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DR AQUARIUS AND THE GYPSIES

Macedonia

Saints are always good for a holiday. A couple of weeks ago it was Saint George and, now, in the middle of a Balkan summer, it’s Saint Nicholas who really ought to be celebrated at Christmas. But who cares if they want to honour him twice? It’s an excuse for a party and the fact that I’m working all weekend is no obstacle. Not in Macedonia, not among the doctors and nurses and drivers of Skopje 194.

Along the potholed road into the city, looking out from the peeled tinting of the side window, I catch glimpses of grubby youths half-heartedly kicking footballs in overgrown parks under the bleak housing blocks where they live. None of them waves at the ambulance as kids always do back home, hoping for a blast from our siren. On benches, watching them play, stumpy old men sit with motionless wives, saying nothing. At a corner where we pause for a red light a little boy sells eggs from a tray. A gypsy girl does a half-hearted tap dance in front of cars and someone throws her a coin. Homeless dogs scratch themselves in the heat. At a nearby kiosk with torn beach umbrellas outside, a row of bicycles lean against a sun-cracked wall. Behind that, the spire of a mosque rises between apartment blocks where laundry flaps from narrow windows. Here the best suburbs can look like decrepit public housing estates. Like my parents’ photographs from their European travels in the 1970s, everything seems faded and bathed in a vinegary orange light, as if one is moving through an era long passed.

Skopje is littered with the evidence of better times. This city was a base for Alexander the Great, the birthplace of Mother Teresa, the place made beautiful in the Byzantine era and under the Ottomans. It was still beautiful on the day before the earthquake of 1963 when 90 per cent of the city was flattened. Rebuilt by Yugoslavs with a concrete obsession, Skopje became something else and then, when communist rule ended between 1990 and 1992 (and Yugoslavia broke up with Macedonia claiming independence in 1991), the money for public works dried up. Once grand fountains ceased their squirting but still remain as concrete eyesores in every empty plaza. City gardens are knee-high in grass and weeds, pavements are fractured or caved in completely and a whimsical Socialist-era fun park on the edge of town has not changed in forty years. As for the Macedonian dress sense, everyone appears to be clothed in drab and mismatched garments they have quite conceivably selected from suburban charity shops while blindfolded.

Three months earlier in Sydney, my paramedic partner and I were called to a woman originally from Macedonia now living in a small flat crammed with imposing floral lounges, a woman who felt the need to phone our emergency ambulance for what she described as a ‘burning tongue’. There is, of course, no documented protocol for such a complaint, but as far as we could gather her tongue was not alight, nor did it look particularly red or swollen or suffering the effects of hot curry or chilli pepper or any other such thing. What we did observe about her, however, was a level of nervous tension that commonly precedes inexplicable symptoms like this and is more often related to mental rather than physical origins.

As a lover of Balkan music I knew a little about the Roma gypsies residing in Eastern Europe, many in the small country of Macedonia, a country of just two million people, landlocked by Greece, Bulgaria, Serbia and Albania. What I didn’t know was that Macedonia is also host to the largest community of gypsies in the world, most of them living in a ghetto – or maalo – known as Shutka.

After the burning tongue I got to thinking about where on earth it might be appropriate to call ambulances for such a complaint. And although people call for some pretty interesting things just about everywhere, my mind persistently returned to Macedonia. Eager to explore not only the blood-and-guts of my industry but the varying cultural peculiarities that affect it, I booked a ticket.

There are two reasons why Macedonian ambulances are always snug in the front seat. Firstly, both doctor and nurse sit beside the driver. That’s three in a row. Secondly, most medics at Skopje 194 have a considerable girth, for which the Macedonian diet is clearly to blame. Here, a meal without yellow cheese is considered inedible, even fresh salad is topped with it. Nevertheless, winters in Skopje can be nasty and the cuddly warmth of a colleague is always welcome.

While all the drivers are male, most of the doctors and nurses are not. Unlike many ambulance services that struggle to attract female recruits, in Macedonia ladies run the entire show. Dr Maja Poposka, the surprisingly young and attractive director of the service is fond of black power suits and high heels, and is a stark contrast to the legion of women she commands who mostly have the attitude and build of lady prison guards. Even in their white scrubs, wooden clogs and dainty black doctor bags, these women could suffocate the toughest male paramedic in their fathomless bosoms. They bark at their patients in voices deepened by Marlboro Reds and give every physical indication that they mean business.

For the weekend of the 2010 Saint Nicholas holiday I have submitted to being the plaything of a lively lady doctor with a black beehive and cherry-red lipstick. She is known simply as Dr Aquarius and she calls me Benja. Dr Aquarius is assisted by a nurse named Snezhana Spazovska who has several sparkling diamantes set in her front teeth and painted fingernails so long she needs five precious minutes to get them into latex gloves. Sammy Rudovski is our driver, has been around a decade or two, and knows the drill. Generally he keeps quiet. Like all the ambulance drivers he is permitted to wear casual clothes, and on this festival night is decked out in a three-piece denim suit. None of them is happy about being on shift while the rest of the country is celebrating.

Like the sound of witches round a cauldron, regular cackles of laughter emanate from the front cabin. The witch analogy is not about evil spells, but rather the wicked sense of humour they share with ambulance workers worldwide.

Just over the river, in the shade of the ancient Kale Fort, we pull up and Dr Aquarius slides back the perspex peep window.

‘Benja, we have a heart problems!’ she shouts.

I appreciate her informing me, as the usual indication I get that we have been given a job is when the ambulance suddenly careens into oncoming traffic with the cry of a siren, throwing me off my seat. Riding in the back like a pet dog is not my idea of a good time. There are few windows and it’s hot, stuffy and claustrophobic.

After a few minutes we move back and forth between apartment buildings; down the driveway of one, reversing up again, going around in circles. Most blocks are identical to one another and confusion is common. When we finally find the address Sammy has picked it by little more than a tiny number scrawled on a wall in white chalk.

Dr Aquarius leads the ascent up a graffiti-sprayed stairwell to the eighth floor carrying her little black doctor’s bag containing a blood pressure cuff, stethoscope, her leopard-skin purse and cigarettes. When I see her do this I lament the many backbreaking years I have lugged every box and piece of equipment to top floor apartments without cause.

By the time we reach the fifth level with three to go, nurse Spazovska is gasping loudly behind me. Like a commando in the jungle, Dr Aquarius motions with her hand for us to stop. We pause a little for Spazovska to catch her breath, and she’s no picture of health. Her heart and lungs are shot by years of relentless fagging, her arteries clogged with Macedonian cheese. Needless to say, performing this job on a regular basis in a city of apartment blocks without elevators ought to keep her in better shape.

By the time we reach the patient’s door, Snezhana Spazovska seems close to respiratory arrest. Our patient, on the other hand, is calmly sipping a cup of tea. There must have been a mix-up, he says. He made it very clear to the call-taker that what he had done was slam his finger in a door. There’s no question that slamming a finger in a door is painful, but calling an emergency doctor and nurse to apply an ice pack hardly seems reasonable.

It surprises me this one has slipped past the control room at Budapest Hospital. When I sat with them a week ago I’d become convinced that only the meanest nurses were assigned to work there. Every second emergency call received would have them abusing the caller for not being sick or injured enough to warrant an ambulance. Phones were continuously slammed down in the ears of helpless victims as services were refused outright.

Nurse Spazovska is pale and sweaty and can barely speak. She leans over the patient’s glass coffee table while Dr Aquarius – who no doubt has seen this all before – rubs her back. Just for a moment I wonder whether I’m witnessing some drama created to give the man with his bruised finger a demonstration of what a real sick person looks like.

‘I … my … is … tachycardia,’ Spazovska splutters.

It’s bad news when someone with shortness of breath speaks like this, catching air between each word.

Her heart is doing double-time when I take her pulse, convincing me she’s genuine enough. Meanwhile the guy with the finger looks on with confusion. Despite our offers, Spazovska refuses medication and we patiently wait ten minutes for her to regain her composure. A recovery of sorts is made but it’s no way to be starting a night shift.

Macedonia is a guarded nation with a great suspicion of outsiders and not many places have had me feeling more like a foreign agent than Skopje. No one gives much away here. Few people are open or candid. Faces are stony, scrutinising you with narrowed eyes. This is understandable considering the country’s communist history, not to mention that ‘a writer is something of a spy’ as Graham Greene once wrote in Stamboul Train. Thanks to a shared block of Schogetten Stracciatella chocolate, the ambulance team now considers me a true colleague and that respect is unreserved.

Zoran Kostovski, the Australian Honorary Consul in Skopje, is a man with incredible personal energy and vibrant enthusiasm. He is also connected at every level of government thanks to the success of his private company, Motiva, which he started after reading Body Language by Australian author Allan Pease. The objective of Motiva is to provide its clients with training in superior communication techniques – particularly of the non-verbal variety – and it is through his delivery of these workshops to politicians that Zoran has not only befriended Nikola Gruevski, Macedonia’s current prime minister but, to my great fortune, the current health minister, Dr Bujar Osmani.

When I first shared a bottle of Macedonian wine with Zoran he revealed there were only ever ten or fifteen Australians with no family connection to Macedonia visiting the country at any one time and that despite this minuscule number, they managed to keep him busy round the clock. This may have sounded like a complaint had Zoran not reassured me that he thoroughly enjoyed the entertainment his position afforded him. There was a poet who fell off his chair and fractured his hip. ‘Dangerous work, poetry,’ he said. Not long after, he was called to the police station for a female with schizophrenia found wandering the streets of Skopje in a state of undress. She had run out of medication while on holiday. Then there was the man who got so depressed after arriving in the drab city he promptly threw himself out of the second-storey window of his hotel. As anyone in ambulance work knows, the second storey is a half-arsed attempt at suicide. Once, I tell Zoran, I went to a man threatening to jump off the first level of a high-rise parking station. Ridiculous. Most interesting of all, says Zoran, was the man from Melbourne who arrived in Skopje at the time of the Victorian bushfires wearing little more than shorts and a T-shirt, carrying a handful of possessions in a small plastic bag. Apparently he wanted to get as far away from the fire as he could.

My request to meet the health minister, in order to acquire permission to join ambulance crews in Skopje, was a comparatively easy one, Zoran assures me. ‘And he’s an outstanding guy, in the toughest job, trying to do his best to bring reform.’

Indeed, on the day I’m meant to meet Dr Osmani, the front page of every newspaper shows hospital doctors walking off the job in protest at their low wages. In Macedonia, public hospital doctors earn little more than 400 euros a month, while nurses get 350 euros. Because the average rent is around 150 euros and electricity in the winter another 100 euros on top of that, most in the medical profession cannot even afford to visit a restaurant or have a drink in a bar. The wages are so low that over time it has become common practice to ask patients for money. Jumping the queue for surgery is achieved with cash alone and those without it may wait for a decade. The poor have enough trouble getting a prescription.

There is probably never a good time for an Australian paramedic to take tea with the health minister of a country burdened by such challenges. Nevertheless, I was invited to do so by Zoran and we sat in the very pleasant company of a softly spoken Osmani as he elaborated on his work.

Most significantly, his effort to stop kickbacks in the form of over-supplied medical materials to hospitals has put many of his public hospital doctors offside. At a Holiday Inn conference in 2008, Zoran introduced Dr Osmani to a patient classification software developed by Australia that keeps track of hospital resources and is known as the Australian Refined Diagnosis Related Groups (AR-DRG) system. Many countries suffering the effects of health service corruption have installed this program with enormous success, including Saudi Arabia, Greece and Romania. On behalf of the prime minister, Zoran negotiated the purchase of the AR-DRG software by Macedonia for a very modest price. Two years later it is ‘still in the process’ of being installed. Across Macedonia, hospital heads have made every effort to block its introduction, revealing just how many people are dependent on medical supplies kickbacks to supplement their incomes. As effective as the AR-DRG system may be, it does not address this root cause of corruption.

As for my placement on ambulances of Skopje, Dr Osmani has no objection and simply warns me not to injure myself. He is unconcerned I might pen something critical about the Macedonian health system. ‘It wouldn’t be news,’ he says. ‘Everyone knows the country is poor. Why should we pretend it to be otherwise?’

At a roadside kiosk Dr Aquarius buys us bottles of Pimp Juice, a local soft drink we sip through straws on the way to the next job. Earlier in the week I saw a billboard for the beverage depicting a smiling gangster with gold teeth. This is what many of the young men look like in Shutka, the capital of gypsies, and I wonder if it’s bottled there.

For my benefit Sammy takes the ambulance past the house of Esma Redzepova, known globally as the Gypsy Queen, a singer whose remarkable voice carries the collective emotions of the Roma, and whose music I have followed for some time. In opposition to those who react angrily to being labelled a gypsy, Redzepova encourages the Roma to be proud of the term and has always used the earnings from her record sales to distribute free medicine to the poor.

A little further on, near Topaana, one of the earliest gypsy maalos, stands the ominous new American embassy. Rumour has it this is not just any embassy. The complex is so vast one would need an hour to walk around it. Much to the dismay of Topaana gypsies it has also taken up every inch of what was once the beloved city park they used for weddings and picnics, forcing them onto a small, cramped traffic island in the embassy’s shadow.

Just off the Krimska Road, a family of rotund Macedonians has had a fierce argument during which the father has shattered a framed photograph of his wife and stormed from the house leaving her and his three adult children in a state of hysteria. The two daughters, both in their mid-thirties, are howling uncontrollably on the lounge while a younger man, probably in his late twenties, kneels at his mother’s feet sobbing. One would think the woman’s husband had passed away, but he has only gone to the pub. Were it not for the fact we attend jobs like this every day in Skopje I would not be so cynical. Nor would I be wondering why so many simple disagreements in this country result in group hyperventilation or all-out brawls.

Dr Aquarius tries to calm the lady, gives it about a minute or so, looks at her watch, then twitches an over-plucked eyebrow at nurse Spazovska and rolls up the sleeves of her lab coat. Spazovska knows the drill and opens a black briefcase she has taken into the house. In it are rows of glittering glass ampoules tinkling like little wind chimes whenever she handles them. It’s pretty much all the nurses ever carry, the drugs – the first line of emergency care in Macedonia. The only other items apart from medications are cotton balls for swabbing, needles and saline, and a bunch of thin candles to light for the dead. With nimble fingers Spazovska removes an ampoule of Valium 10 milligrams, snaps its neck, draws it up and hands it to Dr Aquarius.

Seconds after stabbing it in, without further ado, we are out the door.

Valium, valium, valium. Half the briefcase is full of the stuff. At a guess there’d be at least twenty ampoules in there and even that is not enough some nights. Morphine supplies may be out of stock, while some doctors buy aspirin for heart patients with their own money. But the Valium never dries up. This surprises me as the drug is dispensed like candy. So popular is Valium in this city that it is common for ambulance crews to administer ‘one for the patient and one for the relative’. Balkan funerals are the worst. At these there can be fifty, even a hundred, distressed mourners demanding a shot.

Our next job – or ‘invitation’ as the medics endearingly call them – is to a woman with high blood pressure and a headache. Again, along with a prescription for Monopril and a beta-blocker comes intramuscular Valium.

‘We take the Pimp Juice, they take the Valium,’ laughs Dr Aquarius afterwards. ‘That is how the world goes round!’

An hour later everyone is thrilled to have discovered an apartment block with an elevator, none happier than our smoking asthmatic nurse. On the top floor a man has been vomiting for a week. Exciting stuff, I think to myself.

The apartment is painted a deep red and decorated with kitsch throne-like furniture more suited to a medieval castle than a tiny bachelor pad. Gold candelabras rest on a narrow black table in the centre of the room along with a giant porcelain tiger and a vase of plastic irises. Macedonians have less money now than they did in the communist era yet give the impression they are enjoying the spoils of capitalism. All over former Yugoslavia one can find this same quasi-bourgeois aesthetic. If you want to know how a two-dollar shop can make you look rich, just ask a Macedonian.

When Snezhana Spazovska removes a hideous oil painting of a teary-eyed clown from above the lounge where our patient is lying I am momentarily relieved. Unfortunately she has not taken it down to improve the appearance of the man’s apartment but to hang an IV drip on the hook in its place.

The moment she has done this, we leave.

Not one of the three jobs we have knocked over before sundown has had us on scene for more than five minutes and not one patient has been transported to hospital. Only yesterday, a Skopje steelworks employee with a bleeding nose, a case I would normally spend ten minutes or so treating with manual pressure alone, was handled completely differently. Pharmacology was the mainstay and the patient was fixed in half the time. There were jabs of Valium and Frusemide and a cotton ball soaked in adrenalin shoved up the nostril. Again less than five minutes on scene and no transport. Although it could be argued that a certain thoroughness and continuum of care may be lacking here, the Franco-German model of pre-hospital intervention is so far proving highly efficient. In most other countries where I’ve worked, all these patients would by now be clogging up emergency departments. As for the man with vomiting and dehydration lying there on his over-ornate lounge with a drip in his arm, what happens when the solution has run through?

‘We give instruction on how to remove it,’ says Spazovska, ‘How to stop his vein from bleeding. We explain him procedure, don’t worry.’

To a paramedic from a system without physicians such a practice seems daring. Not every patient is bright enough or possessed of the nerves to remove their own cannula and stem a bleed. But these, it seems, are considered worthwhile risks to save a tenuous hospital system from being overburdened.

Our assigned station for the night lies in the somewhat forlorn suburb of Chaiar, not far from Shutka. After a couple of home visits in the Albanian quarter issuing Tramadol to cancer patients, our driver, Sammy, passes the house of Johann the Killer, the commander of a police unit responsible for war crimes against an Albanian village and currently awaiting trial in The Hague. It’s a purple and mauve monstrosity hung with wagon wheels and cowboy paraphernalia, complete with a ten-foot medieval gate. Sammy is also Albanian and finds it incredible the house remains untouched. As we head to Chaiar he tells me how last month a patient refused to get into an ambulance driven by an Albanian and subsequently threatened the crew with a steak knife.

Ethnic tensions run deep in Macedonia. My friends here, even the young and university educated, frequently shock me with their overt racism towards Albanian Muslims. No one even bothers beginning with the customary ‘I’m not racist, but …’ preface as racists in Australia often do. Perhaps this tension is understandable when the last skirmish of gunfire exchanged between Macedonian forces and Albanian insurgents occurred as recently as 2001. And it is only since 2007 that Macedonians dare to walk through the Old City dominated by mosques and ancient bath-houses separated by the worn cobble streets winding to a Turkish bazaar.

Then there is the issue of Vodno, the steep mountain high above Skopje where Macedonians have installed the Millennium Cross, the largest crucifix in the world, sixty-six metres tall. Without a hint of shame my friends admit the cross was placed as a mark of territory rather than a symbol of Christ’s grace and tolerance; ethnic Albanians should be constantly reminded who the rightful owners of the city are. Even by night, from the window of the ambulance when everything is black, the cross on Vodno hovers, brightly lit and imposing against the night sky. It may be a thing of beauty but for me it’s a beauty tainted by the country’s godless divisiveness.

At Chaiar Station, a sweet Albanian nurse with near-perfect English is manning the radio and scissoring small squares of gauze from a giant sheet for sterilisation. Her name is Drenusha Arneri and in our earlier conversations she admitted it took her a year to feel accepted by her colleagues. Now, despite being a Muslim, she celebrates Easter with them, helps colour eggs at the ambulance station and even brings along a plate of homemade baklava. Under Dr Maja Poposka the service has come a long way in creating a positive environment. Whenever she can spare one, Poposka even sends an ambulance to Mecca with a team of Albanian medics onboard to help out.

For Dr Maja Poposka nature helps her deal with stress and that is why in the middle of her office at Bucharest Hospital she keeps a giant indoor tree growing in a pot with branches reaching out around the room and leaning like a friend across her desk. By all appearances this chain-smoking doctor is more Russian supermodel than ambulance service director. Before taking up her position two years ago she had already worked fifteen years on ambulances in Skopje, roughly the same time I have worked on them in Australia.

‘Everything I have seen,’ she says matter-of-factly.

We begin a discussion on the improvements made to Macedonia’s ambulances since she became director. New ambulances donated from around Europe, white uniforms for the medical staff, better training and equipment. It is hard to believe, but up until 2006 none of Skopje’s ambulances had defibrillators on board. Response times were notoriously dismal and the ambulance doctors had a countrywide reputation for being mean and rude.

To some extent, from my random canvassing of locals I have met here, public perception of Skopje 194 is still rather poor. At a taxi stand in town not a single driver could recite the emergency number and an informal survey I conducted at a Bob Marley tribute party in a city park revealed the widespread opinion that ambulances still take forever to arrive and are staffed by ‘bitches’ anyway. Neither of these perceptions is at all fair, as I’ve discovered first hand, and I ask Dr Poposka why the service has not done a better job of public relations since she took office.

‘Problem is we cannot advertise our improvements,’ she replies. ‘It is better for us to go about our work quietly and rely on word of mouth. You see, we are still under-resourced and only just manage to meet the eight minutes response time standard for 90 per cent of top priority cases. What will happen if we tell the world how good we are now, how quick and polite and professional we have become?’

It’s true that public ambulance services do not generally benefit from advertising. The better a service looks the more people will call, leading to a higher demand that will negatively impact on response times. The only publicity campaigns an ambulance service should probably entertain are those that concern prevention and discourage calling for inappropriate reasons. This is a vastly more difficult campaign for a service with general practitioners on every ambulance and a public that knows it.

Maja Poposka’s frustrations working on the road prompted her to apply for the top job when the former boss retired. Four old Russian-built Lada station wagons are still parked in the basement of the ambulance headquarters, cobwebbed and rusty. Only a few years ago they were all the city had.

‘You can imagine our reputation, driving around Skopje in these things,’ said Dr Poposka when she took me to see them. ‘We were always late and even then we couldn’t do much for the really sick ones. See, look how low the roof is. None of us ever did CPR in these cars, impossible.’

‘So what did you do in cardiac arrests?’

‘Drive fast.’

Hearing this I understand completely her reasons for leading the service. Watching people die from a lack of space would be maddening for any ambulance worker, let alone a medical doctor.

Behind her office lies a larger ambulance graveyard containing numerous donated vehicles from around Europe, all hand-me-downs still bearing the logos of their former masters. Here I saw a Johanniter Mercedes from the Germans, a 118 van from Rome and a French Renault from the SAMU. Up until recently Skopje 194 used these vehicles as they were. On any one day it was common to see ambulances from various European nations all screaming through Skopje at the same time. This reminded me of a friend who had visited Fiji and happened upon the same ambulance he had driven around Sydney for years being used there since its donation to the country a year earlier.

Chaiar Station is little more than a few cold rooms in the wing of a small clinic, lit by a tiny television with bad reception that everyone put in for. Few want to miss the Macedonian version of Wheel of Fortune known here as Wheel of Happiness. For those who know that money does not guarantee happiness, the game show is followed by an addictive Turkish soap opera. As we settle in to watch the next episode of Yabanci Damat, Drenousha helps us get into the spirit of things by serving Turkish coffee.

Ambulance stations of Macedonia become drop-in medical centres after hours and on the weekends. So an additional doctor is always on duty at night and has a separate consultation room. For the festival night of Saint Nicholas, Dr Save Bobonovski is on shift, his first name ensuring great popularity among his patients. At one time he also worked on the ambulances, but that was ten years ago and he quit after attending a nasty accident at Alexander the Great Airport. On 5 March 1993, eighty-three people died when flight crew forgot to de-ice a Macedonian Airlines Fokker prior to departure and it crashed seconds after take-off. Save was first on the scene. As he tells it, bodies and body parts were scattered as far as the eye could see. He decided soon after he was more suited to working indoors.

A second crew comes by on their way to a chest pain and picks up an ECG machine. At present there are not enough to go round and Chaiar ambulances have to share a single ancient Hellige box with its little rubber suckers and wide leather straps that bind to wrists and ankles and around the chest. It must hark from the 1960s or thereabouts and looks more KGB than ECG. We’ve used it plenty of times, and vintage though the Hellige may be, it is still a functional 12-lead cardiograph.

Dr Aquarius scoffs. ‘Our government doesn’t have money for new ECG machines, but they sure have it for bronze lions in public squares. Have you ever seen a bronze lion save a life?’