Health in Makarska

On Monday, May 25th, all of the students went to the city hall in Makarska to meet with the director of the legal department. She talked to us about the city’s development plan, tourism, and traditions. The government of Makarska is trying to encourage tourism and development of the area, while still maintaining the natural beauty of the city. To help maintain the water quality of the Adriatic Sea, Makarska has recently built a water treatment facility that treats all water before being released into the sea.

After our talk with the director of the legal department, we spoke with Mr. Josip Paunović, who works in the city manager’s office. Mr. Paunović covered a lot of health topics, including smoking, alcohol, substance abuse, and access to health care.

The government implemented the recent smoking ban to help reduce the health care costs related to smoking. The law initially started out as prohibiting smoking in workplaces, but instead of introducing new limitations gradually, the ban was extended to include all indoor public places. To enforce this law, there are inspections in bars and restaurants, and the fines can be at all levels: the individual that is smoking ($200, or a fifth of the average monthly salary), the server allowing the customer to smoke ($2500), or the bar/restaurant owner can all be fined ($20,000).

The smoking ban in Croatia is a very important first step to reducing the number of deaths from smoking and secondhand smoke, but more actions need to be taken. There needs to be a government-funded program to help Croatians stop smoking, whether it be counseling, behavioral therapy, or subsidies to purchase nicotine patches or gum.

About a year ago, DUI laws in Croatia were set to zero tolerance, but the legal limit was changed to a blood alcohol level of 0.05 after complaints from restaurant owners that the law had affected their business. DUIs do not go on a person’s record, but the driver does have to pay a fine. The most commonly abused drug in Croatia is marijuana.

Tourism has many impacts on Makarska. During the year, there are around 15,000 people in the city. In the summer, this number more than doubles to 35,000 due to the large amounts of tourists that come to Makarska. During the summer, there are lifeguards and beach patrol along the busy beaches.

Littering is another problem, especially at the beach. There are people from many different countries visiting the beaches of Makarska, bringing their own customs with them. Some people do not think it is necessary to throw away their trash, while others clean up after themselves. To help with the litter, crews are hired to clean the beaches every morning.

The main problem that comes with tourism is injuries. The ER in Makarska sees about 150 patients daily during the summer, but there is no actual hospital in the city. Any serious cases have to be taken to Split for more advanced care. This can be a problem due to the 2 hour drive from Makarska to Split, and the type of transportation. The ambulances are not actually ambulances, but more like a pick-up van that is not equipped with everything that could possibly needed in an emergency. There are 5 medic teams in the city, and 4 ambulances. The number of tourists in the city during the summer can strain these emergency medical services. Since severe cases from Makarska are sent to Split, this can strain the hospital system in Split. The health center in Makarska was actually designed as a hospital, but because of political reasons, the city has not yet been successful in converting this facility into a full-service hospital.


Following our meeting with Mr. Paunović, the Public Health students went to a local health center and met with the Director of School Health. School health is under the Public Health Department in Croatia. The school system in Makarska has 3,700 students, with less enrolling each year.

A child’s first visit with a school health doctor is usually around May during school enrollment. In the first meeting, the child’s school health record is compiled, consisting of prenatal and maternal health, family history, immunization records, vision, weight, height, etc. A team made up of a psychologist, pediatrician, school health doctor, and the child’s teacher meet to discuss the child’s health record and determine if the child would be best suited for a regular school program or a special education program. The child and his/her family can take the school medical record to their primary care physician and/or keep it with the school health doctor. Comprehensive health exams are conducted in grades 1, 5, 8, and 9. In 3rd grade, vision exams are conducted, and in 6th grade, the student’s motor skills are evaluated.

The school health department provides educational programs on prevention, injuries, hygiene, epidemics, and tourism and prevention programs that encourage early detection through breast self exam or mammograms.

Unlike in the U.S., obesity is not a major health problem in Croatia. The prevalence of overweight and obese students has increased, but only 6% of all children have weight problems, while about 12% of 8th grade students have a problem with their weight.

To help reduce the number of young people that smoke cigarettes, the school health department has anti-smoking programs, lectures, and school classes. As for sexual education in schools, there is no official program. There are two programs that are being debated: a more conservative program teaching abstinence only, and a program that would educate on abstinence and safe sex.

Teen pregnancy is not as big of a problem in Makarska as it is in the U.S. There are only three teen pregnancies per 1,000 population in Makarska. The director of school health informed us that many students that get pregnant during school end up completing their high school education.

Regarding nutrition, the schools serve a snack between the start of the school day and lunch, and then lunch in the afternoon. Some schools have extended programs that also serve breakfast. There are many unhealthy snack and drink machines around the schools. A recent pilot program to introduce healthier snacks was not successful.

- Elizabeth

Tučepi

Sunday May 23

We started the day with breakfast at our host restaurant and got ready to go hiking. We were hiking Tučepi- which is part of the mountain we have behind our apartments, but on a different side. We were told that the hike was going to be steep- but we didn’t plan on it being as steep as it was. We walked mostly on the road, and yes there were cars driving up the mountain, but sometimes we had to venture off the regular road and get in the brush. We braved the heat and the steepness of the mountain and made it to the wall of the mountain- pretty much the tree line.

When we stopped we also visited a Catholic church as well as a small museum depicting Croatian life many years ago. After the museum tour, we were offered some wonderful Croatian snacks. We had dried figs, fried dough, bread with olive oil, and cake. Drink choices were different forms of rakija made from figs or carob or a desert wine. There was an entire table set with food, but when we left, there were just a handful of figs left- everything else was gone!

Our tour guide then took us on another hike, but this time the trail was so narrow you could only put one foot down and walk heel to toe. We saw many homes, even our tour guide’s birthplace. We also were able to see that the people living on the mountain had many options for growing there own food. During the first hike of the day, we saw almond and walnut trees, pomegranates, figs, and a variety of herbs. The second part of the tour we saw artichokes, various fruits, and grapes. Getting up and down the mountain can be very tedious, so the inhabitants have to grow a lot of their food. While having snacks, we also were allowed to see a lamb being roasted. These people are able to sustain themselves very well for living in such remote places. We later had lunch at a restaurant on top of the hill and then made our way back down the mountain by vans.
-Rachel

Makarska Beach

Saturday May 23

We had a tour of the city of Makarska given by one of our faculty members, Dr. Tir. We walked around from our host restaurant to the beach and then into the downtown area. Makarska is very different from any of the other cites we have been to. There is a café’ culture here, but there is not as many as in Zagreb. Everything in Croatia is done at a slow, laid back pace, very different from life in the U.S. There are lots of “tourists” shops lining the outside area of the beach and many different shops and restaurants away from the beach area.

The beach is completely different than beaches back home. There is NO sand- only millions of pebbles and rocks lining the shore and going into the water. The pebbles are smooth from years of been tossed around in the Adriatic. The actual “beach” area is much narrower than those back in the states. We have noticed that the beaches are relatively spotless for so many people to be on them on a daily basis. We were told that people are hired to clean the beaches and remove the trash, especially during high traffic seasons. The water is clear with hints of sea green and blues. The water is a lot colder than what we are used to in the U.S. too. On our tour we were informed of the possibility of stepping on a sea urchin while in the water. Stepping on one can be very painful and the spikes must be pulled out very carefully. There are no warning signs noting the possibility of this danger, nor is there a warning about slipping on the rocks. Makarska sees tourists from all over Europe and the world, so we feel like there should be some kind of warning sign letting people know about the potential dangers of the rocks- such as slipping or cutting one’s foot on a jagged edge of a rock, as well as sea urchin warnings.

The beach has been very family friendly. We have seen many children with school groups and many families in general enjoying the coast. There are paddle boats with slides that can be rented for an hour at a time, as well as many shops selling floats. There is also a large slide located on one side of the beach. Cafés and restaurants line the outside of the beach strip. At any time of the day, people can be found sitting outside having coffee.

We enjoyed spending our first day on the Dalmatian coast. - Rachel

Croatian ER

How would you like to go to the emergency room for treatment and never have to pay for it? That is how the system works in Croatia. Everything is free- even the medicines. The “emergency rooms” here are more like our Urgent Care centers in the United States, but with more on-going services. The ER does not deal with major trauma issues, births, or major surgeries. These types of services are done at the hospital.

May 21st the Public Health Students visited a Croatian Emergency Care Center in Labin. We were given a tour by the Director of the Emergency Care Center, who is a medical doctor for 8 hours of the day and the manager of the center for 4 hours. We toured many of the different areas of the clinic, from the Emergency Receiving to other specialized areas of the clinic. The ER was built in the 1970s, and was once a full hospital. It is now basic emergency care and other services. Our guide noted that one entire building is empty and there is too much room now, and they have to pay a lot of money to pay for the unused building. There are about 25,000 people in the area and the center sees about 40 patients on a normal day, and up to hundreds on the weekends. The majority of the patient load in the summer comes from tourists. It should be noted however, that the free services are only free for the citizens, not tourists. Tourists have to pay for treatment and medicines.

The ER provides Basic Life Support, Emergency Life Support, x-rays, basic surgery (2 rooms), EKGs, and general care for everyday occurrences (sore throats, headaches, etc.). Other services offered by this Croatian ER were dialysis, hospice, a dental clinic and dental moldings, school health, immunizations, laboratory for blood work, pharmacy, rooms for Hepatitis A and B, and radiology and diagnostics. Dialysis patients come 3 times a week and there are about 22 patients who come. We visited the Dialysis room and saw about 6 patients receiving treatment. The hospice in Croatia differs from the U.S. that when elderly people have been in the hospital and need to monitored in a clinical setting and there is no room for them to be kept in the actual hospital, are moved to the ER center.

There is an on-site dentist and dental lab where false teeth are made due to the aging population near the ER. We also were allowed to go in this room and saw all kinds of teeth impressions, dentures, and workers molding the fittings with flames and paste.

We also visited the school health areas. Children come to this area for immunizations and education. Croatia also takes the vaccines to the children at school. The schools are visited almost everyday. The student’s health records are also kept at the ER center, not just at the school. The guide noted that sex education is presented in regards to STIs and safe sex, but she noted that they do not give out condoms because of the large Catholic influence in the area. Students can come to the clinic and have more sexual health education if they want it. The clinic does offer the Gardasil (quadrivalent-HPV vaccine) shot to females for $1027 kuna, which is roughly $192 per shot.

The ER gets lab work the same day, sometimes in 30 minutes depending on the type of labs requested. The patient’s general doctors will receive the results the next day. Wait times for being seen depend on how many other people are waiting for treatment, and if the doctor is out on an ambulance call. Sometimes the wait time is 30 minutes, and others it is 2-3 hours. There is no triage system, so it just depends on what kinds of symptoms a person is experiencing to determine the order in which they will be seen. Chest pain or asthma attacks will be seen immediately, and those patients who are there for mild illnesses and discomforts will have to wait to be seen a little longer.

The Director noted that the doctors are paid based on how many patients they see and the doctors depend on large amounts of patients, because this is how they pay for other employees such as the Speech Therapist, Psychologist, Accountants, Administrative Assistants, and Cleaning services. This kind of works in their favor since many people come into the clinic for mild illnesses and complaints, but also if the patients General Practitioner is working, the patient is sent there and the ER will not treat them.

We saw inside of the ambulances that are used for bringing people to the clinic and they are very different from ambulances in the United States. The vans are not fully stocked at all times, because it costs too much money to keep them fully stocked. When there is an emergency call, the EMTs pick up a case filled with medical supplies and put it on the van. When we first entered the ER, we got to see some of the EMTs bringing in someone from heat exhaustion.

Other services our guide mentioned were that the Red Cross offered CPR training and diabetes education. Doctors from the hospital were sometimes asked to do presentations at alcoholics meetings. There are other education efforts in the works, but for now will have to wait because of money concerns.

Our time at the ER was very informative. We learned a lot about Croatian medical care and saw a different side of Public Health than we have seen on the other parts of the trip. - Rachel

Drive to Makarska

This morning we departed bright and early from our hotel atop a mountain in Istria and are heading for the coastal region of Makarska. While we are spending over eight hours on the bus today, I have sighted a few things worth mentioning. The regions of Croatia we are traveling through today are located along the cost of the Adriatic Sea and thus strong winds are a daily occurrence. These types of coastal winds provide great opportunities for resources but also offer some challenges for public health. While most days man and wind can interact with no problems, this is unfortunately not always the case. In the winter months especially the tidal winds can be especially strong and have been known to even cause traveling cars to turn over during a strong gust. Obviously this is a very serious traffic safety problem yet some safeguards have been put in place to protect drivers along this region. In many of the stretches of highway most exposed to the tidal winds, special wind barriers have been placed to help prevent serious accidents due to these strong gusts.

While the wind can pose some challenges, it is also a great resource for energy and it seems that many areas of Croatia along the coast are harnessing its potential. Traveling along the highway, I have noticed several mountain tops lined along both sides with turbines for harnessing the power of the wind. It is not every day in the U.S. that I come across so many windmills in one place. It is unfortunate that many coastal areas in the U.S. are lined by high price homes and residents will often protest proposed wind turbines because they don’t wish to have such a ghastly sight near their property. I find that these windmills almost add something to an already beautiful coastal landscape in Croatia. While they are noticeable atop the mountains, they have a certain serene nature and I believe add character to the landscape. Beyond aesthetics, these wind turbines can help to improve air quality and thus human health. If you have watched t.v. over the past year, you’ve probably seen commercials featuring the well known oil tycoon Boone Pickens. Over the past several years, Mr. Pickens has become a strong advocate for energy independence, or reducing our dependence on foreign sources of oil. While many of these commercials focus on increasing the use of natural gas, which is abundant in the U.S., Mr. Pickens is also an advocate for wind energy. In fact, he is currently planning the construction of the largest “wind farm” or collection of wind turbines in the U.S. which will be located in the state of Texas.

The energy power of the wind is significant and its production has virtually no negative impact on the environment. Yet, wind power alone will never be enough to provide all the world’s power. A sound energy policy will utilize all possible environmentally friendly sources of energy: wind, solar, geothermal, and even perhaps nuclear to reduce the amount of energy from fossil fuel burning facilities. Currently the most common method of energy production is coal burning, which emits large amounts of so called greenhouse gases such as carbon dioxide, nitrous and sulfur oxides, among others. Through various mechanisms, these greenhouse gases pollute the air and can cause increased mortality and increased rates of various respiratory disorders and some forms of cancer. Thus it is exciting to see these wind turbines lining the mountains. By placing even more along high wind regions, Croatia will further eat up the part of the energy pie occupied by fossil fuels. With this small step Croatia will help to ensure cleaner air and better health for the people.

-Ben

Pula and Health Communication

The ancient ruins of the Coliseum in Rome are among the most recognizable landmarks on earth, but did you know that Croatia is home to an ancient amphitheater of its own? Our journey today took us into the city of Pula which is home to the 6th largest and 2nd best preserved Roman style amphitheater. Pula and the entire region of Istria have some very noticeable differences from the rest of Croatia, especially the regions we have seen around Zagreb. This is because Istria is heavily influenced by Italy and has at various times been under Italian rule and the rule of others as well. While this makes for cultural and architectural differences such as Italian influenced cuisine, does this impact public health in any way? Following our lecture at the University of Pula with David Mandic, I would have to say that it does. Professor Mandic spoke about the unique aspects of language in Istria, a region where several different dialects are spoken. While there are some similarities among the different dialects, there are also great differences which can make communication among the various people of Istria difficult at times. This can impact public health by making health communication a very challenging task. Can you imagine being in charge of a public health campaign and having to reach people of multiple dialects within a single city? This seems like a big challenge and one that could leave those in the minority dialects with lack of access to important health information. This unique language situation of Istria could also cause problems for individuals trying to communicate with their health care providers, who may not speak or understand the given dialect. While I am not sure how much of a problem this is for public health workers in Istria, it seems like something that would certainly need consideration before undertaking any type of public health endeavors.

-Ben

Roč and Hum

May 19- Our charter bus took us to the border where Croatia and Slovenia are having disputes over a bay that touches both countries. We heard from two speakers while at the bay about how long it had been going on, what was the current status and what could potentially happen. Members of the E.U. virtually share all borders, there is no “line” to state when you are entering one country or leaving another. Slovenia is delaying Croatia's acceptance into the E.U. by not providing a unanimous vote for Croatia to join the E.U. This dispute will be resolved in Croatia gains acceptance into the European Union.

After our visit to the bay, we met up with a familiar face, Dr. Alexandria , to visit the cities of Roc’ and Hum. These towns were both very old and situated high atop a mountain. In the city of Roc’ we saw children having class at an elementary school, a small church, and the beginning of the Glagolitic trail leading to Hum. The Glagolitic language is one that has a rich history that was almost forgotten, but a few people decided to restore it to Croatia and its heritage. We stopped at four Glagolitic symbols along the road to Hum. These visuals were put up in the 1970ties so that the Glagolitic language would not be forgotten and would be remembered as an important part of Croatian history. We saw a table with three legs to represent the Trinity; a block statute, stone seats and a chair to represent learning in nature, and the Glagolitic letter “S”. We then stayed on the bus to view the other seven symbols. All of the symbols were made of stone. The final symbol led us into the city of Hum. Hum was recognized as a city a long time ago by a King, and still maintains being a city, even though there are only twenty people living in the city. Our guide told us that it Hum has everything a regular city has, but just a handful of people. The view from Hum was really pretty. It was really interesting to see how these cities were still in existence, since they were so remote and so tiny.

After our tours here, we were on out way back to the top of the mountain to Hotel Kastel.

- Rachel