Saturday, June 2, 2007

St. George peak at 1762 meters on the Biokovo Mountain

MPH students at the Dalmation dinner overlooking the Adriatic Sea and the mountains
Hvartown, Hvar
Dubrovnik, Croatia: The wall that dates back to the 15th century overlooking the Adriatic Sea
Harbor in Dubrovnik, Croatia with the old wall in the background
The day after our visit to Bosnia, we took 3 minivans up the Biokova mountain to the peak of St. George. In about 45 minutes, we went from sea level to the peak at 5900 feet, which is the third highest point in Croatia. For those of you from Georgia, Brasstown Bald is about 4700 feet and is located in the mountains, so going from the base to the top is not as quick of an ascent because the base is higher than sea level. We didn´t have the opportunity to get out of the minivans and hike to the top due to inclement weather, but were able to drive to the top and the view from there while shivering in the frigid rain was pretty incredible. The ride to the top was almost as impressionable as the road was a single lane and took some very sharp curves with cliffs just beyond the pavement. Some of these curves required 2 and 3 point turns to get around. Needless to say all of our heart rates were severely elevated during the ride, but the driver was very skilled and maneuvered the roads effortlessly. This mountain has no inhabitants because it has no water or electricity, and the roads are impassable in the winter. However, this area is a popular location for summer homes, which dot the green, rolling hillsides. The bura that are native to the area can pack winds up to 280 km/hour, which can be very dangerous for anyone driving along the narrow roads during the bura. Another health hazard is the large amount of tourists driving along the treacherous roads and having to back up along the way to allow cars to pass in the road. The local guides would like to have nothing but vans allowed on the mountain but have been unsuccessful thus far in accomplishing this. They do have a handicap accessible van that allows individuals with disabilities the opportunity to ride up the mountain.
On Thursday, we took a ferry to Hvar, and I must say that watching a massive 60 passenger bus load the ferry was one of the highlights of the day! The ferry ride was beautiful as we were able to take in the sights of all the coastal villages with the beautiful aquamarine Adriatic Sea in the foreground and the lush green mountains in the background. Once on the island of Hvar, we bussed 62 km from one end to the other. The island doesn´t have its own water supply and has a pipeline from the mainland that supplies all of its water needs. Amazingly this pipleline wasn´t installed until 1987, so they used cisterns before then to collect water. Because of their water situation, fires along the sparsely populated farms is quite frequent, and we were able to see some of the fire-ravaged destruction. Another problem that stems from having to pump water to the island is the shortage that they often experience during the summer months due to the massive influx of tourists. Sometimes during summer months they have to limit showers to conserve water. They do have a sewage treatment plant on the island, so they are able to properly dispose of all the water that is used on the island. Minor medical care can be attended to on the island but severe cases must be flown by helicopter to Split or Zagreb. During the summer months tourists flood the harbor town of Hvartown, and if lucky one may even have a celebrity spotting as many U.S. celebrities have discovered the luxurious views and beautiful sea found on the island.

On Saturday we took a bus to Dubrovnik and were able to walk around the walled city that has buildings that date back to the 9th century. In the old part of town, we were able to walk on top of the wall that dates back to the 15th century and take in magnificent views of the sea and the city. As we have noticed in other tourist hot spots in Croatia, there are certain health issues that could be hazardous to tourists. The worn cobblestones that line the street are very slippery and uneven, which makes traversing the city for the elderly or disabled a difficult trek. There also is little accomodation for persons with disabilities as we saw very few ramps or elevators. As is the case in other coastal areas in Croatia overcrowding during the summer months is a major health hazard and Dubrovnik has to have traffic patrols to direct foot traffic through the narrow streets in the old town. Another observation regarding the safety of tourists is the lack of guard rails in areas overlooking the sea some 100 feet below. However public health was an important issue to the historical inhabitants of Dubrovnik, where they made any visitors into the city stay in a quarantine house for 40 days to make sure they weren´t diseased before they could be allowed to enter the city. They also had government regulations against throwing out trash in the streets and other acts to prevent the spread of disease. Dubrovnik is the home of the first pharmacy in all of Croatia.
This was our last excursion as a study abroad, except for the lengthy trek back to the U.S., and we hope you have enjoyed reading about our experiences in Croatia. We have had a wonderful time being immersed into their culture and appreciate their hospitality. This has been an incredible learning experience that a textbook could not describe. We will post more of our pictures soon, so stay tuned!

Friday, June 1, 2007

Pictures in Mostar and Split

Mostar, Bosnia
The Beautiful hills of Mostar, Bosnia

rebuilding is in progress

Split, Croatia: Diocletian´s Palace in the center

Mostar, Bosnia

Dalmatian towns and Mostar, Bosnia

After a restful first few days in Makarska, we started exploring the coast. First, we hiked up the Biokovo mountain that lies behind Makarska and visited some village towns. We got a chance to see the mountain culture up there and took note of the herbs, berries and flowers that grow everywhere. The smells we experienced while hiking were incredible. We sampled fresh berries right off the tree and tasted dried figs and herb tea.

The next days we went to Trogir, which is the most intact medieval town on the eastern Adriatic coast. The combination of old and new leads to some problems with sewage disposal and moisture in the buildings, which becomes trapped in the porous limestone. This could become a potential problem for infectious diseases and mold related health problems. The city itself is beautiful, and resembles Venice, since much of it was built by the Venetians when they had control of the city for 400 years in the middle ages. The next day we visited Solin and Split and toured the ancient ruins on the hilltop above Split, and then Diocletian's palace in the center of town. Diocletian was a Roman emperor who built his summer palace in Split. After he died, Solin, the town on the hilltop, fell to the Avars and the refugees built a new town inside the walls of the palace. They stored their trash and sewage (the porous limestone rocks that the foundation was built on seemed to serve as a sort of giant septic tank that filtered the water into the basement where it flowed back into the sea) in the basement, which actually led to it being the most perfectly preserved part of the palace. The villagers used stones from the palace to build the new homes, but did not take any from the basement because it was so filthy. Today the basement is an intact example of the architecture and engineering of the Roman time period. Some of the public health issues that would have been experienced during this time were sanitation, infectious disease (since the people were living so close together inside the palace), sewage disposal and clean water. One of the most interesting facts of the day was that the city of Split still gets 1/3 of its water from the ancient Roman aqueducts! These aqueducts were crucial to the people of this time period, and allowed the town to flourish.

The next day we visited Mostar and Stolac, both in Bosnia. The other graduate students and I were just children or young teenagers when the Bosnian conflict was happening, so we were excited to learn more about this war that occured in our lifetime. Mostar was an important city for this war, as it was the place where the Croat-Muslim alliance dissolved. Prior to 1993, the Muslims and Croats were united in fighting the Serbian troops, but that fell apart when the Croats destroyed the old bridge in the center of Mostar. The Croats claimed that this was a strategic maneuver, but the Muslims insisted that it was an attempt to erase their identity, which was one of the atrocities that arose out of this ethnic conflict (others included rape, torture, and ethnic cleansing). Mostar is also the site of a tragic massacre, when the Serbian troops invaded and killed 2,000 women and children, who were the only ones left since the men were all fighting in the war. The Croat-Muslim alliance was restored at the end of 1993 through the efforts of the Clinton administration, but tensions still exist between these two ethnic groups, even today. The city is segregated into Croat and Muslim sections. The students do not even attend school together anymore. Our tour guide told us that prior to the war, both groups existed in harmony, but since the war they have lived separately. The scars and stress from both the recent war and the struggle of living this kind of life are still apparent. 80% of the population of Mostar smokes according to our guide. This is a coping mechanism for the chronic stress that the population still endures. This stress also leads to other maladaptive behaviors, such as domestic violence, alcoholism, child abuse and suicide. Our professor, Dr. Carol Cotton, told us that there are ways to reduce the stressors of situations like this, and they include rebuilding the city, not just in terms of buildings, monuments and religious centers, but also in terms of identity and belonging. The city is slowly but surely rebuilding from this war, and there are actually more mosques in existence now than there were before the war. This is an attempt to reclaim the identity that was stripped when the war was raging on. There are also programs available to help the survivors deal with stress. JICA, a philanthropic Japanese agency, gives €200 a month to survivors who still experience post-traumatic stress disorder. Mental health treatment is also a part of this program. The only downside is that once a part of this program, individuals cannot work again, for they are permanently labeled as disabled. Another public health issue that we learned while in Bosnia are that the health insurance is not employee mandated like it is in Croatia, and emergency medicine is the only type of health care that is funded by the government. This means that those who are unemployed face many difficulties when it comes to obtaining medical care. We also briefly visited Stolac, another town still experiencing ethnic tensions, and talked to a local family and also toured the town's mosque.

These few days were incredibly eye-opening for me and my classmates. We learned about the daily lives, struggles, and health issues of people living in Roman times, the medieval period, and during the recent war. It was both exciting and humbling to step briefly into the worlds of these people, and learn what life was like for them. These were experiences that none of us will soon forget.

A Closer Look at Healthcare

We had an opportunity to meet with a physician at the PolyClinic in Makarska on Friday. This is a unique experience for us, as most of us know that it can be much more difficult to arrange this type of meeting in the Sates!
Dr. Ivanda described for us the system of health care for children in Croatia. Physicians at the PolyClinic conduct thorough and comprehensive exams for all children in Makarska and surrounding areas. There are only 2 physicians in the clinic and they are referred to as ''school physicians''. In addition to conducting physical exams and administering vaccines in the outpatient clinic, they also travel to the schools in the area. Their exams are extremely detailed; they assess not only physical health, but also childhood development, food intake and diet, progress in school, and social skills and dynamics. Dr. Ivanda told us that they also routinely conduct health education programs for teachers and students in the schools.
Methods of administering care and records-keeping are very organized and thorough. Pediatric health care begins for each child, when the parents bring the infant to the clinic for a well-baby check-up. All children in Croatia must also undergo a physical examination and must receive vaccinations, including DPT, MMR, polio, tuberculosis, and Hepatitis B prior to entry in the school system. Documentation completed by the physicians is kept by the PolyClinic, by the Ministry of Health, and by the child's parents. These records are updated by the school and family physicians until the child reaches the age of 26. Following that, they are always kept on file by the Ministry of Health. This is extremely important, since the lack of data in developing nations is one of the biggest problems in international public health intervention and research.
Dr. Ivanda reported to us that many of the health problems that exist in the pediatric population in Croatia mirror those that we find in the U.S. There is a rising incidence in childhood obesity, with a corresponding risk for juvenile diabetes. Diet has changed relatively little over the years, but is consistently high in fat and carbohydrates. The rising rates of obesity therefore, may be related to inadequate physical activity in conjunction with this high-fat diet. Though I had always thought of eating disorders as primarily an American phenomenon, I learned that rates of anorexia and bulemia are increasing in Croatia as well.
There are also problems with aggression in both younger and older age groups. Dr. Ivanda relates this to the fact that children regularly see acts of violence on TV and video games. Cigarette smoking and alcohol consumption are also problems among youth, just as they are among the adult population. Physicians administer anonymous questionnaires to assess the extent of alcohol and tobacco use with this age group.
Dr. Ivanda told us that overall, she is pleased that the system of health care in Croatia has been successful in avoiding the epidemics that sometimes occur in developing nations. However, she also relayed a frustration with an apparent lack of progress in decreasing aggression in children.
So, as you can see, we have had the opportunity to interact with some wonderful health professionals and we are learning a lot!
We're working on getting some more photos posted!

Monday, May 28, 2007

The Beautiful Coast of Croatia

After about an 8 hour bus ride down to the Croatian Riviera, we arrived in Makarska. I really cannot describe the beauty of this area, but the crystal blue sea and bright white rocky beaches took my breath away. I still have not gotten used to looking out at the sea and turning around to 1700 meter mountains. They have got the best of both worlds down here!

On the way to Makarska, we stopped to visit Plitvice Lakes National Park. This national park holds a several natural lakes that are crystal clear blue and so pure you can drink out of them. Huge waterfalls and streams feed into the lakes and creates a sight that everyone must see if given the opportunity. I would try to take the time to describe this park's wonder, but again, I lack the words to paint an accurate picture, so I will let you see them for yourself when we post the pictures. There are trails and bridges that allow guests to walk amidst the lakes and around the parks. I was surprised to see how many people go through there each and how perfectly preserved the park is. I expected to see park officials everywhere, but I think I only saw one. This fact illustrates how awe that is sparked in guests and that they respect the environment. We noticed while in the park that there were hardly any amenities for people with disabilities which is very different from the States. There were no handrails or guardrails running along the steep and rugged trails, and the walkways over the lakes were irregular and would be easy to trip on. While this seems like a negative aspect to us as Americans, it illustrates a theme that we have noticed in the culture of Croatia. This theme is a reliance on people to take responsibility for themselves and not rely on the government or other systems to hand everything to them. Croatia's health system is characterized as a "health system in transition," and while they are making huge strides, they are not yet to the point where they can reach their citizens on the same level as more advanced systems. We have seen this trend in other areas such as caring for the elderly. Families are very important to the care of people with disabilities and the elderly population.

Life on the coast is much slower and laid back than the city. Makarska's main industry is tourism and there are outdoor cafes and restaurants everywhere. We are lucky to be here before the peak of tourist season because the population in the town will increase two to three times its normal size. We were able to be apart of the "Celebrate Summer" festival to ring in summer and tourist season. They had concerts all around the town which lasted all night and people were everywhere. We had a great time needless to say! While this tourism is crucial to the survival of the area, it does not come without problems. Some of the main problems Makarska must deal with during the summer months are overcrowding of the health clinic, funding of the health clinics and environmental initiatives, and issues with water, sewage and waste disposal. It is difficult for the local government because the people that use a majority of their services are not paying into the system to contribute to its maintenance.

The food here is AMAZING! Now, I know I'm a little more obsessed with food than most people, but the seafood is out of this world and they eat fresh vegetables all the time. There is also a very heavy Italian influence which is never bad. We were able to find a market to buy fresh seafood to cook dinner on our free day and I am not ashamed to brag about how delicious it was! :)

We have noticed a bigger problem with obesity here because life is much slower, but an interesting difference is that the main contributing factor is lack of physical activity and not quite as much as diet (diet was bigger in the city). Smoking, alcohol and an obsession with coffee is still everywhere down here.

As you can see we are learning alot and having a blast still in Croatia! Thanks for all the posts and keep them coming!!

Wednesday, May 23, 2007

Zagreb ER

Today we visited the hospital in Zagreb. It is the only major hospital in the city, and also receives patients from all over Croatia, as it is the only hospital in the country with a trauma center and a burn unit. The hospital also specializes in spine and pelvis surgery. The first thing that we noticed upon arrival was that it was hot and small. The air conditioner was under-used, but this seems to be a tendency throughout the entire country, which may be due to lack of funding as opposed to the desire to save energy. Our group spoke directly to the director of the hospital, and then we were divided into two groups. One group went to view the ambulance bay and ER, and one group went to the outpatient part of the hospital to view some minor wound care. I personally was in the group to witness the wound care, and there were several things that I noticed. We were required to don scrubs and face masks before entering the room, and there was a nurse present at all times, according to strict policy. The doctor was very thorough about cleaning the wounds, using four different types of antiseptic solutions. They were also very fast with their work. We witnessed the doctor stitch up a cut finger on one man, and then drain a hematoma on another in about 15 minutes. We also noticed that their records are all computerized, which is very advanced technology, as the United States has only recently switced to this.

Next we viewed the intensive care unit and the burn unit (both groups got to do this). The equipment in the ICU was state of the art and our professor remarked that they use the same machines in the United States. There seemed to be a lack of privacy, however, as the beds were not separated by curtains and were placed very close to each other. There also seemed to be a problem with space, as there were only about 12 beds, and the room was filled to capacity. In this room we learned the importance of time and place in relation to the likelihood of survival in an accident. There was a woman who had been hit by a tram right outside the hospital. Had she been any further away, she would have died. This is an important consideration because the hospital is the only one in Croatia with a trauma center, and many cities and villages are many hours away. Transportation to the trauma center in a timely fashion could mean the difference between life and death for many accident victims. There are some helicopters that will airlift people to the centers from some of the islands or remote locations, but are not abundant enough to solve the problem. We also learned that many of the accidents that occur in Croatia are seasonal agricultural injuries, such as falling off of a ladder while picking cherries. This could mean that the ICU ward would be more full during these periods, which could lead to problems with the space issue.

The burn unit that we toured was state of the art and brand new. While visiting this area, we learned some important facts about burn victims. The most common victims are usually old or disabled, and suffer burns while at home, such as falling onto a hot stove. Diabetics are also susceptible to burns; there was a man in the unit who was a diabetic and scalded his leg because he could not feel the temperature of the water. The most severe burn victims in the hospital were victims of traffic accidents, and had been burned in their cars. We also learned that advances in burn care, as well as orthopedics, tend to happen in times of war. Croatia experienced war in the early 1990s, so advances have recently been made.

The visit was extremely informative and educational, and our group left feeling as though we had learned a great deal about Croatia's healthcare system and quality of medical care. We would not have been able to tour the same facilities in the United States, so we were very grateful for this opportunity. Overall, we felt that the aesthetic issues were troublesome (the building is very old, so it appeared unclean and rundown in spots), but that the quality of care and technology are up to par with other nations in European Union, which Croatia hopes to join in the next few years.