Some time ago a patient told me that he needed to borrow money from a neighbour to buy a train ticket to come to his appointment at the practice. At the same time, this patient told me about the scarcity of food at home, and how it was a constant struggle to feed his daughter. The shocking thing is that this is happening in Portugal. The daily life of an increasing number of people in Portugal is affected by poverty and hunger, two of the most dramatic consequences of the austerity that has been crippling Portuguese society for the past year and a half. A recent report by the Organization for Economic Co-operation and Development states that the spending cuts in the health sector in Portugal have been two times larger than those agreed by the “Troika”—the International Monetary Fund, the European Central Bank, and the European Union). The Portuguese Ministry of Health denies this. But, the report adds that Portugal’s spending in the health sector is expected to fall to 5.1% of GDP in 2013, down from over 10% in 2010, and much lower than the average of 7% of GDP for the Eurozone.

There are reports that an increasing number of children go to school without eating breakfast and are being seen in hospital simply for being hungry. This may be hard to believe in a first world country, but it is partly related to the fact that unemployment continues to soar (it has now reached 16.5%), and the number of couples where both individuals are unemployed almost doubled in 2012 compared with 2011. In fact, according to a report by TNS Global, roughly three out of four people in Portugal struggle to have enough money to last for the month and pay their bills.

Some patients who live in households where everyone is unemployed have told me that they have had to move back to their elderly and often ill parents’ homes. It is important to note that unemployment rates would actually be much higher if so many people were not leaving the country to pursue employment opportunities overseas as they are now. It is not surprising that many people who could previously be considered middle class are now beginning to slide below the poverty line and are having to resort for the first time to shelters and soup kitchens. They are being labelled the “embarrassed poor,” as in some cases we’re talking about people who previously had good jobs, a certain social status, and could afford luxuries such as holidays overseas. Many children are being transferred by their parents from private to public schools.

Portugal’s Catholic background has been helpful, as parishes are currently one of the strongest drivers for providing social aid to local communities. I have witnessed this when carrying out home visits and seeing parish staff deliver meals to patients at home. And it goes further. Lisbon’s central mosque, near where I live, provides meals to dozens of non-Muslim people on a number of days every month. Likewise, Portugal’s family oriented culture also remains as one of the most powerful support networks for many deprived patients.

In terms of daily clinical work, more patients than ever are reporting anxious and/or depressive symptoms, particularly among those who are unemployed or at risk of becoming unemployed, and those facing borderline poverty. There is much less demand for sick leave than before, as many patients report being afraid of losing their jobs, even if that means going to work when they are unwell. Moreover, more and more of my time is now taken up writing medical reports requested by foreign employers for patients who are about to leave the country to work abroad. I’ve already done it for all sorts of professions, including healthcare professionals such as nurses and dentists. A hospital in West Suffolk has just recruited 40 Portuguese nurses, and many of Portugal’s “best and brightest” young professionals are simply moving on.

Tiago Villanueva is a locum GP based in Portugal, and a former BMJ Clegg Scholar and editor, Student BMJ.