In a waiting room in the Georgian capital of Tbilisi, 80-year-old Diana Bogonogedskaya sits patiently to see the doctor.

Without the free medical services and medication offered by the clinic, one of several run by Caritas Georgia, “we would have simply and quietly died,” she says with a plain, matter-of-fact tone. At her side, her husband nods in agreement.

Despite the Georgian government’s recent attempts to reform the nation’s health care system, the Bogonogedskayas – and tens of thousands of other Georgian families – still cannot afford medical care. Caritas’s program represents their only hope for healthier, stronger lives.

Started some 14 years ago with a few bottles of donated medicines and the desire to help, Caritas’s clinic in Tbilisi has blossomed into a sophisticated medical program with branches in three regions of the country that offer primary health care, physical therapy, dental treatment as well as free prescription drugs and home care.

According to Divine Word Father Witold Szulczynski, who directs Caritas Georgia, the clinics focus on people who fall through the cracks – elderly pensioners abandoned by family and friends, the homeless and the displaced – but who deserve to “live as humans and die with dignity.”

The desire to help Georgians living at or below the poverty line (who make up more than a third of Georgia’s total population of 4.6 million) has been at the heart of the mission of Caritas since its establishment in 1994.

At the time, a newly independent Georgia had emerged battered and bruised from the collapse of the Soviet Union in 1991, two territorial conflicts and a bloody civil war. Refugees flooded Tbilisi by the thousands, though little in the pockmarked capital remained extant to accommodate them.

This civil unrest accelerated the unraveling of Georgia’s economy and social welfare system, which had been planned, directed and controlled from Moscow since Soviet Russia absorbed Georgia in 1921.

The country’s health care system – which at one time ranked among the best in the Soviet Union – all but dissolved. From 1990 to 1994, for instance, the real per capita expenditures on health care plummeted to less than $1 from around $13.

The nascent government simply lacked the resources to provide its hospitals, clinics and dispensaries with desperately needed drugs and supplies – much less fund and manage an unwieldy, government-controlled health care system. As a result, most health care facilities closed. Those that stayed open deteriorated as patients paid out-of-pocket for the majority of their health care needs.

Interestingly, the very day the Holy See opened its nunciature (Vatican embassy) and Archbishop Jean-Paul Gobel, then apostolic nuncio, submitted his documents to the government for recognition, then President Eduard Shevardnadze asked the archbishop if Catholics could assist Georgia’s needy – especially its refugees. Assisted by Father Szulczynski, Archbishop Gobel created Caritas Georgia using funds from generous donors in Europe and North America, including CNEWA. At first, Caritas provided food and other basics to Georgia’s needy.

“When we started to feed people, I remember the first people were elderly professionals, not beggars. These were the intelligentsia who ended up on the street without any means,” said Father Szulczynski.

However, it quickly became evident that many Georgians needed much more than food assistance.

“The first need was to give them something to eat. But then everyone started to ask about medicine or doctors,” he continued.

The initial success of Caritas’s food distribution programs provided the momentum to launch a small first aid station, which in turn expanded into a full service medical facility.

Recently, Georgia’s fledgling democratic government has initiated a number of sweeping reforms to its health care system. These include decentralizing the bureaucratic system, regulating copayments and out-of-pocket expenses and privatizing many of its components, including most hospitals and other facilities.

Yet large numbers of Georgians still cannot afford even the most basic medical services. The practice of charging patients for expenses in addition to preestablished fees remains commonplace. For many families, a visit to the doctor and the cost of prescription drugs can consume most of a family’s monthly budget; while the hospitalization of a family member – even for a short period – can ruin the family financially. As a result, many Georgians turn to Caritas.

Dr. Nona Piraeva has played a central role at every stage of the program’s growth. An ambulance medic during the early days of independence, she has served as Father Szulczynski’s de facto health care adviser from the outset.

When Caritas, for instance, unexpectedly received a shipment of wholesale medicines from Germany in 1995, it was Dr. Piraeva to whom Father Szulczynski turned for input. She had never seen so much medicine at one time.

“We started to give out the medicine and accept sick patients,” she said. “But you know, medicines are not potatoes – you can’t give them to just anyone.”

In the beginning, the first aid station was a tiny room not far from the center of the city. Eventually, Caritas brought on board another doctor and a nurse to help out, creating the foundation of the current clinic.

Word of the free clinic spread fast, leading Caritas to create several additional small clinics in and around Tbilisi – and eventually throughout the country.

“There were lots of people [in need],” Dr. Piraeva said.

“At that time there were no government programs. It was a catastrophe. Now it is also hard, but it is nothing in comparison to what it was like back then – 13 years ago.”

In its early days Caritas did not keep strict records. Dr. Piraeva remembers there being over 1,000 patients at one point, with an average of 50 to 60 patients arriving each day. But as the program grew, the steady stream of incoming patients became more manageable.

Georgia’s population continues to demonstrate need across a wide range of areas. Under Father Szulczynski’s direction, Caritas Georgia has opened an impressive umbrella of programs, each overlapping just enough to shield the recipients from the sting of hunger and the pain of sickness.

Among his newest and most successful initiatives is the home care program, which reaches out to patients whose condition prevents them from leaving their homes. Caritas’s small army of 17 nurses, specially trained in home care services, assists nearly 300 patients in their homes in Tbilisi, Kutaisi (a small city in the central region of Imereti) and Ozurgeti (a town in the western region of Guria).

One such nurse, Maia Mikadze, regularly cares for four patients in Tbilisi, traveling by foot or catching a ride on the marshrutka, the city’s public shuttle bus, to reach their homes scattered across the historic neighborhoods downtown. Having been with the clinic for more than a year, she finds the work hard but fulfilling.

“God forgive me for saying it,” she said, “but a lot of these people would be dead if it weren’t for us.”

Addressing her patients as “love” and “gold,” Ms. Mikadze provides much more than the necessary booster shot or sponge bath.

For the elderly and bedridden Gurgen Isrealian, Ms. Mikadze is a welcome source of social contact every other day when she stops by to bathe him and change his clothes.

Alternating between cantankerous and kind, Mr. Isrealian jokes and directs the nurse through her hourlong ritual. The frail 74-year-old lives alone and can do little more for himself other than light a cigarette. But when Ms. Mikadze negotiates his feeble limbs to make him more comfortable, his eyes sparkle and the spirit of a younger, healthier man returns.

Whereas the home care program thrives in the urban centers of Tbilisi, Kutaisi and Ozurgeti, it has not yet taken root in the largely rural, southern region of Samtskhe-Javakheti. Patients requiring home care must rely on family members and the good will of neighbors and Caritas doctors, who make occasional house calls.

Strapped for funds, the five clinics that Caritas operates in this impoverished region can barely cover basic costs much less offer additional services such as home care. According to Dr. Piraeva, the five clinics operate on a shoestring budget; the same money a Danish humanitarian organization allocated to subsidize the clinics for three years has been stretched to cover costs for six years. She does not expect the clinics to remain open much longer.

“I have to say that when I speak to people [about our projects] no one is very interested in the elderly,” said Dr. Piraeva, explaining the clinics’ financial troubles.

“Children are beautiful – they dance and talk. You see a result – they develop.

“An elderly person has already lived his or her life,” she continued. “They thought that in retirement they would have something. Now they sit at home with a 50-70 lari pension [$119 a month] … what can our patients do?”

The Caritas clinic in Vale, the organization’s largest in the region, now serves some 500 villagers, most of whom depend on it as their primary health care provider. While the clinic is only open four days a week, its resident doctors, Mari Khabeishvili and her husband, do all they can to fill in the gaps, visiting patients at their homes when necessary, sometimes just to drop off medication.

For villagers with neither family members nearby nor money, all of their hopes rest with the clinic’s small team of medical professionals.

“This is coming from my soul,” said Tamara Chernuka, a patient at the clinic. “I am 70. I have not seen my son for 20 years. I don’t know if he is alive or dead. But they help me here. If it didn’t exist, I would have already been in the ground long ago.”

The nearest public health care facility is located in the adjacent town of Akhaltsikhe, about seven miles away. But while the distance does not represent an obstacle for most of the patients at Vale’s clinic, the cost does. Even with government antipoverty programs, a trip to the facility and prescriptions are too expensive.

Nodari Jaranishvili, who suffers from a diseased liver, has been coming to the clinic in Vale since it opened six years ago. He cannot afford the public clinic in Akhaltsikhe.

“What would I do [without the Caritas clinic]?” he asked. “I can’t work and I don’t have any money. My pension is not enough. I would have simply died.”

The future is even bleaker for the 400 registered patients at the Caritas clinic in the tiny hamlet of Naokhrebi. Just a couple of miles from the Vale clinic as the crow flies, the trip actually takes nearly a half hour by car. For most villagers who rely on a horse and cart travel time is even longer.

The clinic, which opened its doors in 2000, serves the predominantly Armenian community that lives in the six small farming villages on the outskirts of Vale.

According to the clinic’s resident physician, Dr. Mariam Garagezian, the patients have neither the financial resources nor the time to make the trip to the clinics in Akhaltsikhe or Vale. In fact, most women give birth at home simply because they cannot make it to the hospital in time.

The clinic in Naokhrebi is a far cry from its much larger and better-equipped counterpart in Tbilisi. Within its two tiny rooms, Dr. Garagezian and the facility’s only nurse, Nino Sukarzian, see as many as 13 patients a day during the four weekdays the clinic is open. Despite its diminutive size, the clinic boasts an impressive inventory of services, including blood tests, immunizations and sonograms.

“The only thing we haven’t done is deliver babies,” Dr. Garagezian joked.

“The people [here] are hard workers,” she continued, noting that most patients wait at the clinic’s door for it to open and few arrive after 10 or 11 in the morning because they have too many chores back home.

“Today, a patient is working and tomorrow you will hear that he died. No one rests here. They are all struggling.”

  Caritas and the War

Most recently, Caritas — the aid agency of the Georgian Catholic community &mdash has been on the frontline of the war involving Georgia, its breakaway regions of South Ossetia and Abkhazia and the Russian Federation, providing urgent medical care for the injured and emergency assistance to refugees.

According to Dr. Nona Piraeva, Caritas Georgia’s program manager, Caritas provided medical assistance to more than 1,000 refugees in three relief centers in Tbilisi, deploying four of its full-time nurses and coordinating the work of an additional 19 volunteer nurses to further its efforts.

Caritas has also supported the capital city’s primary healthcare facility, Republican Hospital, and in cooperation with the Italian Embassy has provided assistance to the general hospital in Gori, where some 2,000 war refugees received medical treatment immediately following the war.

For the most part, however, securing shelter and beds for refugees has proven the greatest challenge.

Nona Djanishvili and eight members of her immediate family fled Artsevi, a village currently under Russian control in the South Ossetian conflict zone, when fighting erupted in early August. The family followed the tide of Georgians seeking shelter near Tbilisi and now resides with more than 80 other families at a temporary shelter set up in a public school in Gldani, a working-class suburb.

Though quick to thank Caritas for providing her and her family with much-needed provisions (they were forced to leave behind all their belongings), Mrs. Djanishvili was equally quick to stress what they needed most and what they have not yet received: a new home.

“A place, that is what is most important,” she said. “The children need a place to live.”

Based in Tbilisi, Molly Corso’s work has appeared in many publications, including EurasiaNet.org.