After a financial bailout earlier this year, fees in Portugal's health system have risen substantially. As a result, nongovernmental organizations say, the poor and elderly in Western Europe's poorest country can no longer afford essential care. Some Portuguese fear that austerity measures are threatening not only their livelihoods, but their lives.

Alfredo Silva, 67, showed up at an anti-austerity protest in Lisbon last month dressed as a skeleton. He says the costume shows the effect of Portugal's $100 billion bailout on retirees like him.

"I blame the IMF," he says in Portuguese. "For me, it means more unemployment, more misery and more hunger," 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. According to Portugal's Health Ministry, 11,600 people died in the first two months of 2012, compared with fewer than 10,000 deaths in the same period in previous years.

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 one-third of Portugal's hospitals are insolvent.

Francisco Reposo was at the same protest as Silva. Reposo is a 51-year-old public school teacher whose salary was cut by 30 percent. He is also on dialysis, awaiting a kidney operation. And he says patients like him increasingly face a stark choice between food and housing, or medicine.

"A lot of people had to stop taking their pills," Reposo says. "Many people also avoid to go to hospital, because they have no money to pay the fees."

The European Union 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.

"If you go to the emergency department in a large hospital, you have to pay 20 euros [$26], and if you do some complementary exams like X-rays or CT scan or something of that sort, you may go up to 50 euros," Barros says.

That cost — about $65 — may not seem like a lot to Americans, but it is to Portuguese who, like many Europeans, have been used to universal health care that was essentially free.

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 in Portugal.

"The fact that the health 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," Figueiras says. "So imagine now — they need to pay for transport, and they need to pay the fees. So people decide not to go."

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.

"They don't have money," Baqueira says. "We have to give them the gas and receive [payment] three weeks later, or more."

Fuel taxes are up, too. Gasoline now costs the equivalent of nearly $8 a gallon. Baqueira holds up 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, it seems, is that winter is just about over.