Public health and Põlva

A number of people have independently remarked on an odd thing about Põlva: the high number of people in the scenic town of 6,000 who look and act somewhat different. Many rural communities worldwide straddle the line between "close-knit" and "questionable intrafamilial alliances," but Põlva, which is surrounded by some of the thicker forests and natural barriers in Estonia, appears to sit squarely on the other side.

For a while, it seemed like good material for a particularly irreverent routine at one of the comedy nights that have become a hot taco item in Tallinn and Tartu. Driving into town with the family for an afternoon dip in the lake this summer, we would sometimes have to proceed carefully, encountering people who would become oddly indecisive about their direction on crosswalks and begin, like a cartoon character, to move down the road instead of across the road.

What didn't help were curious features, such as the fact that Põlva has hundreds of light bulbs on an island in the middle of a manmade lake downtown. It is, and ordinarily would seem like, a pretty cool public art installation, but in the context it suggested that all the bright ideas in the town had been exiled to an uninhabited island while - not to put too fine a point on it - the town was controlled by a bunch of retarded zombies.

It all no longer seems as funny (which, albeit in bad taste, it was) after my son and I were both let down by the local medical establishment this summer. Given the neurological look to many of the symptoms around Põlva, I wondered if many local people have undiagnosed Lyme disease that has progressed to the later stages.

I suppose I'll blog about the details of our own encounter with Lyme eventually, but basically Põlva Hospital ER dropped the ball both times. I had a localized infection without a unequivocally clear set of symptoms and due to lack of action by the ER, I developed a full blown case of Lyme flu before I finally got an appointment with a competent local family doctor who prescribed antibiotics. It was more serious in my son's case -- he never had the classic bull's eye ring, and after a secondary, transient rash was misdiagnosed by Põlva ER, he developed neuroborreliosis with partial facial paralysis, for which the (luckily effective) treatment is intravenous antibiotics. It involved some inpatient treatment in Tartu.

Southern Estonia has a very high incidence of tick-borne illness. I can't say the medical staff anywhere was ignorant of the disease and its potential for harm, and they sounded an even more serious note on encephalitis, for which a vaccine is available. But there was a combination of bureaucratic obtuseness and foot-dragging that was maddening. They were eager to pass the buck to a family doctor who, they levelled with us, might not be able or want to see us, and who certainly had no obligation to do so.

It was a medicalized version of the dream where you are running but unable to budge from the place where you are standing. Or where you are trying to point out something that is blitheringly obvious but the person is still running through some standard operating procedure and won't listen to you. An example: I was waiting to give my own blood test in late June (I had already started antibiotics and my symptoms had resolved) in Veriora. I had been asked expressly to come in at 10am on Friday because the last samples that week were to be taken to Tartu by courier at 11am and the samples would no longer be fresh on Monday. After ten minutes of waiting in the hallway, at 10:10am, I saw a guy in a brown uniform and a cooler go into the examination room. I knocked on the door, and ventured a question but a woman peremptorily (angrily?) told me to keep on waiting in the hallway. The man with the cooler re-emerged and left the building. I chased after him and asked if he was not by chance taking blood samples to Tartu. He was. I ran back and tried again, but it was too late. "Why didn't you tell us?" asked the nurse while her assistant radiated resentfulness. Luckily, it turned out that the sample would keep until Monday. Then the nurse missed my vein on the first try and I had a big bruise there for the next 10 days or so.

On different levels and in different institutions, and in different situations, farces like this seemed to keep repeating. Twice blood sample scheduling was involved. Morgan was weighed twice before any substantive Lyme-related tests were administered or before they even knew where the tick bite location was. Etc.

On the basis of our experience, I would also say the Estonian medical system is also plagued by a surprising amount of regional disparity and lack of communication. It appears to be a big problem to be seen by a family doctor if you are not on his or her list. (Our family doctor in Tallinn has gone off to the States to work and we have not met the substitute we were automatically assigned.)

When your child is sick and facing the never-knows -- treating Lyme sometimes becomes like a game of Whack-A-Mole in the later stages once the bacterium goes dormant -- you extrapolate and imagine worst-case scenarios. I wondered if for some reason the system would not be able to treat him. What if his test results were a false negative (common)? I envisioned Morgan 15 years from now crossing a road and wondered if he, too, would set off running down the road ahead of the car instead of across the road. Also, when you deal with the medical system in any capacity, you inevitably come into contact with people and their children who are far worse off, and it gives you pause.

Is Põlva Lyme-ridden? it is a long shot, but it is possible. Neither my son nor I had an absolutely clear classic bullseye rash. And from what we can surmise, the blood test is only administered only on such clear visual evidence, but at least 20% of people don't have any symptoms. We got tested, insisted on it, because we're a bunch of hypochondriac freaks who read too much about diseases on the Internet; we also worry about the food supply and even have the idea that pork fat and nitrates might actually be a big mistake in excess. Would ordinary Põlvans really even think of getting tested for Lyme? Given that Lyme is a great mimic, and the chicken-and-the-egg nature of many neurological symptoms, do we really know why Rein started hitting the bottle harder at a certain point in middle age, or why Tiit has vertigo, or why Laine has strange bouts of depression and bone-crushing fatigue? Many Lyme infections don't have overt symptoms in the early stages and people often have the impression that they can tough it out or simply don't see a doctor. Lyme is basically syphilis, with a less dramatic, rarely fatal outcome. From what I understand, it doesn't destroy tissue the way syphilis does, but the disruption of pathways and potential madness can be similar. As for TBE, people who have had tick-borne encephalitis, Dr. Kolk of the University of Tartu Children's Hospital neurology unit told us, are rarely the same again. Since I actually don't think there's that much inbreeding, organic phosphates or other bad stuff around, the results of comprehensive testing for tick-borne illnesses conducted in some small towns in Estonia just might be surprising.