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ROBERT SIEGEL, HOST:

Portugal is the poorest country in Western Europe. And after a financial bailout earlier this year, fees in its health system have risen substantially. NGOs say the poor and elderly can no longer afford essential care.

As Lauren Frayer reports from Lisbon, some Portuguese fear that austerity measures now threaten not only their livelihoods but their lives.

(SOUNDBITE OF CROWD)

LAUREN FRAYER, BYLINE: Sixty-seven year old Alfredo Silva showed up at an anti-austerity protest last month in Lisbon dressed as a skeleton. He says the costume shows the effect on retirees like him of Portugal's $100 billion bailout.

ALFREDO SILVA: (Foreign Language Spoken).

FRAYER: I blame the IMF, he says. For me, it means more unemployment, more misery and more hunger. The Troika and the IMF, more unemployment, he says. Silva's costume is a rather theatrical way to illustrate a serious problem.

Portugal's death rate spiked by nearly 20 percent this winter, mostly among the elderly. The government blames it on a nasty flu strain, but NGOs and opposition politicians say austerity measures are at least partly to blame. Fees for the public health system have doubled in most cases and a third of Portugal's hospitals are insolvent.

(SOUNDBITE OF PROTESTERS)

FRAYER: At the same demonstration was Francisco Reposo, a 51-year-old public school teacher whose salary was cut by 30 percent. He's also on dialysis awaiting a kidney operation and he says patients like him increasingly face a stark choice: food and housing or medicine.

FRANCISCO REPOSO: A lot of people have to stop to take the pills. Many people also avoid to go to hospital because they have no money to pay the fees.

FRAYER: The EU and IMF asked Portugal to hike its medical fees as a condition for the bailout that went through earlier this year. Health economist Pedro Pita Barros describes the changes.

PEDRO PITA BARROS: If you go to emergency department in a large hospital, you have to pay 20 Euros. And, if you do some complementary exams, like X-rays or CT scan or something of this sort, you may go up to 50 Euros.

FRAYER: That's about $67, which may not seem like a lot to Americans, but Portuguese, like many Europeans, have been used to free universal health care. The new fees are especially burdensome for the elderly, many of whom survive on state pensions that average about $400 a month.

Ana Figueiras runs the charity Cidadaos do Mundo, which cares for the elderly here in Portugal.

ANA FIGUEIRAS: The fact that their system is not free of charge anymore, the fact that old people - they live alone, a big percentage is poor and, even before, they would not go to the health system because they could not afford for transport. So imagine now. They need to pay for transport and they need to pay the fees, so people decide not to go.

(SOUNDBITE OF MUSIC)

FRAYER: In downtown Lisbon, folk music wafts through cobblestone streets and an elderly woman hobbles past, selling lottery tickets. Nearby, Imanuel Baqueira sells gas canisters for cooking and heating. He says many of his older customers are in arrears.

IMANUEL BAQUEIRA: They don't have money. We have to give them the gas and they receive three weeks later or more.

FRAYER: Fuel taxes are up, too. Gasoline now costs the equivalent of nearly $8 a gallon here. Baqueira shows me a stack of pension checks that customers have signed over to him and he shrugs. The cost of merely surviving keeps going up amid austerity measures and the only good news here is that winter is just about over.

For NPR News, I'm Lauren Frayer.

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