A Tale of Two Feet
... or my dumb-ass natural experiment in foreign health care
One of the most interesting, and sometimes confusing, aspects of moving to a new country is figuring out how the healthcare system works. Like most bureaucracies and legal systems each country develops its own way of doing things in little steps going back dozens or hundreds of years. So naturally, no 2 systems are exactly alike.
Due to some unfortunate circumstances, I created for myself a sort of natural experiment to compare the American and Moldovan health systems. Back in 2010 I broke my left foot while on Spring break in Florida. It was a kinda weird break where I rolled my ankle in such a way that the tendon on the outside of my leg went beyond its stretching limit - either it was gonna go or the bone it was attached to was. The bone proved less resilient and a small bit fractured off where the tendon was attached. Then, in 2020 I broke my right foot in exactly the same way in Moldova.
So, 2 countries, 2 emergency rooms, lots of doctors. Let’s look at what stupid things I did to break my feet and what the experiences say about the difference in the healthcare systems of the US and Moldova.1
Florida 2010 - The Art of Falling Down 2 Stairs
As soon as I wrote “Spring break” some number of readers must have instantly thought that there must be a good story here - and maybe there is, but not the one you expect. I went to Georgia Tech and as an engineering student with friends who were also mostly engineering students I can say that we didn’t really “do” wild Spring breaks. We’d go beach camping or explore the Georgia coast but “girls gone wild” it was not. More like road trip 300 miles to see manatees only to have these gentle creatures not show up. In 2010 a group of friends and I rented a beach house in Northern Florida to chill for a week.
It was a quiet place near a small town and on the night in question some of my friends got restless and wanted something more interesting. They decided to drive to Miami for dinner and to hang out and then to drive back the same night. Miami was 4 hours away and I decided that an 8 hour drive for dinner and a short party was not worth my time. They set off with a few jokes about me “fun hating” and I settled into a quiet evening.
The house was right on the beach and had a raised wooden path that crossed some scrub brush and then took 2 steps up and 2 steps back down to cross the sand dunes and get to the beach. On the top of the dune was a little porch with a few beach chairs. At around 9 pm I was sitting on one of these chairs looking at a perfectly clear sky and chatting with my then girlfriend (different school and spring break schedule). As I chatted on the phone and looked up at the stars a sudden and absolutely torrential rainstorm came out of nowhere. I shouted into the phone “HOLD ON” as I jumped up to run back to the house. I took the 2 stairs in one leap, rolled my ankle, collapsed face first into the wooden walkway and knocked myself out.
I came to a short while later to find myself lying in a bunch of bushes. It seems that I had rolled off the walkway after hitting it and fallen around a meter to land in the soft sandy scrubland below. From there I got up, limped (jumped really) back to the house and called my girlfriend back from a nice covered porch. My foot seemed wrong but didn’t really hurt and I figured I probably just twisted my ankle. A friend of mine helped me get some ice on it and then I went to bed. As I lay down I felt a light fever coming on and realized2 I broke something and that the next day would involved the emergency room - bummer.
Doctors and Lots of Choices…
The emergency clinic the next day was actually really easy. It was a small town and the place was empty. I’ve broken bones before and this was the first time I didn’t spent 4-8 hours in a waiting room with everyone else who was having a terrible day so this was nice. They took an x-ray and said, “yeah, it’s broken - you probably need surgery.” The doctors helpfully said that this wouldn’t be serious and they would happily get it done right away except… it was Sunday and the surgeon had a day off.
It’s important to pause here and note that I had health insurance - actually 2 policies. Thanks to the Affordable Care Act I was still covered on my parents insurance and as a Georgia Tech student I had some coverage from the university as well. So paying for these doctors’ visits wasn’t an issue. Something that I didn’t realize at the time made me a very lucky person in the States.
The next day our break was over and we all went back to Atlanta and I set up an appointment at the university’s clinic. They specialized in sports medicine given the particular dangers of college football and so had a bunch of top doctors in the area of foot injuries. The doc there told me that I needed a screw in my foot that would re-attach the broken bone piece - but that he was super busy and couldn’t do this for a month or more.
This led me to some doctor shopping and referrals. The next doc looked at the x-rays and said “oh no, you can’t put a screw in that! the bone fragment it too small and it’ll just shatter!” He had a different idea where he would insert two nails on either side of the broken piece and then use a tiny piece of stainless steel cable to lash my bone back in place.
So here’s the first issue - I had a choice. Multiple doctors, different ideas and I have no idea how to parse them. Most agreed that surgery was preferable to make sure things healed right. I was actually walking around during this whole process so I kinda took that on faith even though things didn’t seem so bad. I wound up going with Mr. nails because he was available and a week or so later I was in for surgery.
While prepping, the anesthesiologist explained that I’d be under for the whole thing and as he went down a checklist of questions he stopped short and exclaimed “oh! your insurance will cover a local anesthetic too - do you want that?” I could not help but hear the excitement in his voice and knew immediately that he wasn’t excited for me so much as his billing prospects. Do I need this? I have no idea. I don’t even know how to decide if I want it. I do know that the only specialist I can ask for advice has a financial incentive that *could* influence his answer.
I did not like this. I didn’t like “choices” that I wasn’t qualified to make being advised by people who had incentives other than my foot being better. It doesn’t mean they didn’t want to help me - it’s just that they also wanted to bill me in the best way for them. Maybe one guy could bill more for nails than screws? I’ll never know. It’s also worth noting that getting me to agree to things and have some agency in the process of choices helps insulate them from legal liability. All told it made me as a patient feel lost.
Thankfully the surgery went well and everyone was very nice to me the whole time. An hour later, groggy but without much pain, I exited the place in a wheelchair and got picked up by my roommate. They had put on a cast and given me a *large* number of pain pills that I later realized were Oxycontin.3 A month later the cast was off and I was learning to walk again.
Moldova 2020 - Invisible Snakes
Right off the bat I’ll tell you that the story of breaking my right foot is no less stupid than my left. Back in 2020 my wife and I bought a “fixer-upper” village house in Pohrebea Moldova. It was the kinda place you would say “had potential” but was also last inhabited by the kind of person that enjoyed stapling things to the wall as a hobby. My initial task was removing 1000s of staples and cleaning up after what had to have been a slightly unstable tenant. After that began years of renovations to bring in running water, plumbing, electricity (it had a power but it was a mess) and the other comforts of home. So in Summer 2020 going to the house was kinda like camping. We cooked shashlik over a fire and I spent the days focused on building a usable outhouse.
The sleeping arrangement was a soba-bed. This is basically a masonry bed built into the wall over the soba (wood fired stove). The soba kept the house warm in the winter so in cold weather this little cubbyhole bed would be the coziest spot in the house. The only issue was that it was around 120 cm (around 4 ft) off the ground. This meant that you had to kinda jump up into it… and that falling out of it onto a concrete floor was a bad idea.
Presumably you see where this is going. One night I had a sort of nightmare / night terror situation involving snakes. I kinda jumped / sat up, yelled something about the bed being filled with snakes, and then rolled out of the bed. The “roll out” would have worked perfectly in a normal bed and I would have landed on my feet in a crouch. Since this bed was super high up it did not work out so well. I crashed down landing on my right foot in such a way as to turn it. Insert here the story of the tendon and the bone thing again and you get the picture.
After my wife recovered from waking up to the news that the bed was filled with snakes and then seeing me crash to the floor (destroying a small stool in the process), it is fair to say she was not thrilled with me or the house sleeping arrangement. It was decided right then to head back to the city in the morning and not return to the house until there was another bed available.
Once again my foot felt “wrong” but not in much pain. As I went back to sleep I felt that light fever come on and knew I had done it again. Off to the hospital in the morning.
The Chisinau Emergency Hospital
These days if you go to the Chisinau emergency hospital you will find a big, modern facility with computerized intake and medical records and state of the art reception facilities. Back in 2020 that was still under construction so it was a much more “Soviet” experience. The reception area was a door at the top of a concrete ambulance ramp that kinda spiraled up to the second floor of the building. There, an orderly signed you in on a paper pad and you got to experience the cultural experience of an Eastern European “line.” That alone is worth a short digression but I’ll leave it in the footnotes4.
After waiting for around 10 minutes another orderly came and collected me in a wheelchair. He took me to get an x-ray and then delivered me and the results to a doctor. The doctor looked at the x-ray, said “yup, it’s broken” and asked me if I wanted a soft cast or a hard one5. I took an old fashioned Plaster of Paris soft cast - I’ve had both types and figured this one would let me take it off sometimes for a bath.
Before getting the cast though I asked the doctor about the foot healing on its own. I mentioned that I had a nearly identical break before and was told I needed surgery. Over the course of this process I had looked at this new x-ray and compared it to my previous one in my phone while waiting.
The doctor looked at me quizzically and asked “are you a doctor?” I said “no” and, considering the matter settled, he simply walked away. I got my cast and was on my way.
Now let’s make one thing clear - I’m not a doctor. Just because these breaks looked identical to me doesn’t mean that he didn’t see something I couldn’t. At the same time, I always knew that the US break was not something that was in the “100% you need surgery” area. It was a strong recommendation and I was given a choice. In Moldova, you aren’t.
How Insurance in Moldova Works
Another aspect of this process is money. Chisinau has a first class private hospital called Medpark and if I had gone there I could have paid out of pocket, or used some kind of fancy expat insurance. As a bit of a “man of the people” I chose the local hospital and my national insurance policy. In Moldova healthcare is universal and is paid for through dedicated income tax contributions. As I owned a restaurant at the time and had around 25 employees I knew just how much I spent each month on this insurance - and it was a lot. So it’s important to note that while healthcare may appear “free” to the end user in a country with this kind of European system someone is paying for it.
So through my work I had a national insurance policy which I gave to the orderly at the door and he wrote down as part of my intake. Now, only a few years later, this is done via a fancy computer system and I can access my own health information through the EVO app6. In any case none of this cost any money out of pocket. This also means that there aren’t really financial incentives in the way that the medical personnel care for you compared to the US.
There is endemic corruption in parts of the medical system and many many people have had the experience of needing to pay doctors a bribe for care. I haven’t had that experience but it’s important to note - Moldova has something between a Soviet and a European system and there are issues.
Back to my experience though, I did accidentally go to the wrong clinic once for a checkup. Before leaving the hospital the doctor told me to go to the district non-emergency clinic 2 weeks later for an x-ray to make sure my foot was healing properly. I went to the wrong one which meant I needed to pay out of pocket for the x-ray. This cost 200 lei (around $11)7.
What is an Emergency?
To wrap up this article I thought I’d note how even answering this simple question has some important cultural influences. Back when I was a Peace Corps Volunteer in Kazakhstan the post’s doctor was a Moldovan. Dr. Victor was something of a legend in the Peace Corps and quickly became a favorite among the volunteers for his warm manner and dry wit.
As volunteers living in a country 4 times the size of Texas we were expected to take care of some immediate medical issues on our own and call the Peace Corps medical office for advice or help as needed. Dr. Victor gave us a presentation in a training session which asked us to gauge what is and isn’t an emergency. On one slide he showed a picture of toilet bowl where a recently deposited stool sample floated, teeming with worms. He asked for a show of hands on whether we thought this situation constituted an emergency - I assure you we all did. He said, “no, this is not emergency. It might be psychological emergency for you, but not medical emergency. Either way you can call me if you want.”
Dr. Victor started his career as a Soviet Army doctor during the Angola War. He explained to us that he had re-learned aspects of patient care after starting work with the US government. Specifically, that Americans were individualistic and wanted to have a feeling that they were in charge of their own care. Basically, he had to pretend that the opinions of non-specialists were valid and then talk a person into helping themselves. This clearly made no sense to him but he chose to play along.
Culturally, this is one of the main differences when you go to the doctor in Moldova. Sure, you can talk to the caregiver and I have rarely found people to be rude - but they are an authority, and you are not.
One other difference? When I left the hospital in Moldova no one put any opioids in my hands - they suggested I get some Tylenol.
I’ll end this short essay by noting that 15 years later I feel the after effects of my left foot surgery every day. It doesn’t often hurt, but I know what happened and it reminds me of those 2 steps I fell down on Spring break. My right foot? It healed good as new.
Obviously this is a limited case and subjective experience. Through other health related encounters over the years I can say that the lessons and observations I draw out here pretty well describe the different cultures and organizations of these health systems. At the same time, this is just a broken bone (not some complicated disease) and for sure people will have other stories and opinions - feel free to leave them in the comments.
I’m not really a clumsy person but I’ve broken a number of bones. Once you get beyond the terrible pain part - which wasn’t really a feature of my broken feet - you realize that a light fever is a sure sign of a fracture.
This was before the opioid backlash but even then I knew this stuff was worrisome. I took a pill the first day and enjoyed a wonderful high for the rest of the afternoon. The second day I took a pill and it hit only half as hard - same pill, less high, want more. Immediately I realized this is a *bad* idea and switched to Tylenol.
The concept of standing in an orderly line to buy a train ticket or get seen by a doctor is very alien once you move east of some imaginary point in Europe. Here people kinda cluster around whatever the goal is and it can appear (and sometimes be true) that people are just kinda elbowing their way past old ladies to get seen first. In reality there is a social norm whereby the newcomer asks everyone in the crowd “who is last [in line]?” As the newcomer you establish then who is in front of you and you become the last person for any new people. Everyone keeps track of the person immediately in front of them and behind them. There’s a kinda logic here for people culturally accustomed to long waits. Instead of standing and holding a place everyone can kinda spread out and occupy whatever the waiting room is while being assured that your time will come. It’s very disorienting at first but over time I’ve come to appreciate the process.
Sometimes we call a soft cast a “splint” in the US. Basically it’s a Plaster of Paris molding with a cotton bandage wrap around it. More modern fiberglass casts were available but a newer thing in Moldovan state hospitals at the time.
A lot has happened in the last few years on digitization in Moldova. Here’s a link to the EVO site. It’s a kind of citizen portal app that allows you to access various personal data and information (healthcare, taxes, unpaid speeding tickets, etc). You can also request state services and create digital versions of your drivers license and national ID. The whole thing is a work in progress but is already really useful. The app was partially funded and supported by USAID and until Trump and Musk decided to destroy this institution would have served as a real testament to the good work being done there.
For anyone wondering this was an official payment with a check provided - not a bribe.
Some aspects of Moldovan health care are seriously impressive to a Brit, (and this even before recent years, when the UK system has basically ground to a halt).
For example, my wife can call the number of her family doctor (GP equivalent), and get through to speak with her! Unheard of in the UK.
They generally seem to act VERY fast, operating the next day as soon as my wife was diagnosed with cancer. (Long time back, she's fine now).
I also had to use MedPark one time while here, for a minor operation under local anaesthetic. I was impressed by the service, and the cost was barely above the minimum of my health insurance, so I did not claim.
Great piece! That invisible European queuing line? It starts in Germany! In my experience, they are terrible queuers…and without the social system of identifying the last in line you describe. Last time I was there, it was no holds barred! I also appreciate your point about incentives. One great thing about the UK’s NHS is that medics have no financial incentives about what care they recommend. There ARE resource limits but that encourages doctors to focus on those with the greatest need. Which can, admittedly, be frustrating if you have a painful but not life-threatening condition. But when our little boys needed any kind of care, they got it immediately.