The Sunday TimesPlus

25th August 1996



Health sector: a mixture of bad medicine

By Anoj Dharmawardene

Health concerns all of us regardless of our position in society. Disease is part and parcel of life itself, and thus prevention and treatment are also vital ingredients of every society.

In this context, a sound health-care system is a must for every nation aspiring to achieve economic stability. But today, we find our health sector in turmoil and a widening gap between health authorities and health workers, including doctors.

In the past two decades while our economy was advancing in leaps and bounds, the health sector received hardly any attention from politicians, perhaps because if lacked the crowd pleasing vote pulling ability of housing schemes and dole handouts to the poor. There was thus a lack of foresight of funding or investment in health infrastructure, which led to hospitals becoming overcrowded, unable to meet the needs of a growing population. In fact, The Sri Jayawardenepura hospital was the only major hospital constructed in the last decade.

Since 1976 only fifty new hospitals have been constructed, while the number of hospital beds increased only marginally, hardly in keeping with the population growth (See table I).

Meanwhile, the so-called upgrading of central dispensaries to peripheral units and peripheral units to district hospitals continued, just by the unveiling of a new signboard by a prominent politician with no extra facilities being added. In base hospitals and general hospitals one finds two or three O.P.D. doctors in a small room, consultations taking place in such cramped quarters.

When the present government came into power, the Health Minister A.H.M. Fowzie made several startling revelations. Firstly that 5,000 more doctors were needed to fill the vacancies in the government sector. Getting down specialists from other countries like Cuba was even considered. At this time (in 1995) about 400 medical students graduated each year from local medical faculties, while another 150 to 200 foreign qualified medical graduates also returned and were available for employment.

Barely a year after his first statement, the Minister changed his tune, indicating that the cadre of government doctors was complete and that it was not possible to employ future local medical graduates. It was not revealed from where the 5,000 doctors had emerged to fill the existing vacancies (or at least 2,000 doctors, according to health ministry statistics).

Then Minister Fowzie considered banning private practice by government doctors, presumably to allow the future medical graduates to practice in their own private dispensaries. This appeared to be a great solution to two nagging problems; the unemployment of future medical graduates, and the private practice of doctors even during their duty hours.

But this very pleasing idea was also found to be unworkable. One could well query why this is so. Actually our health system needs more doctors, as the Minister earlier said. We only have a doctor per 5,500 patients, whereas our neighbouring India has one per 2,500 and developed western countries one for 270. Under these conditions if private practice were to stop, the government hospitals would be more over-crowded, and the patients, not just doctors, hard hit. It would be more appropriate to take to task the doctors, who practice in private hospitals during duty hours.

Medical students feel that they will be the losers if they are not going to be employed in the government sector. The failure of successive governments to invest in the health infrastructure development has led to this situation where there is a lack of vacancies in the government sector (according to the Minister). But then why take it on the medical students who are innocent, ask the students.

"We have sacrificed our youth, almost eight to ten years studying to be doctors, and if we don't get a job it's very unfair", said one medical student. "It's not our fault that the government didn't build new hospitals", a student we spoke to said.

After graduating, medical students have to undergo one year's internship just like hands on training by a specialist. Without this, medical students will be like inexperienced drivers, who are given licenses.

Another major consequence of this problem, will be the lack of specialists in future. If the future medical graduates are to do postgraduate degrees, a few year's experience in a hospital is compulsory. If future medical graduates are left on their own, this experience will not be forthcoming, and Sri Lanka might have to import specialists at great cost. Who knows in another fifteen years, our hospitals could be run by foreign specialists and consultants while local doctors are limited to the private dispensaries and hospitals, writing out prescriptions.

Adding insult to injury, the government planned to recruit another 600 AMPs last June. (100 AMPs according to the Health Ministry). "If the government cadre of doctors is filled, how can 600 or 100 AMPs be recruited?", was the question medical students asked.

The AMPs are providing a great service to the country without a doubt. But as it was pointed out a few years back, the AMPs are not made in the same mould as the MBBS qualified doctors. Hence, there should be no doubt as to whom to turn to, especially as there is a possible unemployment threat to medical graduates.

"We can't quite understand the rationale behind this. We have to face tough exams and cram for about six years, and then wait for two more years for internship appointments, while the AMPs who go through a three year course get jobs before us", a baffled medical student said. "Worse, they'll be taking our jobs while we are left jobless," he said.

The students who get the highest aggregates at the A/L exams qualify to enter the medical faculties, while the selection of students for the AMP course is not just academical, but political also, sometimes with the "MP's chit" opening closed doors.

Meanwhile, another controversy is brewing regarding the foreign qualified graduates. A few years ago, the then USSR granted Lanka several scholarships to their medical faculties, which were on par with local universities in standards. But after the destruction of the Eastern Bloc, a large number of so-called universities mushroomed in these countries, and the standards of these are being disputed. (It is alleged that some universities sell the certificates without proper examinations).

Hence, the quality of these graduates who have studied in foreign countries (sometimes for two to three years) is highly variable. "It's as if like a private medical faculty has opened up. Last year 177 graduates came here. This year it would be more. At this rate, they'll exceed our output," said a medical student. Last year about 430 local medical graduates entered the government sector.

There are moves to make the Act 16 exam compulsory for foreign graduates but the local medical students feel that's not tough enough.

"Act 16 is an oral examination, which compared to a written exam is easy. Take the law exams for example. Any lawyer who wants to practice here has to sit the final exam in law college", a medical student pointed out.

"Even then, local graduates should be given preference, if there's a job crisis. These students are just like graduates from a private medical college, whereas we have qualified to be here", he added.

Whatever is said and done, the local medical students feel that their future is in the balance. They may rejoice after having passed an year-end exam or after finishing a tough clinical appointment, but a general gloom has overshadowed the local medical faculties. Unless the situation is addressed, this malaise could spread to engulf the entire health sector... and it's future as well.

Year 76 81 85 90 95 Hospitals 460 488 490 502 510 Hospital beds 41,069 44,082 45,211 47,079 54,641 Central Dispensaries 351 340 338 278 386 Doctors 2,248 2,233 2,151 2,440 4,580 AMPs 1,059 925 957 1,074 1,324

Rape still trivialised?

"Towards Change" focuses this week on a seminar held recently by the Medico Legal Society in collaboration with the National Council of Women on- "Abuse of women-problems and remedies"

Speakers at the seminar discussed amendments made to the Penal Code late last year which attempted to correct some of the more obvious absurdities in our criminal law. The new laws introduced the offense of marital rape in instances of judicially separated spouses and the offense of sexual harassment.

In addition, the amendments provided for an enhanced punishment for rape and specified a compulsory minimum sentence. The age of statutory rape was also increased to sixteen years.

Describing the more important aspects of the changed penal laws, Secretary to the Ministry of Justice Dhara Wijetilleke pointed out that the laws did not seek to tilt the scales in favour of the woman victims but merely endeavoured to balance the scales.

"Enactment of these laws will go some day towards redressing injustice. But we should not think that all that should be done has been done. The new laws should be enforced in the spirit in which they were enacted," she emphasized.

Following are extracts from the addresses of two of the speakers at the seminar.

Lecturer in Human Rights at the Faculty of Law, University of Colombo and Director of the Human Rights Centre, Dr. Deepika Udagama.

"As a human rights educator, it is not worthy that discussion on any Human Rights issue is treated very seriously except discussion on women's rights. The Medico Legal Society is to be commended therefore for hosting such a seminar.

What is sexual harassment? In short it means unwelcome sexual advances, activities or attention. It is necessarily a behaviour pattern focusing on that person's gender and using sexuality to demean that person. In other words, if not for the gender to which that person belongs to, she would not be subject to such harassment.

The range of sexual harassments is very wide. It does not mean only unwelcome physical attention but includes sexually suggestive looks, words and sexual innuendoes. While it would be incorrect to say that only women are subject to sexual harassment, an overwhelming majority of victims are in fact women, specially when they are in positions of subordinate to the harassor.

Sexual harassment can occur in several places. It can occur in controlled places like work places, educational institutions and places of custody like hospitals and police stations. It can also occur in public and open spaces, as for instance when using public transport or while walking on the road.

In Sri Lanka, there is an appalling dearth of statistical information as to documented instances of harassment but surveys have shown the large number of factory girls who get hasassed not only at their work place, but also while walking back and forth to work. Meanwhile, another often unnoticed segment of Sri Lankan society subject to very severe sexual harassment are domestic servants. In positions of abject subservience to their masters, they suffer in silence.

It is interesting to note the reactions of individuals to the whole concept of sexual harassment. In 1992, at a workshop held by the Legal Aid Centre of the University of Colombo, undergraduates discussed what is meant by sexual harassment. What is its effect? Does is make the victim squirm a little and feel momentarily embarrassed only? Or does it make one victim feel dirty and make her internalize it so that she puts the blame on herself and thinks "It is my fault, somehow, I must have provoked this behaviour.

"Students put forward some reasons commonly used to justify sexual harassment. It was pointed out that ours is a sexually repressive society. Some men resort to sexual harassment because of their own frustrations. Others indulge in it as means of showing their appreciation of a member of the opposite sex. Still others feel that this is a good way of showing an overly confident and capable woman her place. And one of the most common reasons remain: "She asked for it. She should not have worn that dress.

"Sexual harassment cannot be justified or excused for whatever reason. It denies women the equal right to participate in public activities. It denies her the freedom of movement for, in our society, if woman travels around alone after dark she is treated like a sex worker. It also denies her the freedom from degrading treatment.

Two sets of laws can be devised to deal with sexual harassment. On the one hand there are anti- discriminatory laws enacted with reference to work place and educational institutions. In fact some American and British laws make the employer liable even for sexual harassment by one employee over another employee, if the harassor is supervisor. In all instances, the employer must take some action when instances of sexual harassment are brought to the employer's notice or be held liable.

In those countries, therefore, employers fall over themselves to minimize instances of sexual harassment in their work places, otherwise it means that they have to pay big money in court costs, damages etc.

The other manner of dealing with sexual harassment is, of course, through the Penal Law. The Sri Lankan Penal Code was amended recently to create a new offense of sexual harassment and to provide for the punishment in respect of that offense.

The new law provides that whoever by assault or by the use of criminal force sexually harasses another person or by the use of words or actions causes sexual annoyance or harassment to such other person commits the offense of sexual harassment. On conviction, he is liable to be punished with imprisonment of either description (maximum five years) or with fine or with both. Additionally, he may also be ordered to pay compensation of an amount to be determined by court.

In Sri Lanka, one law to deal with sexual harassment is therefore finally in place. But the law itself is not sufficient Laws will remain valid only in the statute books if attitudes of law enforcement officers, lawyers, judges and the whole of society are not progressive and understanding. We need to launch a multi pronged attack therefore if this whole issue of sexual harassment in Sri Lanka is to be effectively addressed.

Former Dean of the Faculty of Law at the Open University and presently Professor of Law at the University of Colombo, Savitri Goonesekere:

"Society has often responded to the sexual harassment and violent treatment of women by trivializing the issues. They are considered as being occupational hazards of being a woman. Violence against women is trivialized even by law enforcement officers who advise abused women to back to their allusive husbands.

Rape is also trivialised. Recently, the newspapers reported a rape case from the High Court of Ratnapura where the judge had suspended sentence. This means in effect that the offender virtually goes scot free. But the impression given by the news report was that a suspended sentence was a harsh punishment.

The legal argument in pressing for a suspended sentence is based on such pleas as saying that the offender is the father of so many children, that he is the sole breadwinner of the family, that he was drunk and did not know what he was doing and so on. When judges give decisions in this manner, a powerful message that this kind of violent behaviour is condoned is passed on to society.

At least now, we have had a legislative response to the problem of violence against women though it has come after a hundred years. What the recently enacted penal laws emphasize is that women along with men have a right to protection of their bodily integrity.

When these amendments were under consideration, it has discussed whether it would be more appropriate to enact a special law dealing with violence against women. Ultimately however, it was felt that if one is to perceive this as a serious problem, it is imperative that the penal laws themselves should be amended.

But these amendments while undoubtedly praiseworthy also have significant disadvantages or defects. One of the crucial amendments which permitted medical termination of pregnancy where there is rape, incest or where there is a risk of birth of a child with serious abnormalities was later dropped after intense opposition. As a result we have a peculiar situation where the same law outlaws and severely punishes rape but decrees that a foetus born out of that rape cannot be aborted. It is ironic that a law which has changed its fundamental premise so significantly as regards violence against women should adopt such an obvious double standard.

At present therefore, women who find themselves in such situations can only go in for backstreet abortions. It is highly unlikely that our doctors would risk the chance of prosecution to intervene.

Meanwhile, marital rape has been introduced as a new offense but could be resorted to only by judicially separated women. As experience has shown us in Sri Lanka, judicial separation is resorted to only by a very rare percentage of upper middle class women. In the vast majority of cases, women either go in straight for a divorce or physically separate from their husbands. With respect to the policy makers who initiated these laws, I would like to say that introduction of laws like this therefore only amounts to mere tokenism.

The amendments also on incest not only where there is formal adoption but also in informally adoptive relationships. But written permission of the Attorney General is required to prosecute for incest. This is not all that satisfactory as there might be reluctance to prosecute for reasons of family privacy and so on. Additional guidelines, when permission should be given should also be introduced so that there would not be an arbitrary exercise of that discretion.

Surveys done here have shown that incidents of incest specially in dysfunctional families of migrant workers are very high. It is therefore an issue that should be effectively addressed.

There should be guidelines set down even for sentencing in rape cases. Otherwise, there would be no coherence in the law with one High Court Judge sentencing for seventeen years and another giving suspended sentences. In the 18th century, Justice Derrick said that we have a habit of taking our law making in words and not in action. This remains true even today. For law to amount to more than mere tokenism, much more has to be done than mere enactment. There must be an effective partnership between lawyers and doctors specially in cases like rape so that the necessary medical evidence could be elicited easily. It is not unusual sometimes to find a doctor being treated like an accused in court, where he is questioned extensively on his medical qualifications and so on.

As a result, most doctors are to come forward and testify, leading to postponement of cases.

Moreover, the state should also provide effective back up support for law enforcement officers. We are talking here about actual allocation of resources. It is well known that the women's and children's set up at police stations have nothing more than their desks. Provision of the necessary infrastructure is therefore vitally necessary? Above all, making the new laws effective has to be a shared effort between policy makers, judges, lawyers, doctors, law enforcement officers and the people who are ultimately the beneficiaries. There should be shared commitment, not professionals fighting over turf.

Continue to plus page 4 - Sarachchandra's unique contribution

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