Hippocrisy (26/9/12)“ I swear to fulfill, to the best of my ability and judgment, this covenant:
…I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
…Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God…
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.” – the Hippocratic Oath (Modern Version), as taken by Kenyan physicians (abridged)
Today is day 14 of a nationwide doctors’ strike. In solidarity, over 90% of medical officer interns, residents and consultants who are paid by the government to provide health care to the country, have stayed away from work. And it is not the government who is suffering as a result.
Many sick people in Kenya cannot afford any health care at all. Some can scrape enough resources together to pay for the cheapest, subsidised medical care – the government hospitals. An elite few can afford to go to the private hospitals – medical care at the price of US or Australian hospitals, and almost at the same standard.
In between sit the mission hospitals. All set up with the goal of providing affordable health care driven by a desire to serve the poor, the vulnerable, the disenfranchised. Services for those who can afford it usually cost a little more than the government hospitals, but there is also funding to serve those who can’t afford care – and care is usually an order of magnitude better, as they are staffed by committed, highly trained physicians and nurses, working long hours for little or no pay. Staff who don’t leave in the middle of the day to supplement their incomes with private practice, as occurs at the government hospitals, but who work long into the night because they are there, quite simply, to help. These hospitals are within the grasp of a rural Kenyan, whereas the private hospitals simply are not.
So with the complete shutdown of the government hospitals for the last 2 weeks, it is the average Kenyan who has borne the brunt of the strike, with the mission hospitals furiously trying to keep up with the workload that comes from transfers from closing government wards, transfers from private hospitals when desperate people have run out of money after seeking care they couldn’t really afford, people who come straight to us because they know we are open for business, as well as our usual patients (plus the 2 bus accidents we’ve seen in the last 2 weeks with 30-50 casualties each time).
The worst part, however, is the patients that get here too late. The mother in labour whose baby’s umbilical cord has been hanging out, suffocating the baby while his mother goes to 3 hospitals before finding us. The father that after travelling through Uganda, Rwanda and most of rural Kenya finally found us to help fix his daughter’s esophagus injury after botched medical care elsewhere. The baby with pneumonia who sits here waiting to be seen for 6 hours because we are so overwhelmed that we don’t notice her in the back of the waiting room, almost succumbing to overwhelming lack of oxygen. The 26 week premature baby who was born somewhere else and may have survived if an ambulance could have been found to bring her here sooner.
This doctors’ strike is about a lot of things. Talk to each side, and you’ll get a convincing argument about who is right, who has been wronged, who deserves more, who should be patient. The reason the strike started is that registrars (doctors who have entered a training program to become a pediatrician, or surgeon, or radiologist) want to be paid to be in training, and are demanding that the government pays them – after they signed contracts saying they would sponsor themselves, knowing that the government could not afford to pay them. With approximately eight thousand doctors for the population of over 40 million, Kenya needs over thirty two thousand more doctors to meet the WHO recommended doctor: population ratio of 1:1000. The government is disastrously underresourced – and a strike isn’t going to change that. You can’t get blood from a stone. and even if you could, it sure wouldn’t be overnight. Now the strike is also about unmet promises from last year’s negotiations.
I’m at the point that I don’t care what it’s about anymore. What I care about is these kids, these mothers, these fathers – whose health, living in Kenya, was on a knife edge already.
When I was in Australia, the emergency doctors threatened to strike because we were underpaid compared to our colleagues of similar responsibility. I participated in the dicscussions, we liaised with our union, we negotiated with the government. We resolved things before the threatened strike date. And to be honest, I’m not sure, if push came to shove, that I could have gone through with it. Because I have a responsibility, not just as a human being and as a Christian – as a newly graduated doctor, I recited a version of that Hippocratic Oath, and I believed in it.
We went through this last year. 10 days of patients dying, doctors sitting, governments promising, optimistic returns to work. And here we are again 12 months later. I sympathise when the doctors are underpaid compared with other African countries, when promises are not kept by a government that finds itself out of money, out of ideas, out of poker chips to cash in.
But at a Cabinet meeting on Sept 20, it was noted that “provision of medical services was a right enshrined under the constitution and that the Government will introduce a bill to ring-fence the provision of essential services against future strikes that compromise the right to life”. With that I just have to fundamentally agree.
I think doctors should be bigger than going on strike. I think there are other ways to get what you want without literally killing people. And I think the union should be leading the way on this rather than recommending that the doctors just throw a tantrum, throw down their bat and ball and go home. Maybe they could work, but just send the patients go home without paying their bills – that would make a statement to government funded facilities. They could endorse, as a union, a candidate in the upcoming election, showing the current leaders that their promises have not been enough. They could strike overnight or during the daytime only, as some committed doctors I’ve heard of are doing – killing a few less patients. I’m sure there are literally a hundred ways to make a point which doesn’t end up with funerals around a country that, at its best, has far too many people dying every day anyway.
Update: 26/9/12 – The government has just fired all the doctors on strike, and is going to advertise to replace them from who-knows-where.