Medicare dollars to hospitals, and anyone who argues it is in the patient’s interest, well, they’re misguided.

    And the boy who fell out of the tree with a GCS of 3 at 72 hours post injury. His chances, according to the best studies I could find, are something like 5 in a 1000 that he will make a “satisfactory” recovery, ie, moderately to severely disabled… The other 995 hang out in ICU wards and “rehab” wards until they die.

    And countless other futility problems. The last thing I heard that absolutely blew my mind was about some whacked-out OB researchers wanting funds to research devising a medium that 20 week olds can gestate in if born preemie…..stories like this do make me feel that something is deeply wrong..

  19. That’s why “progress” was in quotations marks – I can see it’s not always progress in the most positive sense of the word, but it is a moving forward, at least chronologically.

  20. Your expressed opinion about the quality of care for the uninsured in the US dead is wrong. Even the most vocal opponents to universal care admit to it, glossing its significance by stating the quality of the care for the uninsured is estimated at 50-60% that of paying patients. That must explain why there are twice as many hospital deaths of uninsured children in the U.S.

    Given that you have been deceptive on that point, I am very suspect of the rest of your account.

  21. Correction: “Your expressed opinion about the quality of care for the uninsured in the US is wrong.” Editing typo.

  22. Chronic diseases and complications thereof account for the bulk of both health care expense and death in the U.S. With the increased ability of early medical intervention to actually make a difference in the mortality from many chronic diseases, and given the promising research today which may soon yield treatments for the underlying causes of many of these diseases, — in that near future, wouldn’t timely intervention and early maintenance most likely succeed with a system that actually reaches the entire population?

    Since I am on the topic of utilization, I read recently that countries with universal care typically report more physician visits per capita than we do in U.S. That suggests to me there is at least the possibility of a greater preventive role of medicine, especially since predisposition to chronic disease and even early disease itself is asymptomatic. (Countries with universal care also report 50-70% lower costs per capita. That suggests that many of the problems you cite may be because they spend so much less than we do.)

    Under our current system, routine utilization of health care services by at risk groups is not very good, and I would suggest at least part of the reason is because there are still many barriers in place to the average person. As you know, in the US both doctors and hospitals “do the insurance” for patients, even though it is a contract between the patient and his insurer, not the health care provider. That is a barrier doctors usually lift from the path of patients, but it is at a steep cost, and it does not address other kinds of hurdles.

    Other barriers include: frequently changing rules, a bureaucratic patchwork of coverage, provider turnovers, high co-pays, denied service, dropped plans, and more. All these obstacles seem to me one of the main reasons for the lower utilization of basic healthcare in the U.S. I would therefore argue patchwork reform tends to worsen that problem UNLESS it really streamlines both the front-end (as well as back-end) paperwork and insures the stability of access to facilities of choice.

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