20th June 1999
A life and death issue
By Kumudini Hettiarachchi
Children are howling. The stench of vomit is strong. The queue, mostly of women carrying babies and children, is very, very long, snaking past benches. Some mothers, cradling inert and sick babies, are leaving in despair. It is Tuesday morning at the outpatients department (OPD) of the Lady Ridgeway Children's Hospital in Borella and a doctors' strike has crippled medical services islandwide.
Two doctors are busy and people are peering over their heads. But there should have been six at work. Suddenly there is a rush of feet. Loud weeping and an old woman rushes in screaming, "The baby is not breathing."
One doctor jumps up, grabs the 24-day-old baby and taps her lightly on the soles of her feet and the colour returns to her face. Then the baby is carried to the next room and an oxygen mask placed over her face. The baby is okay and the momentary excitement is over.
The child's breathless grandmother Mary Margaret from Hendala says they didn't bring her to the hospital the previous day because the doctors were on strike. By scraping a few rupees together, this fisher family took the baby to a private doctor and he prescribed some medicine. But on Tuesday the child's condition worsened and there they were at Lady Ridgeway Hospital for Children (LRH).
But two-year-old Thilanka is not so lucky in getting treatment at this premier children's hospital. His parents have waited long hours and decided to leave. He has very high fever and diarrhoea. While his father B.A. Nishantha, a mason in Makola, stops awhile to talk to us, his wife urges, "Let's go soon. Otherwise we may not be able to get medicine even from a private doctor."
"Why should we, my child, suffer because top people are having problems," he says and leaves.
Samanjith Wanasingharachchi, a corporal at Panagoda, had brought his three-year-old child also with high fever and diarrhoea, with the hope of admitting him, as he was not retaining any food or water. "Children are facing immense difficulty because of the doctors' strike. An adult can wait, but can we do that with children?" he asks. He too is taking his son home.
For G.M. Ramani from Veyangoda it has been a long wait. She left home early morning at 5, as her child was vomiting and very ill. When we spoke to her she had been in the queue for more than two hours. Normally, her child would have been treated within 45 minutes, she said.
"The humble shouldn't be asked to pay for other people's faults," she says. "Me okkama duppath hindane, apita 'private' ganna salli nethi hindanne," (This is all because we are poor and cannot afford to go to a private doctor), Ramani explains adding that she had not even had her breakfast. The time was 11.45 a.m.
The story is different at the Colombo National Hospital and the De Soysa Hospital for Women. The OPDs are deserted. At the National Hospital a lone woman is asleep on the bare benches. Hearing that the doctors are on strike the patients have not turned up.
Usually, around 2,000 children seek treatment at Lady Ridgeway, 1,500 men and women at the National Hospital and 450 women at the De Soysa Women's Hospital daily. But on Tuesday, the Children's Hospital staff said only about 500 had come to the OPD. The clinics also attract about 1,000 to Lady Ridgeway, 1,500 to the National Hospital and 400 to the Women's Hospital daily. But with the doctors strike on, only emergency services were functioning. Those who sought treatment at the clinics in all hospitals were being turned away.
Even in the OPDs only emergencies were attended to, except at LRH, where doctors were attempting to see most children.
The Acting Director of the National Hospital, Dr. Hector Weerasinghe said the Government Medical Officers' Association (GMOA) had ensured the smooth functioning of all emergency services. But neither the OPD nor the clinics were functioning. The clinics included ENT (ear, nose and throat), diabetes, hypertension, surgical, medical and psychiatry.
The GMOA has made arrangements for emergency admissions. But doctors are not attending to their usual duties such as routine ward rounds, operations and clinics. If a patient in a ward requires urgent attention, that has been provided for and essential services such as the intensive care and cardiology units are also functioning, he said.
The Accident Service is functioning as usual due to the arrangements made by the GMOA, Dr. Weerasinghe stressed, pointing out that when 108 people, mostly with fractures, were brought after the tragedy at St. Anthony's, Kochchikade, on Sunday night, they were attended to and emergency operations carried out.
When asked whether there were any deaths among the patients due to the doctors' strike, he said no, adding that in hospitals a few people die anyway. 'There have been no deaths because of the strike," he reiterated.
A senior consultant at the De Soysa Hospital who declined to be identified said routine duties such as ward rounds, operations and discharge of patients are not carried out. The OPD was not functioning and expectant mothers were not seen at the clinics. But all emergency services, such as emergency admissions and emergency Caesar operations were being carried out by the GMOA. The intensive care units and the premature baby units were functioning normally.
The other day, the consultant explained, there was a power failure because of a cable problem outside the hospital. This was during the strike. The hospital generator also failed. But the doctors carried out an emergency caesarean in torchlight on a mother and saved her baby who was under stress. Doctors were seen running upstairs to the Special Baby Unit carrying the baby.
"However, it has to be accepted that when doctors go on strike, patients do suffer," the consultant said. We came across one problem at the Women's Hospital. Diagnosis cards are not being issued to patients on discharge, because doctors have stopped all routine work. A mother with a newborn baby, who was fit to go home was heard grumbling that she was leaving without the card, which is essential for future referrals.
It is obvious that hospitals are in crisis. Why isn't anything being done?
What is the real issue? A national medical service based on merit only or a fragmented health system where politicians could stick their fingers and take decisions on life and death matters connected to the common man. Then comes the question whether the central government should settle the doctors' strike by giving a firm assurance that it will look into the grievances of the health service — dubbed the most efficient and effective for which President Chandrika Bandaranaike Kumaratunga accepted an award in Geneva last year — or crack the "essential service" whip. On the part of the GMOA, should doctors have a heart and not hold the poor and the humble to ransom? GMOA President Dr. Ananda Samarasekera asks the inevitable question. "What is our option? Should we allow the fragmentation of the health system by keeping quiet? Then it will be too late. "We are employees of the government. We are also very fortunate in that we have been called upon to do a noble profession, that of looking after people. But it is unfortunate that a situation has arisen where it has become imperative for us to ensure that the government and the politicians do the right thing. "It has become our responsibility to see that Sri Lanka's health service is not fragmented. That the country does not have eight different health systems for the eight provinces," Dr. Samarasekera explains. "If we do not take it up now, it will be gone forever, like in so many other fields and then it will be too late. Once the political interference, not only on health issues but also on crucial matters such as doctors' appointments and transfers start s, we will not be able to do anything, he said alleging that already in four provinces — Western, Uva, Wayamba and Central — acting provincial health directors have been appointed contrary to procedure and without the requisite qualifications. These were 'political' appointments.
Deploring the "irresponsible" attitude of Health Minister Nimal Siripala de Silva, Dr. Samarasekera said that when there is such a burning issue in the country, a crisis in hospitals, the Minister on Tuesday claimed that Cabinet may not have time to discuss the doctors' grievances.
What are the other issues which have national importance now, with the exception of the war? he asked.
Referring to the 'devolution' of health to the provinces under the 13th Amendment, the GMOA President said, at that time it was decided that the maintenance and establishment of hospitals would come under the purview of the various provincial administrations, while the services and personnel would be under the Central Government.
He said that in 1989, a committee which studied this whole issue recommended that 10 public services including the medical service should come under the label 'all-island' as against 'central' and 'provincial'.
This system worked well for some time but some problems were identified. Since 1996 after intensive consultations among the central and provincial administrations, the doctors, the Attorney General's Department and all relevant officials a policy was formulated.
This was approved as a government policy on March 23, 1999. On the other hand political interference was also seen in appointments as in the case of the acting directors, he said.
Dr. Samarasekera stressed that the GMOA is only seeking a firm assurance from the central government that it will do the right thing by the health sector, be it amending the law or enacting new legislation.
"Identify the problems or legal obstacle to a national policy and take remedial action, is our appeal to the government," he said.
Decentralisation of the health sector has failed even in other countries. It has been accepted internationally that it is detrimental to providing a good health system at a low cost. See our achievements in polio eradication, immunisation etc., which have all been carried out through a national health system. In the 1970s we controlled cholera very quickly, now we can't even do that, he said.
He pointed out instances where the provinces have handed back 10 hospitals, including Matara, Ratnapura, Kurunegala, Kegalle and Gampola, which were under their purview to the line ministry, because they couldn't manage them.
When asked whether it is ethical, Dr. Samarasekera said the strike may look unethical. "But we have done our best to ensure that all emergency services are functioning smoothly and hope the government will do something quickly to settle this. "We are the only association where one-third of our membership of 4,500 work during a strike to minimise patients' suffering. We will also set up free clinics to serve people if the government drags its feet and we have to continue trade union action."
Most doctors, senior and junior, are of the view that the cause — political interference — has to be dealt with and were wondering what other means they could use to bring pressure on the government.
They conceded that the poor man, woman and child would be compelled to undergo hardship, but felt the government too had a responsibility to work out a solution fast.
"The government should not allow this to fester. It's a matter of life and death," a young doctor said. "On the one hand the patients suffer, but on the other can we allow political interference?"
A woman doctor explained that from the day that doctors passed out of medical college their appointments were on the basis of merit. Those who had performed well could pick and choose the hospitals in which they wanted to serve, while those down the line had to take what was left.
This system has worked very well and cut out favouritism and all other types of corruption.
If provincial politicians are allowed to mess around with this system what will happen? Who will decide where the doctors will serve? What about transfers between provinces? she asked.
The need of the hour is for both the government and the GMOA to take the suffering of the patients into consideration, take a conciliatory approach and bring about a health system which is just and fair, sans political interference. A collision course would be disastrous.
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