Immediately after the overthrow of the Ceauçescu regime in December 1989, European medical relief agencies discovered several hundred babies infected with AIDS in decrepit and filthy state orphanages throughout Romania. Images of the wasted bodies of infants, two and three to a crib, appeared on European and American television, arousing public outrage. Many people sent contributions, and humanitarian organizations went to Romania to try to help the AIDS orphans and to understand how such a nightmarish situation could have occurred.
In the fall of 1990, we wrote in these pages how the Ceauçescu government had ruthlessly set out to raise the country’s birth rate, and how, in doing so, it had thoroughly corrupted Romanian physicians. The many elements necessary to infect abandoned babies with AIDS came together, as in a deadly game of dominoes. In prohibiting contraception and abortion at a time when the Romanian standard of living was falling, Ceauçescu’s policy put many families under enormous financial and emotional strain; at the same time, by forcing doctors to keep all newborn babies alive, the government encouraged them to perform such bizarre practices as giving minuscule blood transfusions to under-weight babies. At the same time, the government coerced people into donating blood, refused to screen the blood supply, and did nothing to prevent the reuse of needles. All these measures led to the spread of AIDS to children in hospitals and institutions.
At the request of Jeri Laber, head of Helsinki Watch, we recently returned to Romania to investigate the current condition of the institutionalized children as well as the current state of the medical profession. Three years after the fall of Ceauçescu, we tried to find out whether the ambitious international relief efforts have had any lasting effect.
International organizations have changed conditions in Romania in a most unexpected way. Hospitals and homes for AIDS orphans and handicapped children now have both larger staffs and larger supplies of drugs and equipment than the regular day-care centers and health clinics. The attention given the children with AIDS has helped to remedy shameful conditions—but it has also created new problems.
The generous contributions that began in January 1989 have continued and the many relief groups working in Romania seem as energetic and enthusiastic as ever. The official Romanian directory of foreign humanitarian organizations working in the country is fifteen pages long and lists 170 groups. Every orphanage has a foreign sponsor, and several Romanian officials wondered whether they should establish a few more institutions so that every interested organization could adopt one. Among the organizations involved are the London-based Romanian Orphanage Trust, the Swedish Save the Children, and the French, Belgium, Luxembourg, and Switzerland chapters of Médecins sans Frontières. The World Health Organization and UNICEF are still active, along with some twenty American organizations including Project Hope, Project Concern, and Feed the Children. In addition, Princess Margaret, the daughter of Michael, the last king of Romania, has established a foundation devoted exclusively to AIDS babies.
As a result of all this activity, physical conditions in the orphanages we visited in and around Bucharest and Braçov, some two hundred miles to the north, have vastly improved. In Tatarai, where three years ago we had seen children in rags lying tethered on the bare ground, we now found them decently dressed and playing among the ramps and slides of a modern playground. In 1990, these children had desperately grabbed at us, hungry for human contact and recognition. This time they ignored us and seemed more contented. In Mures, the orphanage had the latest in physical therapy devices, and was well stocked with drugs. Almost everywhere we went, we found screened windows, comfortable beds with thick mattresses, colorful plastic dishes and utensils, stalls for showers, hot water, toilets that flushed.
While these improvements were being made, the number of children in the orphanages dropped by 50 percent. We rarely found two children to a bed, as can be the case in the intensive care units of Romania’s general hospitals. The decline partly reflects the impact of legalized abortion. Since the pill and intrauterine devices are not available or are too expensive for 99 percent of the population, abortion is the chief method of birth control. In a country with a population of 22 million, there are between 800,000 and 900,000 abortions, a year. But whatever the psychological effects of the frequent abortions, the rates of illness and mortality among Romanian women have fallen and there are far fewer abandoned children.
The decline in the numbers of children in institutions also reflects the large number of Europeans and Americans who flocked to Romania to adopt babies—more or less legally from the orphanages, and illegally directly from mothers whom they paid for their babies. By September 1991, Americans alone had adopted some 2,200 Romanian babies. (Friday afternoon flights out of Bucharest, we were told, had so many infants on board that companies making baby products were competing to distribute samples to the passengers.) Initially the adopted children came from Romanian orphanages, but when this source was exhausted, a private market in “baby trading” grew up, with infants bought directly from their families. By July 1991, so many children were being adopted that, with the cooperation of foreign governments including the United States, Romania declared a ban on private adoptions.
International organizations have also supplied child-care institutions with thousands of disposable needles, syringes, and sterilization equipment, along with an ample stock of oral antibiotics and vaccines against hepatitis B. As a result, the spread of both HIV and hepatitis B viruses has been markedly reduced. The number of new AIDS cases has dropped dramatically; the disease is now found mainly among children between the ages of one and four (1,351 of an estimated total of 1,961), most of whom were infected during the Ceauçescu years. There seems little infection among adults, but HIV testing is too limited for public health officials to be sure.
Children with AIDS are receiving exceptional medical care. In 1990 the infants we saw at Bucharest’s infectious disease hospital, Colintina, were so gaunt and wasted as to resemble concentration camp victims; one now sees plump and lively children who appear to be healthy. A team of English nurses supervises their care on cheerful wards that are decorated with bright murals and filled with toys. These nurses even arranged to open a group home for some twenty of the children on the outskirts of Bucharest. The Colintina children receive virtually every treatment now available except AZT.
But however impressive and reassuring these changes, the legacy of the Ceauçescu era is not easily overcome. The foreign nongovernmental relief organizations (NGOs) are free to do as they please. No Romanian agency oversees them, and the special interests of the sponsoring agency are apparent in each orphanage. If an NGO’s self-defined mandate is to donate equipment, the playgrounds and kitchens are exemplary. If it is dedicated to staff training, the nurses are attentive; if it has missionary aims, religious instruction has precedence. Thus in Romania, as in countries like Mozambique and Cambodia, the NGOs, for all their good works, remain apart from the government and do not share responsibility or power with local groups; as outsiders, they tend to create among the Romanian public some hostility toward themselves and toward the children they are helping.
Just as the Romanian government is incapable of controlling the agencies’ day-to-day activities, it cannot force them to meet their commitments. In 1990, teams from the French-based Architectes du Monde, modeled on Médecins du Monde, came to Bucharest to renovate old buildings and construct new ones. They promised to divide the costs of several proposed building projects, and taking the group at its word, the government, at considerable expense, began to construct a new building for children with AIDS at Colintina hospital. But Architectes du Monde never made good on its promise and the shell of a half-completed building stands forlornly on the hospital grounds.
The weakness of government supervision also means that Romanian institutions set their own policies, subject only to the wishes of the international agencies. Every orphanage we visited segregated children who were HIV-positive, and no one, so far as we could find out, protested this discrimination. The children are quarantined on their own wards and not allowed to play or eat with the others.
Several institutions are reserved exclusively for children with AIDS, such as the eighty-bed facility at Vidra, some fifteen miles outside Bucharest. Thanks to the financial and technical help from several European organizations, the institution is well maintained and the director, an energetic pediatrician, seemed deeply committed to the welfare of her charges; during our conversations, the children raced in and out of her office, where they were given candy and cookies. But the pernicious influence of a segregated system is beginning to be felt. Many of the children at Vidra are reaching school age, and the director is struggling to get them enrolled in the local schools. The townspeople, who had always been uneasy about the presence of an AIDS center, want them kept out. In Vidra, as elsewhere, it is far easier to segregate children who bear a stigma. These children are likely to remain completely isolated during their brief lives.
Moreover, the de facto rule of the NGOs makes life easy for medical adventurers. In 1992, David Hughes, a sixty-one-year-old Scottish inventor and researcher (with a doctorate in “hyperbaric physiology” from the University of Grenoble), arrived at Colintina Hospital and easily persuaded its director and its staff to let him test his new cure for AIDS on their children. His drug proved worthless and, luckily, harmless. But such casual experiments on children reveal just how vulnerable the system is to abuse.1
When we saw Dr. André Combiescu, head of Bucharest’s most respected medical research and pharmaceutical production institute, he told us how relieved he is not to be bartering cigarettes for xerox copies of medical journal articles and how pleased he is to be sending his best graduate students abroad. Students feel they are now part of an international community of researchers.
Some attempts are also being made to give medicine a much needed sense of professional ethics. A recently enacted governmental decree on the “Basic Principles of the Status of the Profession”2 declared that “the physician is not a public functionary,” that he has “total professional independence in the interests of the patient’s health.” (In fact, much of the document’s language is lifted almost verbatim from the Helsinki Watch report that we, with Holly Cartner, wrote after our first visit.)
The decree demonstrates that some Romanian physicians are listening to outside criticism, but it does not provide for enforcing the goals of its highflown language. Romanian medical societies remain weak and disorganized and many doctors are incompetent. Professors of medicine from abroad are often amazed at the ignorance and lack of training of local doctors, including those at the university medical hospitals. We also heard numerous stories about corruption and greed among physicians. Private practice is still outlawed, and official salaries remain very low (below the level of municipal workers). Doctors, particularly specialists like surgeons, insist that prospective patients pay them under the table, in money or in goods. Patients who can’t pay find that they are ignored.
People often told us that doctors want to be free from state control not to gain autonomy as professionals but for the larger rewards of private practice. Physicians frequently told us that once patients paid them directly, medicine would become more honorable, efficient, and effective. When we suggested that the fee-for-service system in the US was often inequitable and ineffective, they did not want to hear about it.
Thanks to international medical and humanitarian agencies, many of the children that Ceauçescu most despised are favored, indeed privileged. As might be expected, the change has produced public resentment. When we traveled about the country, our interpreter, a Bucharest doctor, was at first amazed and then became increasingly angry when she found that drugs were in larger supply and more up-to-date than at her clinic. The staff members were more alert than those working with her own children in public school. So too, other physicians were dismayed by the differences between the wards for AIDS children and the wards for adults with non-fatal diseases at Colintina Hospital. To walk the hundred yards separating them was to go from first-class medicine to third.
Such objections are predictable, but not persuasive. The charitable funds now supporting children with AIDS almost certainly would not have gone to “normal” Romanian children. Moreover the desperate plight of the powerless orphaned children with AIDS or handicaps justifies all the outside help they have been given. Because the new initiatives reflect the policies of outside groups, however, and not a Romanian consensus, they risk being reversed. And what will happen when European and American organizations eventually leave Romania? Will the country be capable of manufacturing its own needles, syringes, antibiotics, and condoms? Will it be able to adequately promote health and social welfare? Indeed will it pay any attention at all to its most handicapped citizens?
Surprisingly, there are some grounds for optimism. Probably the most promising is the World Bank’s recent decision to give Romania a $150 million loan over fifteen years to reorganize its health-care system. In recognizing health care as part of the country’s fundamental economic needs, the Bank’s experts proved informed and perceptive. They have allocated funds for medical equipment and supplies to rural, maternal, and child health-care clinics, and for training programs for physicians and nurses. The bank is also seeking to reorganize the Romanian pharmaceutical industry so as to ensure an adequate supply of drugs and vaccines. (Dr. Combiescu hopes that World Bank support will enable his institute to manufacture products not only for his own country but for export through Eastern Europe.) Finally, the Bank is underwriting the planning for a new, decentralized, health-care system that will be more responsive to the patient, and more competitive. Romania is not the only country in which the World Bank has invested in health care, but it is doubtful that it would have made so large a commitment without the AIDS scandal.
Romania’s deep political and economic problems, however, remain acute. The main political factions derive from the old Communist bureaucracy. The more “conservative” party of Ion Iliescu is still in power. He has not curtailed public debate or censored the daily press, but he tightly controls radio and television, and refuses to permit any criticism of his party to be broadcast. The more “liberal” opposition leader, Petre Roman, claims he would more quickly privatize state-owned property but the economic experts we talked to doubted he had effective plans for doing so. There is little prospect that the other main contender for power, King Michael, who calls for a grand coalition of all parties, will ever be restored to the throne.
The prospects for economic recovery do not seem promising, since foreign companies are reluctant to invest in improving Romania’s broken-down transportation system and utilities, or in financing new factories. But the Romanian industrial workers have not so far turned against the government. They frequently threaten strikes and then postpone them, although were the standard of living to deteriorate further, they could well take more drastic action. Whether the Romanians, Hungarians, and gypsies who make up the country’s three largest ethnic groups will be willing to coexist peaceably remains a central and unresolved question.
Still, the atmosphere in Romania is dramatically changed since 1990. Privatization has put money in some people’s hands, and Bucharest now has shops, cafés, and restaurants with plenty of customers, while the lines in front of food stores are much shorter. It is true that disparities in income have become greater than ever and that those living on salaries or fixed incomes are worse off than before. But on our previous visit we had found a mood of unrelieved depression; this time many people told us that, at least, opportunities to set up new businesses were gradually opening up.
In one of the hospitals we visited, we met with a physician in her early fifties who talked about what it had been like to grow up under Nazi rule and then spend most of her adult life under the Ceauçescus. She told us in detail how heavy the hand of the state had been, and how physicians had willingly followed medically dangerous regulations without doing anything to protect their patients. She was ashamed of her own part in the system that had transmitted AIDS to babies in her hospital. Then in 1990, she saw, miraculously, the children coming back to life, thanks to foreign food, drugs, and clothing, and to the many nurses who had come from abroad to treat them. But the HIV virus would soon take its toll: within a few years, all of children will be dead. That much was certain. What remained uncertain was whether the country itself could ecape a large-scale disaster.
Nature, Vol. 347 (1990), p. 606. Hughes also managed to carry out an earlier AIDS trial in Lolongwe, the capital of Malawi.↩
Viata Medicala, May 13, 1992, reprinted the decree as promulgated on April 30, 1992.↩