From: Ton Daans
Open Letter to the Prime Minister of the Republic of Albania

Dear Mr. Edi Rama,

My name is Ton Daans and I am a Dutch citizen. I am a retired prison governor and since 2017 I have been in Albania, amongst other countries, as a non-residential expert in the field of corrections. I was involved in several projects and in 2018, 2019 and 2020 I acted as a ‘personal international penitentiary advisor’ for the Albanian minister of Justice.

This letter is not about me, but I’m using a recent private (outrageous) experience to address my concerns, not about the prison service, but about the healthcare system in your country.

I want to share my dramatic experiences with you. In addition, I would like to share these experiences with the Albanian minister of Health, with the Dutch Ambassador to Albania, the Chair of the European Union Delegation, the Albanian parliamentary commission regarding healthcare, the Albanian ruling party, the political opposition, Albanian civil society as well as some Albanian press agencies.

I am convinced that my experiences are probably similar and comparable with experiences of many of your fellow Albanian citizens. I am aware that I am not an Albanian citizen, but my heart cried after my experiences. My heart went out to all Albanians.

What was the direct cause for expressing my worries?

On Saturday April 16, 2022, late in the evening, I got injured after a fall on one of the many neglected pavements in the city of Tirana. I was suffering from severe injuries to my forehead, my nose, and my right arm.

The accident happened on the corner of the intersection of Bulevardi Zugo I and Rruga Reshit Petrela. After this incident, a very good personal friend of mine (with good understanding of the English language) took me to a trauma hospital, called ‘Spitali Universitar I Traumes’, in particular to the department ‘Urgjenca E Traumes’. I was in that hospital for a couples of hours and it seemed like I was thrown back in history. As if I were traveling via a ‘time travel machine’ back in time, back to the (Dutch) sixties of the last century.

Dear Mr. Edi Rama, I would like to explain these experiences. And I ask you kindly to consider these experiences from a certain point of view. Once, the amazing Russian Fyodor Dostoevsky wrote that ‘the degree of civilization in a society can be judged by entering its prisons’. I fully agree with the content of this quotation and in my opinion, it is possible to turn the term ‘prisons’ into other social institutions in society, like psychiatric institutions and general hospitals. Healthcare is among other paramount issues, e.g. the Rule of Law, an essential pillar of a well-balanced civilized society. A good healthcare system is a prerequisite for the well-being of all citizens of a society.

I am presenting a very detailed description, especially because I think it is necessary to understand my final conclusion/considerations and my worries, though I am assuming that you are fully aware of the existence of many weak points in the Albanian healthcare system.

Moreover, I want to note that I am not blaming the (para)medical staff of the hospital. I am convinced that systemic and organizational ‘flaws’ and shortcomings are the actual cause for the poor quality of the Albanian healthcare. My main observation was that the staff have to deliver well-balanced medical healthcare while the conditions do not allow to perform well. And these conditions are outdated. The staff will have to make do with what they have. The medical staff is confronted with a systemic exposure of shortcomings. That is a clinical fact!

Firstly, I wish to present to you some (clinical) facts and some personal remarks:

  • During my visit to the hospital I met many nurses and some doctors. Only one doctor (a general surgeon) had a good understanding of the English language. If I hadn’t been accompanied by my Albanian personal friend any normal conversation with the medical staff in this university hospital would have been impossible because of the manifest language barrier;
  • On the emergency department that I visited, computers-devices were not available and some information about me, my injuries etc. were handwritten in big books;
  • There was no toilet paper available for patients, as well as no potable water (drinking water);
  • In the toilet was no water in the cistern of the public toilets;
  • During my treatment my privacy (as a patient) was absolutely not respected;
  • In the radiology department they used an X-ray device that probably was purchased many decades ago;
  • As a patient in this radiology room I had to kneel on a stone floor because chairs or stools were not available. At the age of 68 and severely injured, this could be best be described as ‘torture’, a real hell;
  • After stitching my wounds, I had to stay in a kind of observation room but the bed that was used by me was not a bed with clean sheets;
  • Because a doctor had diagnosed a fracture in my right upper arm the arm was put in a cast (plastered). During this plastering I was also interviewed by police officers about the accident and the plastering had to be suspended for a short while because the police officers needed my signature;
  • A sling (to support my injured and casted arm) was not available in the hospital; I had to buy one in a pharmacy in the city.
  • I asked for a medical-release letter to hand over to my General Practitioner (GP) in The Netherlands several times. After a couple of refusals, finally a nurse (of an ambulance, who was present), who was not involved in the treatment process wrote some information on a piece of non-official paper. The notes were handwritten, the ‘document’ was not dated and not signed and no stamps on it. There were two diagnoses on this handwritten paper and I was aware that one of the diagnoses interfered with the first (verbally expressed) diagnosis of the general surgeon; in fact, the handwritten diagnosis was the opposite of the verbal diagnosis that this general surgeon presented to me. More about this subject later;
  • I have said many times in the hospital that I use a blood thinner as medication every day, after a spontaneous non-covid-related pulmonary embolism in December 2020; yet again, more on this subject later;
  • I took the X-ray photos with me to The Netherlands (with permission of the medical staff);
  • One of the members of the (para) medical staff asked me if a Dutch medical doctor was available at the Dutch Embassy in Tirana. I did not understand why he asked me that question.

Secondly, due to the accident and the injuries I had to stop my mission and I returned to my homeland on Monday April 18, earlier than planned. After my return to my hometown, Eindhoven, I immediately contacted a traumatology specialist in our local hospital.

I want to note some remarkable conclusions of this specialist in the Dutch hospital:

  1. A very poor cast material was used to put on my arm. The arm should have been fixed. It was not done properly. After some hours I noticed that the elbow of the cast hinged. This is mistake 1.
  2. The Dutch traumatology specialist concluded after checking the Albanian X-ray photos and after doing some medical tests that there was NO fracture in the arm, but there was a severe contusion to the arm; so, a completely wrong diagnosis was made in the Albanian trauma hospital. The (broken/hinged) cast was removed. The wrong diagnosis is mistake 2.
  3. The handwritten diagnosis about the arm was “fractura olecrani”; according to the Dutch specialist this diagnosis is completely wrong. This is mistake 3.
  4. The hand-written diagnosis about the head was “contusion Capitis ET VLC”; according to the Dutch specialist completely wrong. This is mistake 4.
  5. As mentioned earlier, the handwritten diagnosis was also not in compliance with diagnosis of the general surgeon. This is mistake 5.
  6. Taking into account the fact that I was suffering from a severe head injury and taking into account the use of blood thinners, and according to international accepted medical standards, the medical staff should have initiated an examination with a CT scan, and if such device is not available, the medical staff should have taken the decision to hospitalize me for at least 48 hours for observation and surveillance, as there was a risk for an internal bleeding in the head. This is mistake 6.
  7. There was no neurological examination at all, not by a surgeon, not by a nurse, nor by a neurologist. This is mistake 7.
  8. I received a ‘fit to fly-declaration’; again, based on the considerations as mentioned under F, it was a real blunder to hand over a ‘fit to fly-declaration’. And it is more significant that this declaration was given without any neurological examination or short neurological tests. Based on the declaration I took a flight on the afternoon, of Monday April 18 only 38 hours after the accident; the Dutch specialist was of the opinion that the medical staff in Tirana took an irresponsible risk. The combination of head injury, the blood thinner, the pressure in the cabin of the plane could have caused an internal bleeding in the head/brain. This is mistake 8.
  9. After my release, I was sent back to my hotel. No one gave me the advice not to stay alone because of risks of an internal bleeding to the head. Supervision in the hotel should have been a ‘conditio sine quo non’. However, it was not advised in that way. This is mistake 9.

Still, I am thankful that the wound in my head was closed with stitches, but apart from that, almost everything was ‘sub-optimal’ in this university hospital, where (para)medical and staff have to deal with outdated devices and without any computer. Furthermore, I have observed a chaotic working process, with no clear system of tasks, authorizations and responsibilities. The approach was completely non-patient-centered, the communication was confusing, the system of registration is fully insufficient and working processes are not good and not effectively organized. Moreover, I had the impression that some members of staff were not well educated and some of them were performing as if they were completely uninterested and unmotivated.

In my opinion all these facts are ingredients for possible and unthinkable disasters.

Prime Minister, it is not about me, I was able to go home, to visit a well-equipped modern West-European hospital.

However, the Albanian citizens, excluding the wealthy happy few in your country, dear Prime Minister, are not able to travel abroad.

I fear, and this is not unthinkable, that people are dying unnecessarily as this could well be a realistic scenario in the trauma hospital or in other state hospitals.

Before I entered this hospital on April 16 2022, during the past years, I heard a lot about the quality and standards of the Albanian health care service. About the ‘brain drain’, about motivations, about corruption, about the differences between state and private clinics. And people confirm that due to poor healthcare, people are dying.

However, dear Prime Minister, healthcare is not an issue for making profits. It’s a fundamental task for the state to guarantee that there is a (comfortable and free) access for all citizens to a well-balanced and good healthcare system. Based on my experiences, of course in combination with what I have heard and what I have read, I have the humble opinion that there are some significant areas for improvement. A real challenge.

Good healthcare is directly related to human rights. And respecting human rights in all facets is a prerequisite for an acceptable degree of civilisation.

I am convinced Mr. Fyodor Dostoevsky would agree with me that the degree of civilisation of your society is not in compliance with European standards regarding medical healthcare.

Furthermore, dear Mr. Edi Rama, in my opinion healthcare can never be a balancing item of a state budget. When I walk in the streets of Tirana and I compare the sky line of the city to a couple of years ago, I notice a lot of money is available to realize real estate. Perhaps you blame me for comparing apples to oranges and that you wish that I would stop addressing some critical remarks.

However, it is my honest and sincere intention to advocate for the ordinary citizens of your beautiful country. To advocate to improve the access to a good healthcare system for everyone in your society. I consider that this principle of solidarity will appeal to you as chair of the ruling socialistic party (PS).

Prime Minister, I hope that you do not dismiss this letter as overheated emotions, or worse, as an incident.

I sincerely hope that this letter will contribute to some fundamental reconsiderations. And please note, Prime Minister, do not forget psychiatric care, healthcare in prisons and police stations and forensic psychiatry in your penitentiary facilities. Based on an inclusion model, all Albanian citizens, young, old, free citizens, incarcerated people, all of them are entitled to have access to a well-balanced and well-organized healthcare system.


Very kind regards,

Ton Daans

International advisor in the field of corrections

Eindhoven, The Netherlands, April 26, 2022