Estonian Healthcare - Redux & Personal

I've written before about Estonian healthcare - how it's considered crap, though probably undeservedly. Of course, it is difficult to pass judgement on a system that you've only ever used for trivial matters. I've had major surgery when I was very young, but that was still in the Soviet times and I remember nothing of it. Otherwise I never had cause to avail myself of Estonia's hospitals for anything more serious than an adenoid removal, which took half a day and resulted in as much ice cream as I could eat; not a complete waste, then. A couple of years ago I got into a fairly impressive car accident, was ambulanced to Tallinn and checked over at the ER; I was sent home the same evening with some stitches and a concussion. That was luck. But in 2008, I've been deliberate.

I'm a big guy. Always have been. I'd resigned myself to being fat for the rest of my life; and then I decided I was going to do something about it. The key factor was the appearance of bariatric surgeons in Estonia; but the turning point was late last fall, after I'd been swimming regularly, three times a week, for about half a year. I was feeling a lot better and gaining muscle mass, but not really losing much weight. My last bit of self-deception - that I could get into shape through diet and exercise - fell away: there is no way I will ever have the sort of self-discipline for the sort of massive weight loss I need. There are people in the world who've done it, and I have the greatest respect for them, but that's not me. Growing up fat meant a lot of confidence issues; Antyx readers will recognize that confidence is not something I have a problem with. The way I did was to stop hating myself. Self-discipline on the order required to go from the clinical definition of morbidly obese to more or less normal would have to stem from a burning hate for my own body; and that is not a choice I am prepared to make. Even if it kills me.

Fortunately, I now have the opportunity to cheat; to achieve the result while bypassing the part that makes it so difficult for me. Not that the cheat itself is particularly simple, but it's something I can do. There are surgeons in Estonia who do the operations that result - reliably - in radical weight loss; I am still young and have most of my health; and I can afford the surgery. I'm paying a little over two thousand Euro for it, which isn't a lot. Thanks to the Estonian healthcare system.

My first move was at the end of 2007, when I saw my GP (or rather one of the GPs sharing a pool of patients) for a severe sore throat. I got a week's bedrest and a referral to an endocrynologist - a specialist on metabolism. Since this was not an urgent matter, I got put in the back of the queue; a little over a month till my visit.

When the time came, it was all remarkably efficient. I paid 50 EEK (3 Euro and change) for the initial visit. The doctor ran a bunch of tests, some that afternoon, the rest on the next morning. A week later I got the results, with commentary, and some research on the state of bariatric surgery in Estonia. The doc confirmed the diagnosis I'd known already: hyperinsulinemia, the most remarkable thing about which is that it is not diabetes. What it does do is cause an appetite disproportional to consumption. By this time I'd recognized that I eat more than most people; but I do it without really thinking about it. It's the difference between hunger and appetite, and it's something that ought to be fixed well by an operation that constricts the volume of the stomach. The endocrynologist gave the go-ahead.

I then contacted the surgeon, from a Tallinn private practice. It took a while to set up a visit, and when I did travel to the capital, it turned out that he was in surgery; apparently he actually works as a gastric surgeon on the staff of Tallinn's regional hospital as well. Fair enough, really; but what I did find out was that the metabolism workup was not sufficient. I'd also need to be cleared by a gastroenterologist. Fortunately, I could do that in Tartu.

This time I didn't feel like waiting a month, so I cheated. I paid the university hospital for an unreferred visit to a specialist doc. My 300 EEK (20 Euro) got me a time within two business days of putting in the request on the hospital's website. Since I did actually have national health insurance, that was all I paid; the ultrasound, gastroscopy and doctor's consult were all free. The GE was one of those old doctors that somehow instill tremendous trust. (I've never been afraid of docs, not even of needles when I was very little; an old relative that died before my birth had been something important in Estonian medicine, so all through my childhood various doctors had been very pleased to meet an heir to that family. Comes with having an uncommon last name.) She gave me the OK, and mentioned what she knew about the bariatrics in Tallinn; some 70 surgeries had been performed successfully there.

Most of those were of the really hardcore kind. There are three types of surgery available, and the most radical one is an actual bypass, where the patient's guts are rerouted. (Curiously enough, since it's purely surgical and does not involve any medical gadgets, it gets paid for in full by the national health insurance.) The least invasive type is the gastric balloon, which they insert through a tube down your throat - but it stays there for no more than 6 months, and I needed a longer-lasting effect than that. So I'm getting a lap band - a sort of belt that gets tied around the top part of the stomach. The upshot is that very little food can actually fit in there, so I can't overeat - and apparently most of the nerve endings are at the top of the stomach, so I constantly feel really full. It's not a magic pill, but it's been around for decades, and it seems to really work.

The great thing about the lap band surgery is that they're not cutting any internal organs - just adding a new bit. Sounds safer than removing an appendix.

Today, after my extended three-day birthday celebrations involving cake and a last Chateubriand stake from the Crepp meatery, I weigh 149.8kg. My surgery is on Wednesday. I'm about to put my gut where my blogging finger is.

The AnTyx Fix: Education

Wrote about education a few weeks ago, and of course somebody asked me what we're supposed to do about it. Which is a very good point; it's my job as a blogger to suggest the proper way to do things which I think are broken.

There was a news blurb in the papers yesterday: apparently there is something called an IT Council, and they recommended that the national school-graduation exams include mathematics as a mandatory test. This would produce a lot more youths with aptitude in mathematics, solve Estonia's labour shortage, and generally save the dolphins.

Well, that's a silly idea. It would be valid in India or China, but it's inappropriate for what we are trying to do here. Making maths mandatory is going to produce a large number of people with just enough math knowledge to pass the test, and they will be expected to go into IT, and we will have a workforce of semi-competent code monkeys that are far more expensive than semi-competent code monkeys in Bangalore, and nobody will have any use for them.

Estonia needs to be a knowledge economy. Our marketable skill is competence, and the ability to design and implement the optimal solutions to a problem. Solutions which are remarkably useful, and I mean remarkably - so good that you can't help but remark on it. To sustain this, we need to give our people the opportunity to become really good at what they do, and we can't do that by forcing all of them to learn Java.

Now, I've seen something recently which made me think about these things. It was a list of things you have to do when you're poor. It had really sad and hard-hitting lines like "Being poor is making lunch for your kid when a cockroach skitters over the bread, and you looking over to see if your kid saw". It made me think of my own family, back in the early 90s, when often enough my dad would simply not get his salary; he'd do the work, but there would be no money to give him. We were properly poor back then. But these days - I'm not rich, but I've fooled some people. I'm comfortably middle-class, with enough disposable income for a moderate selection of toys. So's the rest of my family. So are my friends, including the ones I grew up with.

And it occured to me that the biggest external contributing factor - other than the fact that I'm just naturally good at something that I've managed to earn money doing - was education. More importantly, the fact that I could go to the best university in the country and pay no tuition at all. I worked through most of my uni days, and my parents helped out, and I took out student loans some of the time (secured by the state - the interest is actually less than inflation now), but I couldn't have done it if I had to pay tuition as well. And yes, I have a BA in English, which is about the most practically useless degree one can have (second only to semiotics and philosophy), but it's still helped to find a good job. It has also given me an excuse to move away from my parents, and get the confidence of being able to take care of myself.

So how do we scale that experience? Keeping in mind that our ultimate goal is to create a steady stream of intelligent, well-trained and highly competent specialists? I don't have a guaranteed solution, but I have an idea on where to start.

1) Money. Estonia's free-market ideology means that the government does not own the companies that provide a government-regulated service. The national universities (like hospitals) are commercial enterprises; and every year, the government calculates how many specialists in a certain field it will be able to use 3 to 5 years down the line. Based on that, it signs a contract with a university, paying it to train the specialists. The university has a certain, significant but limited, number of tuition-free spots, which are assigned to applicants based on academic achievement. Usually, those who didn't make it will have a chance to get a paid spot - a thousand Euro per semester or so. Same curriculum.

Obviously we end up with more specialists than the state ordered. The state is limited by its budget, and relies on the commercial spots and all-private universities to make up the shortfall. The problem is that the all-private universities are generally crap (I think Tallinn's EBS business school might be the only exception). More money for more free spots would allow a concentration of students to the better institutions. We'd be fine with a University of Tartu and a University of Tallinn, and their colleges in Pärnu, Narva, Haapsalu... I have no faith in places like Mainor or Euroülikool.

More opportunities for free tuition will attract more students to the universities that can provide good education. Education from a good university is a useful thing even if the student ends up with a job that has nothing to do with his degree - as a lot of people do.

2) Exams. Currently, there is a single set of exams for high school graduation, and the results of these are used by the universities to generate an average passing grade. The results of all applicants are averaged out, and those who have a grade higher than the threshold, get the free spot.

The problem with this is that the exams cater to the lowest common denominator. Not all the kids who leave high school will go to university. Not all universities are the same in the level of education they offer, and thus the level of student knowledge they require.

The universities need to re-introduce their own entrance exams. This will allow the good colleges to accept good students; or rather, because they will be the ones with an abundance of free-tuition spots, it will motivate more students to study hard and bone up on the subject matter. It should also intrinsically limit the number of kids applying for a major with a low entrance barrier that they have no long-term interest in - just to get that student status.

3) Support. Estonia's tertiary education system has been criticized for mostly being inferior to universities abroad, but that is the wrong approach. Obviously it is not possible for a country of 1.3 million to build up a talent pool as comprehensive, diverse and advanced as a country with thirty or fourty times the population. Fortunately, we don't have to! The fact that it is so easy for our kids to go and study in Oxbridge or the Sorbonne is an advantage, a very significant resource bestowed on us by EU membership, and one that we would be fools to ignore. By the very nature of the Estonian people, they will not stay away forever; even those with an education and a career in the confederacy or further off will still return sooner or later, because of the fundamental Estonian sense of home. EU's best universities should be exploited by Estonia in the same way that EU funds are used to renovate our infrastructure.

Of course any application for EU funds is accompanied by a mandatory self-financing component. The same point applies. The Estonian government needs to dedicate resources - financial, administrative and political - to supporting those of its youths who choose to go abroad and study at the best colleges in Europe, or indeed the world. In the same way that the state secures student loans at a low interest rate, pays for tuition, and ensures discounts on vital goods and services (I'm still convinced that there is a state tender for the 1.90 EEK packets of ramen in the shops near Tartu's dorm cluster), there needs to be an extensive government program of supporting kids that study abroad. Something similar exists in a basic state - you can get your student loans written off if you work for a government agency after graduation - but it needs to be greatly expanded.

So, what do you think? Does any of this make sense?

Current Affairs

Well, it looks like the government's found a loophole to keep the zero corporate tax regime in Estonia and still be in accordance with EU directives - if only just. At the same time they've passed a bill raising excise on fuel, alcohol and tobacco, among other things. All in all, while the income tax will keep falling to 18% (and somehow I'm getting the feeling that's as low as it will go), and additional tax breaks for families with young children are introduced to bolster population growth, a lot of the extra money will be eaten up by the cascading price increases. The point is to cool down the economy - stop discretionary spending, reduce consumer & long-term debt, and prevent the bogeyman that is a "hard landing". I've yet to see a good explanation of this nasty phenomenon, but apparently it'll cause everyone to lose their homes.

Edward Lucas says that we're doing better than most Eastern European countries, because we have a budget proficit (this is a legislative issue, the government is not allowed to spend more than it gets). If you're in the mood for a cheeky chuckle, enjoy master Lucas's elaboration, of high importance to readers of The Economist: quoting "Juliet Sampson of HSBC, a bank."

Now that the economy's sorted, or at least there's a plan of action, we can go on to the next big issue: traffic deaths. Over a hundred people have bitten it on the roads in the first half of 2007 (and somewhat surprisingly for those who know me well, I wasn't among them). This is a major problem now, and a very public one. The reasons are mostly to do with the gung-ho attitude of drivers being inappropriate for the twisting, occasionally dilapidated, all too often slippery highways of this heavily-forested country. The government is getting drastic: besides the standard talk of increasing fines and introducing a point system, they've gone ahead and purchased a bunch of speed cameras. In this first phase they've only got enough hardware to cover about 80km of road, apparently, but if the gatsos are effective, there will be more.

I'm not sure how I should feel about it. As a car enthusiast, I am bound to finding speed cameras repulsive. On the other hand the highway traffic really is getting quite bad. There's a time and place to drive fast, and the behaviour of many drivers on the Tartu-Tallinn road* is quite simply imprudent. Having survived several highway mishaps, I now prefer to stay within reasonable proximity to the speed limit. If gatsos really are an effective deterrent, and if they'll not just be used as revenue generators, I can't in all honesty complain.

There are, however, sillier ideas going around. Reader letters in Postimees have suggested mounting a speed limiter on the cars of rookie drivers and repeat offenders, physically preventing the car from breaking the speed limit - this ties in to the EU idea of banning cars capable of going faster than 160km/h. The problem is that this is presents a safety concern: in some situations, you need power to pull off a maneuver safely, and an arbitrary engine limiter could very well put you in harm's way.

In Tallinn**, they're thinking of reducing the speed limit to 40km/h. Now, a basic principle of legislature is to not pass laws that cannot possibly be enforced. The traffic speed in Tallinn today is more organic than prescribed; very few drivers follow the 50km/h limit unflinchingly. If all the cars around you are travelling at 70km/h, you'd better do it too. Reducing the limit would achieve no more than criminalize the population, which would do nothing for safety, but would generate resentment. Bad idea.

The only things I can think of that would seriously improve traffic safety are road construction - freeways especially, as it's rather difficult to kill yourself in city driving (although there are bright sparks who've managed) - and saturation of the traffic flow with police presense. To the best of my comprehension, raids on the Tallinn-Tartu road during peak hours, when you'll see five or six squad cars over the length of your trip, have been effective. There's no need to enforce the letter of the law rigorously and punish people harshly for every minor infraction, but the mere presense of traffic police in the flow at all times should do wonders. Estonians are sufficiently civilized that they won't break the law while the police is watching. ;)

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* The road I'm most familiar with, and the major artery in the country. They're doing things to it - diverting heavy trucks during peak hours, extending the autobahn-style separated sections, etc. Curiously enough, while dangerous, it is not responsible for most of the fatalities - people kill themselves a lot more on country roads. There's a known phenomenon with twisting mountain passes, that it's statistically a lot better to not put up any barriers at the edge of the road - drivers who are scared shitless will drive more prudently and get through safely. The appalling traffic of this freeway probably acts as a similar inhibitor.

** I'm too tired to think of a way to convincingly blame this on Edgar Savisaar, so use your imaginations.

The AnTyx Fix: Schools

Let's be constructive, shall we? In the very admirable and very Estonian spirit of not listening to people saying it can't be done, here's one ostensibly excellent solution to a very difficult problem.

The disenfranchisement of Estonia's Russian-speakers in the new generation is usually attributed to two things: hostile foreign media, and russian schools as an impediment to integration. The former comes down to the fact that Russians en masse will not speak Estonian and do not speak English, in fact they're having a hard enough time learning their own language; the upshot being that the underclass lemmings stay in front of the television showing channels piped over from Russia, and forego any sort of critical analysis of the propaganda therein.*

The latter compounds this problem by making sure that young Russian-speakers have very little opportunity to escape the vicious circle. Friendships and afterschool activities are maintained within this virtual ghetto, under the watchful eyes of a faculty mostly carried over from the Soviet days. Like the rest of the Russian-speaking population, the teachers are likely to be immigrants, but their training includes both indoctrination and the imperative to indoctrinate the kids.

Russian-language schools are actually an example of the astounding tolerance towards the community by Estonians; in very few European countries will you find massive, municipally funded education networks in languages other than the state tongue. The fact that russian schools exist is, however, mostly a consequence of a lack of ideas - Estonians aren't particularly happy about them, and Estlanders increasingly prefer to put their kids in estonian schools. The russian education is being phased out slowly, as the demographic balance shifts and the Russian-speaking population shrinks faster than the national average; however, every single school closed provokes a wave of indignation and accusations of malice.

The reason the educational system was not transferred entirely into Estonian right after independence is one of logistics. At the time, it would've been politically possible, I think. But there simply weren't enough teachers to go around, and after a while the integration policy - a mix of assimilation tactics and "ignore the ruskies, maybe they'll go away" - made the question one to dodge.

Whenever it was brought up - both at the time I was in school myself** and later - it was always the same thing: start from the top, switch the higher years to Estonian and work your way down. I'm not entirely sure what the logic behind this is. My best guess is that because the last three years are not mandatory - children can leave school after Year 9, even though they are guaranteed an education for free up to Year 12 - the assumption was that any kids who make it into the final stage will be both reasonably bright and reasonably motivated. So the cut-off point was set to Year 9; above that, some of the classes are now taught in Estonian - particularly things like Estonian literature and history - and more are to come. Even that project is stalling because of a lack of teachers able to speak the language properly.

The vision of a Russian teacher reading the material to Russian students in Estonian is, admittedly, extremely funny.

However, the approach itself is fundamentally wrong. Kids who don't speak Estonian as a first language will resent it, of course - it's more difficult for them; the result will be that on the one hand, the students will resort even more to rote memorization instead of actually comprehending the material, and on the other, their attitude towards the impossibly complicated tongue will not improve. A bit of extended vocabulary is hardly the same thing as linguistic proficiency.

The trick is to start at the other end: phase out Russian-speaking first years. As anyone who's either taught or learned a language will attest, it is incomparably easier to pick up the skill at an early age. Seven-year-olds who are suddenly forced to spend their day talking in Estonian will have no problems growing bilingual (and there's no reason why the scheme can't be extended to kindergartens; most of my Estonian now is a pale remnant of the proficiency I had when I went to kindergarten with two dozen Estonian kids). Furthermore, it is far easier on the teachers. I am not going to claim that elementary school teachers' jobs are simpler - but the material itself is, especially in the context of a new language.

Set a cut-off date: from the year 2008, no more russian first grades. The existing ones will be allowed to run out - their teachers can then either retrain or retire (which most of them should be about ready to do, after fighting uphill for the best part of two decades), and within twelve years the problem will have been solved.

Education specialists in the audience - you know who you are - is there any objective, pedagogical reason why this wouldn't work? I can't think of any.

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*This is not to say that Estonian media don't engage in blatant and grossly inappropriate propaganda; however Estonians by their nature are too sceptical to buy into the crap wholesale.

**Yes, I went to a Russian-speaking school. Supposedly a fairly good one, too. Though its principal has been in the news last year for being unable to speak any Estonian whatsoever, despite it being a job prerequisite and him being able to produce the necessary certificates.