From ... in Health — Aug 4, 2020

Hungary: Health Care Failures Endanger Lives

(Budapest) – Longstanding neglect by the government has left the Hungarian public healthcare system under-prepared to handle the Covid-19 pandemic, Human Rights Watch said today.

Human Rights Watch found poor conditions in hospitals, including a lack of hand soap, sanitizer, and proper cleaning of premises; lack of sanitation supplies and personal protective equipment for health workers and patients; an insufficient number of single-bed rooms to isolate people with suspected or confirmed infections; insufficient microbiological testing for specific pathogens and lengthy wait times for results; and lack of reliable data and statistics on hospital-acquired infections, including resulting deaths. “People shouldn’t fear that going to the hospital will expose them to conditions that will make them sicker,” said Tom Porteous, deputy program director at Human Rights Watch. “Although it seems Hungary has not been hit as hard as other European countries, by the novel coronavirus, the virus has not disappeared, and Hungarian authorities need to urgently put in place reforms and more investments to protect patients and health workers from infection or death.” Between May 2019 and July 2020, Human Rights Watch interviewed 24 survivors or relatives of victims who had contracted infections while hospitalized in previous years. Six of the patients died.

Their stories are painful testimonies to the shortcomings of the public healthcare system, weaknesses highlighted and sometimes exacerbated by the Covid-19 pandemic and the government’s inadequate response. Official statistics for 2018 put the number of recorded hospital-acquired infections at 15,151, of which 541 resulted in death – the actual number is most likely much higher.

The deficiencies in Hungarian hospitals may have contributed to the spread of Covid-19. According to the Chief Medical Officer of the State, as of July 12, 1,062 patients had contracted Covid-19 in hospitals, of whom 260 died. With 4,263 confirmed cases and 595 deaths reported to the World Health Organization (WHO) by July 15, this means that 25 percent of reported confirmed infections were contracted in hospitals, and hospital-acquired Covid-19 infections led to almost 50 percent of reported deaths. Similar to other Central European countries, Hungary’s official overall Covid-19 infection rate is relatively low compared with the rest of the European Union.

The findings indicate that the Hungarian government is not upholding its obligations under the right to health, to either patients or health workers, as required by international law. Under the right to health, governments must ensure adequate sanitation and healthy working and environmental conditions, and take adequate action to prevent, treat, and control diseases. Doctors reported difficulties getting personal protective equipment and confusion around guidelines and procedures for handling suspected Covid-19 patients. Doctors and health experts said testing capacity for Covid-19 was limited, that it was difficult for people to get tested, and confirmed or suspected Covid-19 patients were not always properly isolated in hospitals.

The first Covid-19 cases in mid-March were confirmed among foreign students in Budapest who were quarantined at a local hospital. Human Rights Watch interviewed one quarantined student, who described a lack of social distancing and isolation. She said she was put in an ambulance with several other patients and then in a room with two other unrelated people before the hospital had assessed their infection status.

The lack of sufficient protective personal equipment, including medical masks, gloves, eye protection, and gowns, and proper training and guidelines for staff also most likely contributed to the high number of Covid-19 infections of healthcare workers. According to information obtained from the government coronavirus taskforce, as of late May, 576 health workers had tested positive – 14.8 percent of all known cases. Government authorities should collect and publish disaggregated data about health worker infections and deaths during the pandemic, Human Rights Watch said. Hungary’s public healthcare system has been dysfunctional for decades. During Prime Minister Viktor Orban’s 10-year tenure, public health care has not been a priority, with spending under 5 percent of Gross Domestic Product (GDP). According to a 2019 WHO report, Hungary’s 2016 public health spending accounted for 4.9 percent of the country’s GDP, compared with a 7.8 percent EU average.

The WHO said the Hungarian health system was “chronically underfunded,” with the public share of spending accounting for only two-thirds of total expenditures in 2017. Out-of-pocket spending on health by Hungarians accounted for around 27 percent, far above the EU average of 16 percent. On April 7, an order from the Human Capacities Ministry, which deals with healthcare issues, obliged public hospital directors to free up 36,000 hospital beds nationwide to make room for potential Covid-19 patients. As a result, some non-Covid-19 patients were discharged without adequate alternative care, and others may have been required to share already full rooms with other patients. In one case in late May, which the authorities told the patient was to make room for potential Covid-19 patients, 7 children and 7 adults were crammed into 1 room, where they were unable to socially distance, while at least 4 rooms in a children’s hospital ward stood empty. Human Rights Watch also documented similar issues with poor isolation of suspected patients with hospital-acquired infections.

The Covid-19 pandemic brought longstanding problems with the lack of transparency and obstacles to public information in Hungary into sharp focus, Human Rights Watch said. A government decree adopted under the March 30 declaration of a state of emergency, which allowed the government to rule by decree without parliamentary scrutiny, extended the response time allowed for public institutions to freedom of information requests from 15 to up to 90 days.

The state of emergency ended on June 18, and with it the provisions of the decree. Governments have an obligation to protect health workers and patients in health facilities from infection and should provide health information and adequate protective clothing and equipment to minimize risk of infection.

The Hungarian government should, as a matter of urgency, allocate necessary funds and resources to ensure that public healthcare facilities have adequate equipment, supplies, and staff to ensure the highest possible quality of care.

The government should also improve its monitoring of healthcare facilities, their compliance with regulations and protocols on hygiene, sanitation, and infection control, and its reporting of infections. Finally, the government should regularly and transparently publish data on hospital-acquired infections and deaths and Covid-19 infections and deaths, disaggregated by regions, localities, and hospitals, as well as age and gender, and increase oversight of adequate recording and reporting of cases. “Orban’s claims of protecting ordinary Hungarians ring hollow when his government is letting hospitals crumble, forcing patients to bring their own soap and, in some cases, depriving people of care,” Porteous said. “Instead of funding xenophobic campaigns or building hundreds of football stadiums, the government should invest in its public healthcare system to benefit all Hungarians.” For detailed findings, please see below. Between May 2019 and July 2020, Human Rights Watch interviewed 24 patients or relatives of deceased patients who contracted infections during medical treatment in public hospitals, as well as 3 medical experts. Since the Covid-19 pandemic was declared, Human Rights Watch interviewed 2 general practitioners, 1 medical expert, and 3 patients hospitalized during the pandemic. On August 9, 2019, Human Rights Watch requested detailed information on hospital-acquired infections from the Human Capacities Ministry. On October 7 the ministry sent a one-page letter referring to existing legislation and providing a website link to the Hungarian Statistical Office. Human Rights Watch sent three separate requests between October 2019 and January 2020 to meet with the government’s chief medical officer, and requests to five public hospitals in January of detailed information on procedures and guidelines, but received no replies. Hospital-Acquired Infections Hospital-acquired infections, also called nosocomial infections, are contracted in hospitals or other healthcare facilities during the process of care, and were not present or incubating when the patient was admitted.

They can also appear after patients are discharged.

The risk of contracting such an infection is highest in an Intensive Care Unit, where patients may be immune-compromised and where medical procedures and contact with health personnel and contaminated equipment can facilitate infection. Basic personal hygiene, sterile tools and conditions, isolation rooms for infected patients, and appropriate hospital infection control and cleaning procedures help to reduce the number of infections and deaths.

The WHO considers hand washing and hand sterilizing to be the primary method of infection control to reduce these infections. It was a Hungarian-born physician, Ignac Semmelweiss, who in the 1840s first established a link between doctors washing their hands between patients and a radical drop in child fever infections and maternal deaths. Since 2010, changes to Hungary’s public healthcare system have weakened independent monitoring of healthcare institutions and quality control of the healthcare profession.

The Orban government folded the previous Health Ministry into the Human Capacities Ministry, which is also responsible for culture, sports, education, social policies, and health care, to list a few.

The government also dissolved or replaced previously independent institutions, including the National Public Health and Medical Officer Service, tasked with monitoring and controlling public health and epidemiology security. Ferenc Falus, Hungary’s former chief medical officer, affirmed to Human Rights Watch that centralization of the public healthcare system from local level to state level has undermined important checks and balances on the quality of care. “Monitoring and enforcement mechanisms are not independent from each other and this is a problem,” Falus said. Failure to address shortcomings in the public healthcare system, including underfunding and understaffing, exposes patients to preventable risks of contracting hospital-acquired infections.

The Hungarian Civil Liberties Union (HCLU) , a leading human rights organization, and medical experts also told Human Rights Watch that there is a lack of independent oversight of the extent to which hospitals adequately investigate and report hospital infections. A leading epidemiologist at the governmental National Health Center estimated there were 78,000 infections in 2015, though the 2018 official statistics put the number at just 15,151, of which 541 resulted in death. According to the HCLU, the number, which on its face could imply an apparent 80 percent reduction over 3 years, does not cover all types of infections, and cases are not always diagnosed correctly or recorded. Obtaining reliable, comprehensible official data is difficult.

The government released the questionable 2018 data in November 2019, only after a June Supreme Court order based on an HCLU lawsuit. Dr. Zsolt Hegedus, an orthopedic surgeon and expert on hospital-acquired infections, told Human Rights Watch that even medical professionals struggle to make sense of the government’s statistical data, which uses terms and tables that are difficult to understand.

The government further restricted access to information during the state of emergency declared in response to Covid-19, extending the response time for public authorities to requests submitted under the Freedom of Information Act from 15 days to 90 days. On June 18, the government ended the state of emergency and with that the extended response time.

The government coronavirus task force refused to respond to most questions from independent journalists and outlets. Lack of Adequate Preventive Measures in Hospitals The lack of sufficient personal protective equipment, including medical masks, gloves, eye protection, and gowns, hygiene, and adequate cleaning guidelines is a longstanding problem in the public healthcare system. Inadequate preventive measures appear directly related to the prevalence of hospital-acquired infections in Hungarian hospitals and may have played a role in the spread of Covid-19.

The National Public Health Center chief epidemiologist said in April 2019 that 30 to 50 percent of hospital-acquired infections could be prevented. According to another government health expert, the average use of alcoholic hand sanitizer, at 8.1 liters per 1,000 care days, although slowly increasing, is significantly lower than the EU average of 24 liters. According to the chief medical officer, as of July 12, 1,062 patients had contracted Covid-19 in hospitals, of whom 260 died. This means 25 percent of all recorded infections were contracted in hospitals, and hospital-acquired Covid-19 infections led to almost 50 percent of confirmed Covid deaths. In response to media requests, the government coronavirus task force reported that 576 healthcare workers have tested positive for the coronavirus, 14.8 percent of all cases.

The government stated that healthcare workers were tested every 7 days. Human Rights Watch research documented structural problems related to poor hygiene standards, failure to ensure isolation rooms or wards, lack of personal protective equipment, and lack of testing – failings of the public health system that are all the more alarming in the context of the Covid-19 pandemic. Poor Hygiene Standards People interviewed said they lacked basic sanitary items during their stays in public hospitals, and that they or family members had to bring their own soap, disinfectants, and cleaning products to hospital. From the accounts, it is evident that hospital hygiene and infection control do not meet WHO’s essential standards for caring for patients. Maria, 19, said she contracted a hospital-acquired infection after delivering her baby at a Budapest hospital in May 2019. After a second surgery to treat the infected wound caused during the first surgery, the doctor told her that she was infected with Klebsiella bacteria. Maria was struck by the lack of hygiene and adequate medical supplies: The cleaning lady dragged the same dirty mop around all rooms and used the same rag to wipe bedside tables to inside bathrooms ... nurses also told us that they had to reuse and sterilize single-use items as the hospital didn’t have enough to meet the demand. Helen, whose infant was born prematurely and who contracted an infection in March 2019 at a hospital in Sopron, in northwest Hungary, said personal protective equipment for healthcare workers and patients was a scarcity in the ward for babies born prematurely – where her daughter was treated. After the first critical two weeks passed without issues, Helen’s daughter started violently vomiting, one possible symptom of a hospital-acquired infection. Helen managed, “with some difficulty,” to convince the doctor to run extra tests, which ultimately determined that her daughter had an E. coli infection. First, she said: The doctor just told me that it’s a hospital-acquired infection, and as a precaution put my daughter on four kinds of antibiotics. A week and a half later, the doctor told me it was an E. coli infection. How does a baby in a supposedly sterile incubator get an E. coli infection? Helen said that nurses regularly cradled babies in their civilian clothes and without protection when moving them from one room or ward to another. She added that she and other mothers received tattered cloth robes changed every three or four days or longer, and that there were never enough shoe covers or paper towels. Reka, whose 56-year-old partner died in a hospital as a result of contracting Clostridium difficile after surgery in 2015 at a Budapest hospital’s internal medicine ward, described unsanitary conditions in the shower stall shared by 8 patients.

The Clostridium difficile bacterium can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. It can be transmitted through contact when people do not wash their hands or if contaminated surfaces are not adequately cleaned: It was so dirty and disgusting...

The so-called cleaner used the same dirty mop and rag sloppily cleaning, carrying germs around from one room to another.... When I complained about the cleaning, she took a toilet brush and started scrubbing the wall tiles.... I never saw cleaning staff disinfect handlebars, door handles, or anything else. She said there were two toilet stalls in the hallway, one for men and one for women, with two booths each where one toilet was marked with a sign saying “Clostridium.” “The one without the Clostridium sign was clogged with feces for the duration of my partner’s stay, so both patients and visitors were forced to use the one with the Clostridium sign,” she said. “There was no hand soap, no hand sanitizer at any time.” Bence, 41, said conditions were “awful” in the Budapest hospital where he contracted Clostridium difficile following lifesaving surgery in 2015: There were 2 toilets for 30 people on the ward, and it was about 50 meters down a hallway from my room. Many of us had stomach problems and were weak. My roommate with hepatitis A soiled himself several times as he didn’t make it to the toilet on time. He would wash his soiled clothes in the sink in the common bathroom. Linda, 37, said her baby boy was born prematurely at Miskolc Hospital, northeast Hungary, in August 2013, and died from a hospital-acquired infection caused by Klebsiella bacteria. Klebsiella infections are uncommon in healthy people, and in healthcare settings, patients who are on ventilators or require intravenous catheters, or who are taking long courses of certain antibiotics, may be especially at risk.

The bacteria can cause various other infections, including pneumonia, bloodstream infections, wound or surgical site infections, and meningitis. She said that she went into labor in her 32nd week and that the delivery went well, and the boy was gaining weight on schedule, but died unexpectedly four days later. Police reports indicate the cause of death was a combination of poor preventative hygiene and malfunctioning equipment. She said: It was very hot, closer to 40 degrees, and the air conditioning didn’t work. Instead, all windows to the preemie ward were open and outside was a terrace where the healthcare workers would smoke. Nurses didn’t use specific protective gear, I didn’t see them wash hands, and some of them wore long fake nails. Apparently, as we were told subsequently in the police investigation that followed, the incubators didn’t work properly, and as a result, nurses left the hatches open, leaving my boy unprotected.... Once we filed a police report for malpractice, we found out that 8 other children had died during those 4 days in August. Lack of Adequate Testing for Pathogens Testing for specific pathogens in the public healthcare system appears to be insufficient with long waits for results. This may have potentially lethal consequences for patients if pathogens are not identified soon enough for quick, effective, and relevant treatment. Lack of testing also increases the risk of spreading contagion to other patients. Bence, who spent nearly eight weeks in the hospital after contracting a hospital infection following surgery, said he pleaded with doctors to run tests after he started having diarrhea and a lab test indicated inflammation, but the doctor refused because he thought the diarrhea might be due to Bence’s preexisting condition. Bence said that he was given antibiotics that did not have any effect, and he lost 30 kilos in less than 3 weeks. He discovered he had Clostridium difficile only after he arranged for his girlfriend to have his stool sample tested by a private clinic. In some cases documented, victims said no tests were performed at all, despite obvious symptoms of a hospital-acquired infection. Miklos, 49, was hospitalized in Budapest in June for emergency spinal surgery following a climbing accident. He suffered other injuries during his accident, including a wound that became badly infected. He said: I repeatedly showed my wound to the nurses but no one cared ... no one ran any tests and I was refused antibiotics.... I only got hold of antibiotics because my doctor friend told me to call my [general practitioner] to prescribe it, which he did ... it got more and more infected and leaking puss ... my bed sheet wasn’t changed for three days, it was all yellow from dirt and puss ... in the end, I had to have surgery to clean out the wound. Lilla, a 44-year-old mother of two, contracted a hospital-acquired infection after an emergency cesarean section in 2016 in southern Hungary. Following the surgery, she said, the tube inserted into her stomach fell on the floor and a nurse simply picked it up and reinserted it. Later that night, Lilla developed a high fever, dizziness, and was in a lot of pain. Following three days of severe pain and fever, doctors reopened her wound to clean out the infection; she remained in the hospital for a month with the open wound so it could be periodically cleaned. She said she was not informed of any tests for a hospital-acquired infection and that her hospital documents do not mention tests: “Instead, doctors blamed me for the infection, saying it happened because I’m overweight and run a dirty household.” Lilla is still suffering health complications from her ordeal. She has taken legal action against the hospital, with proceedings currently pending. Government’s Response to Covid-19; Emptying Hospital Beds While official numbers of Covid-19 infections and death are relatively low, the lack of reliable timely healthcare data, combined with limited testing, gives reason to suspect that the actual rate of Covid-19 infections and deaths in Hungary may be much higher. Testing is far below the EU average, with the third lowest rate of testing in the EU, as of July 31.

The National Public Health Center oversees testing in Hungary and may approve testing upon referral by a general practitioner. But a Budapest general practitioner told Human Rights Watch in mid-April that referring suspected patient cases for testing was difficult.

The doctor said some of her requests for testing were simply ignored. Media reports and medical experts stated that in several cases, residents of nursing homes contracted Covid-19 while hospitalized, and were discharged and returned to nursing homes without being tested. Similarly, media reports indicate that testing of healthcare and nursing home workers was also inadequate. In April, the government emptied out hospital wards to make room for Covid-19 patients. In an April 7 letter, the Human Capacities Ministry ordered all public hospital directors to free up 60 percent of their available beds, a total of 36,000 beds nationwide, within 12 days, with no instructions on how to ensure alternative health care for patients.

The former chief medical officer of the state, Ferenc Falus, in an April 16 interview with HirTV, called the sudden emptying of hospital beds a “joke” and said it was unjustifiable to simultaneously empty 60 percent of all hospital beds, leaving many patients without adequate care.

The number of patients affected is unknown as authorities have not shared that information. In one case referred to the nongovernmental group Helsinki Committee, a cancer patient was discharged in April as a result of the order and sent home without alternative care. Her condition rapidly deteriorated after five days at home and she was taken back to the hospital, where she died a few hours later. Media reports in April quoted several patients or relatives of patients with chronic diseases requiring around-the-clock care saying that they had been given a 24 to 48-hour notice to leave the hospital, without instructions on how to care for themselves or their family member. On July 13, the United Nations special rapporteurs on health and extreme poverty and human rights published a letter sent in May to the Hungarian government raising concerns about the order to empty hospitals and the effects on the rights of patients in need of health care.

The government denied any wrongdoing, saying the rapporteurs were “wasting our time attacking Hungary based on false allegations” and were “spreading fake news”. It is possible that the order to keep wards empty for Covid-19 patients may have exacerbated overcrowding in remaining wards, preventing social distancing. Human Rights Watch spoke with two people who spent time in hospitals in May and June. Both indicated that there were more patients in their rooms than the rooms were designed for. Miklos said that in June, he was in a room with a capacity for 5 patients in a Budapest hospital for 2 weeks, but that it often had 6 patients, making social distancing impossible, and that he was not tested for Covid-19. He said that while doctors wore face masks, some nurses did not. Human Rights Obligations Hungary is a party to several treaties that guarantee the right to health, including the International Covenant on Economic Social and Cultural Rights (article 12), the European Social Charter (article 11), the EU Charter of Fundamental Rights (article 35), the Convention on the Rights of the Child (article 24), and the Convention on the Elimination of All Forms of Discrimination Against Women (article 12). While the right to health does not guarantee a right to be healthy, it does guarantee the best possible state of health for the population, based on existing knowledge. As such, governments are obligated to provide a system of health protection that offers equality of opportunity for everyone to enjoy the highest attainable level of health and to enact policies promoting available, affordable, quality health services, without discrimination. This requires health facilities, goods, and services to be scientifically and medically appropriate and of good quality, including availability of skilled medical personnel, scientifically approved and unexpired drugs and hospital equipment, safe and potable water, and adequate sanitation.

The European Committee of Social Rights issued a statement on the right to protection of health in times of pandemic, emphasizing that “all possible measures must be taken to ensure that an adequate number of health care professionals are deployed and that their working conditions are healthy and safe.... This includes the provision of necessary personal protective equipment.”.

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