'We don't do rabies'

When Alyssa McDonald was bitten by a stray dog in Romania, she was given excellent anti-rabies treat

"You want a babies injection?" asked the receptionist at my local GP surgery. "No," I explained as calmly as I could. "Not a babies injection, a rabies injection." "Oh ... I don't know about that," she said. "I'll have to check. Call back at six."

Two days earlier, at the end of a weekend trip to Bucharest, I had been walking through the city when one of the many stray dogs bit me - not badly, but hard enough to draw blood. I didn't really want the hassle of a trip to hospital, and I'd heard some horror stories about the Romanian ones. But then again, hospital was preferable to rabies. Virtually unheard of in the UK now, it still kills 55,000 people each year globally.

It is a particularly horrible way to die: within a week, sufferers become anxious and disorientated, developing an overwhelming thirst paired with an inability to swallow. Delusions, hallucinations and deranged behaviour (including thrashing, spitting and biting) follow; it usually takes another week or so before heart and lung failure lead to total paralysis, coma, and finally death. And once symptoms start to develop, rabies is nearly always fatal. So I was ready to put up with substandard treatment - I just wasn't prepared for quite how bad it turned out to be. And I didn't expect to find the NHS doling it out.

Dogs are a major nuisance in Bucharest. The rehousing programme during Nicolae Ceausescu's dictatorship forced many families to abandon their dogs, and now the city is home to about 200,000 strays. On average, strays bite 50 people a day; some of them carry tetanus and/or rabies. The city council has announced a couple of culls in recent years, but these programmes have never been extensive enough to tackle the problem. Fortunately, because the risk of being bitten is high, the city's hospitals are well set up to deal with the victims. The nurse I limped up to in Spitalil Colentina's anti-rabies unit spoke a little English, and within half an hour I'd been bandaged up, given shots for tetanus and rabies, and was out of the door with a prescription for antibiotics and directions on what to do when I got home. The days when rabies was treated with painful injections in the stomach are long gone; now you just need a series of five shots in your arm over the space of a few weeks. Easy.

The nurse gave me a leaflet containing information about the vaccine for my doctor in the UK. The entire service was free of charge.

As soon as I returned to London, I phoned NHS Direct to find out where to get my first follow-up shot. I was given the names of two NHS walk-in centres and a private Medicare centre before I was told that I could also see my GP.

"We don't do rabies," the receptionist at the first walk-in centre told me. "Tetanus we do, but not rabies." I called the second one. Then I tried again an hour later, and again an hour after that. Eventually I accepted that they weren't going to pick up, but I wasn't quite ready to accept the idea of paying for a treatment that I could get for free on the far side of the continent. So I skipped the Medicare option and phoned my doctor. Maybe I should have taken them up on that offer of a babies injection: I might actually have got somewhere if I had. When I called back at 6pm, the phone was engaged, and it stayed that way until the surgery closed at 6.30pm.

Life-threatening

Stuck for what else to do, I called the hospital closest to my office, St Thomas's in central London. Could they help me? The A&E receptionist was not keen. "Why didn't you call NHS Direct?" "I did," I explained, "and none of the options they suggested could help me. So now I am calling you, because I may have been exposed to rabies, and rabies is a life-threatening disease." "Where do you live?" I told her. "We're not your nearest hospital then, are we? You should have called the Royal London . . ." She was gracious enough to put me through to a doctor anyway.

"Yeah, we can do a rabies injection," the doctor told me. "But we shouldn't have to, really - you should be going to your doctor, because it's a community issue." I didn't ask why Romanian stray dogs are a community issue for Hackney Council.

So far, so incompetent. But the dismal service I'd received had nothing on what came next.

At A&E the next morning, I told the doctor what had happened, and about the five jabs the nurse in Bucharest had said I'd need. I didn't mention the antibiotics I'd been given for the wound itself; neither did he. Half an hour later, a student nurse appeared with a small syringe and the information leaflet from the vaccine, which she handed to me. She gave me the shot and smiled, "That's it! You're fine now." Really? What about the further three injections I'd been told I should have? "Oh, foreign hospitals are usually a bit overcautious with British patients. They're scared we'll sue." She assured me that I didn't need any further treatment, and that I was free to go. So I did. And I had got as far as the door when the doctor rang my mobile. He hadn't told the nurse to let me go, but since I already had, he just wanted to remind me that I'd need to see my GP for the remaining three shots.

I was confused - the nurse had said I didn't need any more treatment. "Did she? Oh, uh, then that's right." "Are you sure?" "Yes." I wasn't. But as I had the vaccine information leaflet, I could check: and like the Romanian one, it said I needed three more doses. (Not surprising, really, as that's the WHO's recognised regimen for rabies.) Why had the doctor needed me to tell him the dosage? When I went back to A&E and spoke to him, I discovered what had caused the confusion: he hadn't even read the information leaflet. And quite clearly, neither had the student nurse.

Rabies is hardly the UK's most pressing health issue, but the Health Protection Agency still treats about a thousand travellers each year who have been exposed to the disease abroad. Its line on treatment is unequivocal: as rabies is a fatal condition, the only available precaution - vaccination - must be used. The substandard treatment I received has serious implications for everyone who uses the National Health Service. In the end, my health was fine, but that doesn't excuse the level of service the NHS offered me. Being misheard, misinformed and passed from pillar to post is bad enough. But for two members of hospital staff to handle a less-than-everyday complaint by dishing out medication and advice without checking the facts is completely unacceptable, and potentially very dangerous. I contacted St Thomas's to ask for an explanation, but it was not prepared to comment unless I made a formal complaint.

According to research by the National Patient Safety Agency last summer, I'm not alone in receiving such poor service: almost 25,000 patients a year receive the wrong treatment in British hospitals. Whether the result is serious harm or just frustration and inefficiency, this is a pretty appalling track record. So, if you're looking for efficient, safe health care, try Romania. You might be less likely to end up foaming at the mouth.

This article first appeared in the 31 March 2008 issue of the New Statesman, Is Boris a fake?

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The dustman and the doctor: fairness and the student fees debate

The idea that education – all education – should be free is intoxicating and liberating. But there's a problem.

The most toxic political imagery of the student fees debate dates from 2010. First, there was Nick Clegg brandishing a sheet of paper bearing his election pledge that the Liberal Democrats would vote against “any increase” in tuition fees. Then, a few months later, there was the sight of protesters scrawling graffiti and urinating on the statue of Winston Churchill in Parliament Square. Churchill was rapidly restored, but Clegg – who, I am told, did not believe in the pledge when he signed it but could not resist the prospect of those student voters in university towns – never properly recovered.

The issue of how to fund English universities had been febrile for years – long before the 2008 financial crisis, the ballooning of the Budget deficit that followed and the 2010 Lib Dem vote for the vertiginous increase in English tuition fees. (University funding is a devolved matter, with the Scots going their own way.)

In 2004, Tony Blair, enfeebled by the absence of weapons of mass destruction in Iraq, had almost been knocked off his prime ministerial perch when he, too, trebled fees, albeit to a mere £3,000, to be paid back after graduation. Gordon Brown’s allies, smelling post-Iraq weakness, hovered over the Labour leader before allowing him – by a sliver – to survive.

The Conservatives have historically been less troubled by the matter. Students largely have not voted in high enough numbers – certainly not for them – to impinge on their chances of electoral success. Meanwhile, the centre left has had lumps kicked out of it while wrestling with the problem of how best to fund higher education. Jeremy Corbyn’s 2017 manifesto significantly changed Labour’s position, promising to abolish fees altogether; he would also, he told the NME, “deal with” student debt. That half-pledge has now become a vague “ambition” because of its estimated £100bn price tag.

As a piece of campaigning, it worked. By contrast, Ed Miliband got nowhere in 2015 with his promise to reduce fees by a third to £6,000. It was too little, too late to mobilise student voters or their concerned parents, but more than enough for George Osborne, an unrepentant Vince Cable and a nervous higher education sector (sotto voce) to raise questions about Labour’s fiscal rectitude and/or the financial security of universities.

The Institute for Fiscal Studies (IFS), in its disinterested and peskily rigorous way, joined in – and with a more subtle point, suggesting that cutting fees would benefit higher-earning graduates the most. Those who earned less over their lifetime would, in any event, not have to pay all of the money back.

Until Corbyn’s swashbuckling manifesto simplified matters, or oversimplified them, the left had been tied in knots on the fairness point from the moment that tuition fees were introduced, relatively quietly, in the peak-Blair year of 1998.

The idea that education – all education – should be free is intoxicating and liberating. It is intoxicating because one’s Enlightenment reflexes are happily triggered: the pursuit of knowledge is wonderful; knowledge leads to individual self-fulfilment and should be made available to the largest possible number. We all benefit from a better-educated population, not least by the spread of liberal values. Utilitarians rejoice – the country becomes economically more prosperous, though the evidence for this is irritatingly murky.

It is liberating because it is a beautifully simple proposition, and thus the complexity of nasty trade-offs – between those who go to university and those who don’t, between generations, between different sorts of universities, between disciplines and courses, between funding higher education and funding a zillion other priorities – is washed away by the dazzling premise. Free.

Alas, there is a problem. Once upon a time, a British university education was for the very few. The state, in the form of the general taxpayer, footed the bill. Now, around 40 per cent of 18- to 19-year-olds are at university and nobody in front-line politics is keen on hauling down the number, notwithstanding the occasional hyperventilating headline about useless degrees in golf course management or surfing studies.

The Liberal Democrats’ ill-fated 2010 manifesto had a little-noticed passage that called for scrapping the participation target of 50 per cent – alongside the now ritual aspiration to improve vocational training and apprenticeship schemes, a promise that is yet another reminder of a long-established and debilitating British weakness that nobody seems to know how to reverse. But mass higher education is here to stay – and it’s a good thing, too.

We could have chosen (and could still choose) both to fund increasing numbers of people going to university and to pay for all of their tuition, but that would not have been a self-funding investment – at least, not for a very long time. Other European countries with decent universities have indeed managed without asking graduates to contribute anywhere near as much as ours. The Swedes pay nothing for tuition. Dutch students pay a quarter of their English counterparts. The Germans have proportionately fewer students in tertiary education (though their vocational education is widely known to be heaps better), but their students are at university for longer and they pay very little for the pleasure. You get the picture.

It would require a lot of extra taxation if we were to go down that route – and there are many other competing demands beyond deficit reduction. Yet the issue is not only framed by tax priorities. We can’t easily afford to have the state picking up the tab because – an ugly fact – we are less well off than most northern European countries that charge less. Yes, we are the fifth-largest economy in the world – how could any of us, since the Brexit vote, not know that? – but we are far from being the fifth most economically prosperous country in the EU, once you allow for the intrusion of vulgar reality in the form of GDP per head. On that measure, we sit somewhere in the middle of the pack.

So who pays? Asking students to pay something is not in itself an outrage. The massive social and economic privileges that my generation accrued from our gloriously free university education may now be spread more widely but that has not eliminated the personal advantages that, on average, follow a degree. Graduates are more likely to get jobs, more likely to get better jobs and more likely to keep their jobs in a recession. The Department for Education puts the graduate premium on average at £250,000 before tax over a lifetime for women and £170,000 for men. These figures may be overstated and might not be sustained, but it is overwhelmingly likely that most graduates will still benefit materially from their degrees.

From the starting point in 2004 – long before the deficit soared – Blair and his then education secretary, Charles Clarke, decided that graduates should pay more once they began to earn sufficient money. I remember Blair at the time doing a BBC Newsnight special with an angry audience, packed with students telling him that he was wrecking their lives and had insufficient respect for their contribution to the greater good. A very articulate trainee doctor told Blair that she faced a mountain of debt (those were the days – that would now be several mountains). Blair responded with a range of left-wing arguments – at least, if you are of a redistributive frame of mind. Here are some highlights of the exchange:

Blair: I think it is unfair to ask general taxpayers – 80 per cent of whom have not been to university – when you have got an adult who perhaps wants to get an additional skill and they have to pay for it if they don’t go to university, to say to those people: we are not giving you education for free. And to say to under-fives, where we are desperately short of investment, to say to primary schools, where again we need more money, that we are going to give an even bigger subsidy to university students. Believe me, if I could say to you, “You can have it all for free,” I would love to.

The student, more than matching the prime minister’s passion, was spectacularly unimpressed.

Student: It really infuriates me that you say, “Why should the dustman fund the doctor?” When he has [a] heart attack, he will be pleased that I went to university and graduated as a doctor. Therefore he should contribute towards the cost of my degree.

Blair: But surely there should be a fair balance. He is contributing to the cost of your degree. Five-sixths of the cost of any degree, even after our proposals come in, will be contributed by the general taxpayer.

Not bad for a prime minister who was not often associated with causes dear to the dustmen part of his Labour flock – nor associated with redistribution in general. Of course, the figure of five-sixths paid for by the state is now, since the introduction of £9,000 tuition fees, a great deal smaller. The trainee doctor of 2017 is expected, over the course of their lifetime, to fork out much more. The average student debt is getting on for £50,000.

The current numbers are the result of decisions taken by Vince Cable of the Liberal Democrats and David Willetts of the Conservative Party. Unlike Blair, these two men were on the left of their parties, with a firm belief in the importance of education and its positive impact on social mobility. The hike in fees led to protests and occupations but also to universities getting much of the extra money that they needed, even if they were markedly reluctant to say so, doubtless for fear of stirring up their students.

There has been no drop in the participation rate of students from poorer family backgrounds. Quite the reverse – despite Jeremy Corbyn’s personal refusal to believe the evidence. But the repayment of fees means that, in effect, recent graduates pay income tax at a rate of 29 per cent once they earn more than £21,000. (The Department for Education cheerily call this “a contribution”, as if it were voluntary.)

The repayment point could have risen with inflation to ease the load but it hasn’t. That allows the Treasury to recoup more money. Why hasn’t the £21,000 limit been raised? The reason is that, under the current IFS estimates, three-quarters of graduates will not pay back all of their debt after 30 years, at which point it is forgiven. Worse, interest rates on this fee debt are 3 per cent above inflation – and thus nearly 6 per cent above the base rate. That is not quite at Wonga levels but it is patently demoralising and much too steep.

That is far from the end of the matter. Until last September, poorer students received a maintenance grant of up to £3,400 to help with their living costs. For better- off students, the state’s supposition has always been that their parents should and would contribute financially to ensure that their offspring could lead a reasonable life while at university. No government has chosen to make this very explicit: there are only so many enemies you want at any one time on any one issue.

But as the number of students rose, so did the number entitled to the grant, and as part of the strategy to reduce the country’s Budget deficit, those grants were turned into loans, too.

The Labour Party, before Jeremy Corbyn became leader, opposed the change when it was announced but not with much elan. From my Oxford eyrie, I was astonished at how little excitement this generated. Perhaps everyone was exhausted by the failed protests five years earlier.

There is mitigation. It is worth remembering that nobody pays anything for their tuition up front (part of the Blair package, too) and some universities, including mine, have good and reliable schemes to help those from poorer backgrounds and hardship funds for those whose circumstances – normally their parents’ circumstances – change while they are studying.

But I know from direct experience that many students worry a great deal about the debt that awaits them. And if graduates were feather-bedded before 1998 (and that includes me), it is hard not to sympathise now. The debt is too much for too many.

Blair defined the problem correctly – the question of who pays is about striking a fair balance – even if Corbyn seems uninterested in the pain involved in thinking it through and has opted for the easiest answer. But what should that balance be? A graduate tax for those of us who went to university when it was both a much scarcer resource and cheap would offend people who want as little retrospection as possible in the tax system. However, it would do something to deal with generational injustice, a subject on which Corbyn’s credentials are sullied by his fondness for the “triple lock” on pensions.

Labour’s policy of telling English students that they will pay nothing for their tuition is nowhere near as left-wing as it sounds, but it was far too successful a piece of retail politics for anyone in his team to consider going back to the drawing board. So now it is the Tories, facing an energised student vote, who have to engage with the issues for the first time since the tumult of 2010. The least they can do – and they should do it fast – is cut the interest rate. They won’t want to do any of it but, as the man said, the times they are a-changing.

Mark Damazer is master of St Peter’s College, Oxford

This article first appeared in the 31 March 2008 issue of the New Statesman, Is Boris a fake?