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Last January, emergency medicine icon Raed Arafat resigned from his post in the Romanian Ministry of Health, sparking unprecedented public protests in defense of Romania’s emergency care system.

In January, 2012, Dr. Raed Arafat resigned his position as Under Secretary of State of the Romanian Ministry of Health, a position he had held since 2007. An emergency physician born in Damascus, Arafat stepped down because he opposed the government’s attempt to privatize and commercialize Romania’s emergency care system. What happened next was unprecedented, not only for the world of emergency medicine, but for healthcare politics worldwide. Thousands of Romanian citizens took to the streets of Bucharest, demonstrating in support of Dr. Arafat and SMURD, the emergency care system he’d created for Romania. It is safe to say that never before has a leader in emergency medicine been so appreciated by his countrymen. “He simply hypnotised us with his words,” wrote Alexandra Mihai on his blog Al Hayat wa Dounia Newspaper. “Dr. Arafat is a hero, a big treasure that God sent to the Romanian people”(1).

Government protesters carrying signs in support of Arafat set fires and threw stones, and police responded with tear gas and water cannons. President Traian Basescu berated Dr. Arafat’s principles and policies on national television. Protests and citizen dissatisfaction grew stronger – so strong that Prime Minister Emil Boc resigned for the sake of Romania’s stability.

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(Top) Romanians take to the street in support of Dr. Raed Arafat (pictured below at a press conference) and the state-run emergency system known as SMURD.

 

altWhat kind of emergency physician could inspire a nation to protest in such a way? Arafat’s story begins in 1965. Born in Damascus, he grew up in Nablus, the West Bank, and by age 14 had mastered the only book in the Nablus library on emergency care: ‘First Aid Without Panic’.

“It was a passion,” he says, recalling that even in high school he was setting up first aid teams. Arafat fixed his sights on medicine and enrolled in medical school at the University of Medicine and Pharmacy in Cluj Napoca, in the Carpathian mountains of Romania. Romania was part of the Eastern Bloc until 1989, and 50 years of political and economic ties to Palestine made it a comfortable choice. Arafat was also admitted to a school in the United States, but his parents hid it from him, afraid that if he left, he’d never return.

In his 3rd year of medical school, a leading faculty surgeon encouraged Arafat’s interest in emergency care and he was soon teaching first aid and splinting techniques to medical students. Arafat then chose a residency in anesthesia and critical care (the closest option to emergency medicine at the time) at the Targu-Mures University of Medicine and focused his clinical and administrative energies on emergency care.

In 1990, Dr. Arafat created the Serviciul Mobil de Urgenta, Reanimare si Descarcerare (SMURD) – or the Mobile Emergency Service for Resuscitation and Extrication – in Targu Mures. This service, modeled on systems from Edinburgh, became the first mobile intensive care unit in Romania. This first ‘unit’ consisted simply of a used Opel Kadette equipped with a defibrillator and resuscitation equipment, purchased in Germany with help of the German Red Cross. Within a year of SMURD’s creation, Arafat’s leadership in emergency care in Romania was well recognized.

Before the development of SMURD, Romanian nurses and doctors worked on ambulances but lacked formal training in the principles of emergency care. Dr. Arafat used his skills in anesthesia and critical care to educate pre-hospital providers in intubation, ventilation, and cardiac resuscitation. As the reputation of the Targu Mures unit grew, so did the system, with new ambulances, monitors, and resuscitation equipment. In 1991 the unit became a joint venture between the Mures Fire Brigade as first responders, and the Mures County Emergency Hospital, fueled by the belief that “emergency care was something for everyone, and daily emergency care also includes disaster preparedness.” Many, if not most, worked as volunteers during this time. In developing these new concepts, Arafat moved quickly, following the adage that it’s better to ask for forgiveness than permission. In the end, having earned the gratification of his countrymen, neither were required.

The result of SMURD was that a whole new set of patients was getting resuscitated pre-hospital and making it to the hospital for care. However, when they did, there was no ‘emergency department’ or ‘emergency room’ in which to manage emergent cases after the initial resuscitation. As was the usual practice at that time, patients were placed in a ‘specialist’s room’ based on the organ system affected. So, in 1993, with direct support of the Royal Infirmary of Edinburgh led by Dr. Keith Little and Head Nurse Margaret White, a surgeon’s changing room in Targu Mures was partitioned as a ‘resuscitation room’. In the first year, the mortality in the emergency reception area, where the new resuscitation room was placed, dropped by 50%. Ideas were turning into reality for Arafat, and relatively quickly. In 1994, the Emergency Service of the Royal Hospital of Edinburgh, with support from the BBC, provided a modular building to serve as an emergency room, and placed it in front of the hospital entrance.

At the beginning, developing emergency medicine in Targu Mures was challenging because the physicians didn’t understand what Dr. Arafat and his colleagues were trying to do. But before long, whenever there was an emergency somewhere in the hospital – be it a difficult IV, an intubation or defibrillation – a call would come to the emergency department and the team would come running to save the day. It wasn’t long until the emergency department staff became recognized experts in critical cases, followed closely by the hospital’s appreciation at their ability to handle noncritical cases as well.  

Support for Arafat’s work came pouring in from every corners, from the local community to the ministry of the interior to emergency physicians around the globe. Eventually even the World Bank and the Romanian Ministry of Health took notice. Thanks to the support of the Royal Infirmary of Edinburgh, the Soros Foundation, and the Rotary Club, additional emergency departments were established in 1997 and 1998 in three major cities. Starting in 2007, the World Bank funded a national Romanian project to create even more emergency departments. Perhaps most impressive, however, was the community support: citizens raised $100,000 in 1998 to purchase a fully functioning intensive care ambulance. When faced with a government request for VAT of $60,000, citizens signed a petition opposing the VAT because the ambulance had been bought by the Romanian people. This led to the cancellation of the tax for that particular ambulance by a government decree.  

What started in 1990 with a used Opel Kadett is today a national emergency care system with 63 emergency departments throughout Romania, standardized by care as levels 1, 2, or 3. There are five national helicopters jointly managed by the Ministry of the Interior (police pilots) and EDs, for medical evacuation. Communication is well integrated between fire, ambulances and emergency departments. There is a national emergency phone number (1-1-2) and there’s training for paramedics and nurses. Between 1993 and 1999, 3-year emergency medicine residencies were expanded to 5 years. In 2011, there were nearly 3,500,000 ED visits in Romania and about 2,400,000 ambulance visits out of a population of 20 million. Arafat contributes the development in part to his role as Undersecretary of State, saying, “The solution for you is to work from top down not down up… Any country who puts a person at this level and gives him the power to do this, the emergency system will develop much faster than if it just developed spontaneously, department by department.”

In 2005, Dr. Arafat went beyond building emergency departments and became instrumental in the writing of legislation mandating prehospital, disaster and emergency care as the right of any citizen and the duty of the state to provide. It was Arafat’s opinion that emergency care could not be left in the hands of the local community or insurance companies; it is the issue of the state. In Romania, though EDs are part of the hospital, they are linked directly to the Ministry of Health and are funded directly by the state budget and not from insurance.

That said, Dr. Arafat is careful to distinguish policy from politics. He views himself as a technical person in emergency care, not a politician. But as a technical person with a powerful political appointment, Dr. Arafat is able to implement system change on a larger scale. As he says, “Emergency care should be looked at how it is delivered on a regional and national level, not as a local level. It is not just a medical system, it is the national safety and security system of any country. It is much more than medicine, it is how your system is developed so that you can take care of everyday and special situations, like mass casualty incidents.”

These top-down views are not without their detractors, as the protests of this past January illustrate, but in Arafat’s words, “Change cannot be brought about without disturbing someone, but with determination and faith in your idea, everything can be surpassed.” (1)

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After five days of rioting, President Basescu reversed his position, with a public declaration that Dr. Arafat’s concept of the delivery of emergency care – that it is a citizen right provided by the state – would not change. So Dr. Arafat returned to his position as Under Secretary to continue his work for the people, and by the people, and he continues in that capacity today. As he explains, “Emergency care is the right of any citizen and the duty of the state to provide. It is not to be left in the hands of the local community. It is the issue of the state.”

This article  originally appeared in Emergency Physicians International (EPi) Issue #9. Read more stories of global EM at www.epijournal.com


REFERENCES
(1) Alexandra Mihai, ‘Dr Raed Arafat, our Romanian Hero’, Personality of the Month on June 23, 2010, Al Hayat wa Dounia Newspaper).
(2) Hartley, Joel, First Aid Without Panic. 1975 Hart Publishing Company Inc; Popular Library Edition May, 1977)



 

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