Harvard Public Health Review
Fall 2004




Letters from Albania

HSPH alum Harriet Epstein, MPH'81, traveled to Albania this past year to build a model system of foster homes, resource centers, and respite services for families and children housed in state-run institutions.

November 11, 2003

Dear family and friends,

Albania is a beautiful country, craggy and varied. This morning I awoke to a magnificent sunrise over the mountains here in Tirana, the capital. I do love seeing mountains to either side of the city. Having grown up in Caracas, I feel that peaks on either side make a city feel like a proper place to live.

Tirana sits in a valley about 45 kilometers inland from the Adriatic Sea. The coast rises quickly into the mountains, with Kosovo and Macedonia to the west, Greece to the south, and Montenegro to the north.

It is wonderful to work in a country that has NOT been at war. The Albanians are warm and welcoming. Progress here is hampered for many reasons, but not for a lack of their wonderful hospitality.

The people are themselves still waking up after a long period of isolation and oppression under Enver Hoxha's fascist rule, which ended in the late 1980s. Albania was the most closed country within the Communist Bloc, with Hoxha aligned with China rather than the Soviets. Then came the pyramid scandal, a hard lesson in a so-called free-market enterprise, which bankrupted many people and sent them fleeing for economic refuge across the Adriatic to Italy.

I arrived here as director of the Albanian branch of a British charity on October 1. The charity was founded about 10 years ago by a former United Nations army officer, who had befriended a group of orphans while in Bosnia and promised to come back and help them. The British built our current facility about 45 kilometers from Tirana in a district of Durres called Shkozet, and has since helped maintain it with staff and resources--everything from diapers to diesel for the generator, to a zillion other things. Called the Home, it is one of five in Albania for infants and toddlers.

Since then, the charity has gone from building state-sponsored institutions to developing community- and family-based services for children and families in countries affected by war, poverty, and HIV/AIDS. My job is to de-institutionalize the Home, in collaboration with the Ministry of Labor and Social Affairs and the State Social Services, by developing a model system of foster homes, family resource centers, and respite services for abandoned and vulnerable babies and young children. People often call the Home an orphanage, but it isn't: there are few true orphans. Many of the babies are abandoned. Some have families who are unable to care for them. Others are "social cases," a catch-all term for children with all sorts of familial and social problems.

Institutions are dreadful places for children. Although we have two full-time volunteers living in an apartment in the Home and pay for five extra staff on top of others paid by the State, we are grossly understaffed. There is usually only one "carer," as the British say, in a room for 8 babies, two carers for 18 toddlers, and two for about 12 older children.

You can imagine the madness at feeding time in the babies' room. And the toddlers have "discovered" a wonderful game: flying from crib to crib with the greatest of ease. Ringling Brothers, send your scouts!

Electricity and water are at a premium. On some days there have been only two to four hours of electricity, and consequently no water, as the pumps are electric. We do have a generator but it is expensive to run, about $6 per hour in a country where the average day's wages are $1. As a result, terrible rounds of dysentery and colds spread through the Home like wildfire.

Medical care too is limited. Last Friday I drove our head nurse to a hospital with Arben,* a toddler who had fallen and cut his lip. There was a bucket of bloody gauze pads on the floor under the examination table, and drops of blood all over the floor and instrument table. As the attendant, with his bare hand, picked up gauze from a pile in a box, I franticly mimed "hand washing." He ignored me, cutting a few uncovered strips for Arben's lip.
I quickly discovered that the project I am to implement is much more complicated than the written proposal appeared, given that certain legal and administrative structures are not yet in place. One of the major issues is guardianship, a concept that has yet to be fully developed here. Also, there is no system for logging parental visits, so it is hard to know if a parent has ever visited. Given no or limited follow-up, reaching out to offer families reunification is difficult. This presents quite a problem for the children, since they cannot be declared abandoned by the courts and moved into an adoptive home if a parent or family has shown interest in possible reunification. You guessed it--I am now coordinating a conference for later this month on legal issues and the standardization of data collection, policies, and procedures for handling institutionalized children.

There is an Adoption Committee to which Albanian and non-Albanian families can apply. Unfortunately, adoption here is a complicated process for which the procedures change rather quixotically. Of the 43 children at the Home, two have left in the last few weeks to adoptive families, here in Albania and in Rome. Five more will leave in a month or two. Yule, a beautiful, shy 2-year-old fellow with big brown eyes and light brown curly locks, will be going to an Albanian couple who are totally mad about him. Following the first court hearing when they were "assigned" Yule, they rented a flat near the Home and have been there every day. The next court hearing is in 15 days.
Enough already. I have to go back to real work.

February 20, 2004

Dear Family and Friends,

Etz! Etz! Gomar! (Go! Go! Donkey!)

When you know how to urge another driver on in traffic in another language in a manner that is not quite polite, you know you are finally settling in! Traffic in Tirana is awful. It usually takes me longer to drive to my office than to walk, and traveling on the Auto Strada (highway) from Tirana to Durres requires half an hour of high-alert navigating. With drivers beeping to pass, people climbing over the middle barrier and running across the road, and carcasses of dogs lying in the way, it is a challenge to get anywhere. Also, Rruga Policia, or street police, are always ready to stop your car and check your documents.

Our census at the Home is down to 32. There were some lovely adoptions, and one child has returned to her family. Hopefully, by the end of next week, two more children will be returning to their grandmother and father. Majlinda and Xhoni ("Johnny") were placed in the Home when Majlinda was 18 months old and Xhoni, 5 months. Now five and six, they were brought here after their mother had abandoned the family, leaving their grandmother unable to support both the children and their father, who is disabled. They are very attached to their grandmother, and over the years they have gone off for visits for a week to ten days. Each time they come back to the befotrof, or orphanage, crying and asking to go "home."
The grandmother, a 43-year-old Roma, or gypsy, had requested reunification but for unclear reasons they were not returned to her. She works as a street cleaner. If you are out and about in the late night or early morning, you see groups of women with long poles with twigs tied to one end, sweeping the streets of Tirana. It is an honest but hard life. Her son, who is learning disabled, collects scrap metal, as do many Roma men in Tirana.

The grandmother lives with her son in a very small, two-room house with an enclosed yard, meticulously kept. Asked what she would need to be able to care for the children, she requested a washing machine, a sofa bed, a door for the outdoor bathroom, some clothes for the children, and tuition for kindergarten. Her most important request, she said, was tuition. Because her own family never allowed her to go to school she is illiterate, something she doesn't want for her grandchildren.

Through home visits and the concerted efforts of various officials and representatives, we have finally formed a plan to reunify this family. The whole bundle will cost about $1,000 per child over a period of 18 months; by then the family should be independent. We are already planning to go to the bashkia, the town hall, to make sure the grandmother gets a street cleaning job with the city, since through her current "contract" position she receives no social insurance or sick leave. Our team is hard at work to get all these wrinkles ironed out so that our first two "re-integration" cases will happen. I am so delighted!

Perhaps even more important is that the Ministry of Labour and Social Affairs and the review board have accepted our agreement to close the Home and set up a continuum of care for the babies, young children, and their families. We have only to finish up the paperwork and have it signed.

April 2, 2004

Dear All,
I'm off to Budapest--can't wait to get outta here and collapse. I'm going to stay at a spa hotel ... and see Buda and Pest.
I'm quite amazed by how much I've been able to accomplish in these last six months. We are now down to 30 children. All those eligible to be adopted will be. And then we have about 18 who have families (of sorts), or who are so disabled that no one will adopt them. But we should be down to 27 by the end of this month. Maybe one or two more, and then the hard work begins, setting up foster care and maybe a group home for the rest.

Sweet Genti with the bedroom eyes has been assigned to an Albanian couple from Tirana who are just wild about him. They are staying nearby for the two weeks they must wait before they can take him home. When they first came to visit, his Mami rushed into the toddlers' room without taking off her shoes. She was roundly scolded by the carers but was soon forgiven when they saw how delighted she was with her new baby boy. She took him into our development center for his nap and was lying beside him and singing so sweetly to him. I am so pleased. He had started not to thrive, and now he has perked right up.

We also got assigned quintuplets--natural quints, all boys. The director of Social State Services said all she had to offer them was institutional care. So, we are coordinating the resources, or lack thereof. The smallest was a thousand grams at birth, down now to 800, but with a full head of hair! There will be no institution for them. Their mom wants them, and we are going to help her keep them.

One of our younger children, a disabled girl whose own family was encouraged to "abandon" her, will be going to a couple in Sweden. One of our volunteers has been spending a lot of time with her, and it's amazing to see what even less-than-good-enough care can do. This part of the work is lovely. Not so lovely is seeing some of the older children who come from very dysfunctional families linger here, without anyone to really be theirs.

So, things are moving along. Albania is beautiful. The roads are dreadful and my vehicle needs new shock absorbers already, but I will keep exploring.

April 17, 2004

Life is busy in the fast lane.

So much has happened. Skender, just over two years old, will soon be going home to Malta. He is a tow-headed little fellow, everyone's favorite, who is called "the Boss" by one of our volunteers since he organizes the other children and leads them in hopping from crib to crib. Last but not least, our little Teuta, who is developmentally disabled, will be leaving for Sweden with her new Swedish parents and an older brother whom they adopted from Lithuania. She is a strawberry blond who has made huge progress since we began working with her. We hope that once her strabismus (a condition in which the eyes don't align, resulting in vision problems) is taken care of and she is living in a family, many of her developmental delays will resolve themselves.

Majlinda and Xhoni are home! The children are enrolled in kindergarten and are doing wonderfully. The family is getting on its feet and doing well. Their father has become quite attached to them, making sure that each day they have a few leke (a lek is less than a U.S. penny) to buy a treat on the way to school. He has pulled himself together and has a companion who is herself thriving in the role of stepmother to the children. I am delighted.

Perhaps most important, the deinstitutionalization process is going well, with local, regional, university, and governmental personnel all "buying in." It has been fun to meet the mayor of Durres, the prefect of the greater Durres Region, the heads of UNICEF, and all the others we need on board to get this project off the ground. It is a very complicated process involving the transfer of funds and operations to regions and municipalities, the development of legal frameworks to enable foster care and alternative care for children, and undoing an entrenched institutional mindset.

I just got back from a week of R and R in Budapest. Other than spraining my ankle rather badly, getting sore feet from walking, and a bad cold, I had a wonderful time. There are many great museums in Budapest, and I saw many, many museums. I came back ready to go again.

My apartment is finally "home." I was able to get a CD player in Budapest at a price that didn't break the bank, and with some locally made kilim rugs and some personal things around it is complete. I am able to entertain or just come home and be comfortable.

Next week we are off to Romania to visit the British charity's programs in Maramurese, flying from here to Budapest and then on to Cluj. It should be another adventure.

Love to all,





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