Diagnosis, according to doctors

By Faraza Farook

Undercurrents and overlapping of duties between the central government and provincial administrations have turned into a national crisis over the past two weeks through the life-threatening strike by doctors.

The complex situation and controversy had been swirling below the surface but now it has come fully into the open.

The powerful Government Medical Officers Association (GMOA) which through its monopoly has pulled out some 4,000 doctors for a showdown with the government is demanding a national policy on health whereby the central government would have control over top appointments, transfers or promotions of medical officers in provinces. 

President Kumaratunga and the provincial councils insist that health is a subject devolved to the provinces and any change would require an amendment to the constitution. 

Pertaining to the devolution of health service administration, the GMOA claims it had been decided that the maintenance and establishment of hospitals would be under the provincial administration, whereas the control of officers and services would come under the central Government. 

In 1989 the Public Administration, Provincial Councils and Home Affairs Ministry issued a circular stating that nine public services, including the Medical service would come under the 'All Island' category.

Though the appointments, transfers, dismissals and disciplinary action of medical officers had been carried out by the Central Government throughout, a clash between the decision taken by the Provincial and Central administration was evident. 

Appointments approved by the Central Ministry were turned down by Provincial authorities sometimes, the doctors say. In some instances, political appointments were also made. Having identified this problem, a policy was drawn in 1996 after consultations with the provincial and central authorities, the Attorney General and the Medical Officers, the doctors say.

Since the policy had not been implemented, the GMOA says it raised the issue again this year along with ten more demands and threatened to go on strike. 

The demands were put before the cabinet and on March 23, the cabinet approved the policy and appointed a Cabinet Sub-Committee to look into the other demands, the GMOA sources said.

The Cabinet Memorandum submitted by Health Minister Nimal Siripala de Silva said that as already agreed in the Public Administration circular on November 15, 1989 the Medical Service (Medical Specialist, Medical Administrators and other Medical officers) had been categorised as an all island service, they said.

The memorandum said recruitment of all categories of medical officers mentioned was vested with the central Public Services Commission (PSC) with functions with the delegated powers of the Cabinet.

Accordingly, appointments, promotions, disciplinary action and the transfers of all categories of medical officers were vested with the central PSC, the doctors said.

Except for the post of the director general of health services, selection to the other top posts have been done by an interview board approved by the PSC, based on PSC approved marking scheme', the Cabinet Memorandum said.

The GMOA said that accordingly the following procedures were agreed for the selection of Administrative Grade posts;

* Line Ministry will advertise identified vacancies and call for applications.

* An interview Board consisting of the line Ministry and the provinces will be appointed by the PSC.

* Interview Board will select the suitable candidates based on the PSC appointment scheme and will recommend to the Governor for appointment to the Province.

* PSC approval should be promptly obtained before the release of the officer to the province to be appointed to the selected post.

* The Governor will issue a suitable letter to enable the officer to function in the respective post.

However, the policy not being implemented even after cabinet approval, led to a series of trade union action by the GMOA, doctors said.

"Why is the government reluctant to implement the policy already approved by them?," GMOA President Dr. Ananda Samarasekera queried. 

He says that is a question that lingers among the doctors, an issue which is not known among the public who are compelled to suffer due to the trade union action by doctors.

The current strike was sparked off recently when the Line Ministry called for application for administrative posts in the Wayamba Province. Wayamba Chief Minister S.B. Nawinna obtained an Interim Stay order to stop the Line Ministry's interference on the appointment of Provincial Medical Officers. 

Dr. Samarasekara says doctors will call off the strike immediately if the Minister of Health assures on behalf of the government that the policy will be implemented. 

"Why should the government backtrack in implementing a policy that has already been agreed and approved by the Cabinet," he asked.

One GMOA member said theirs was the only profession where most appointments were not made by a chit. The doctors fear that this will take place if the provincial councils are given authority.

In backing up the claim that the provincial system is inefficient, the GMOA points to the regular drug shortages and non payment of salaries. 

Though the maintenance and establishment of hospitals come under the Provincial administration, some provinces have handed over many to the Line Ministry unable to run them effectively, the doctors say.

Each province will govern the Health system by its own criteria where senior administrative posts such as the Director and Deputy Director of Health can be handed over to unqualified people, they say.

The Government has defended itself saying that since the court action is pending it could not take a decision on the matter, but GMOA representatives say the Government had ample time to implement the policies which it had agreed upon earlier. Health Minister Nimal Siripala de Silva refused to give an undertaking to implement the national health policy because of the legalities involved. 

"How can I implement the national policy immediately when the Appeal Court has issued an interim order to stop the appointment of officials to administrative posts," the minister asked.

Though he asked for time to solve the problem, the GMOA was adamant in going ahead with the strike, the minister said. 

He said he was unable to take a unilateral decision on this matter. 

The issue between the GMOA and the Government is in a stalemate situation where the union has broken all the government taboos and is still continuing with the strike. On Tuesday, the Colombo District Court ordered the GMOA to end the strike till a petition by a public interest group was decided upon. On Friday district court judge A. W. A. Salam said there was evident that GMOA leaders were trying to circumvent his enjoining order. He thus ordered the police chief to arrest the GMOA president and members of the executive committee. Meanwhile, authoritative sources said the President was planning to meet the GMOA provided that they call off their strike. A meeting to be held with Ministers Jeyaraj Fernadopulle, S.B. Dissa-nayake and G.L.. Peiris on Friday afternoon was also called off further aggravating the situation. 

However, the GMOA had held talks with Opposition Leader Ranil Wickre-mesinghe and the Health Ministry Secretary on Friday. 

Attacks and threats 

Doctors are living in fear with a series of alleged attacks and threats against them over the past few days. 

A car of a Paediatrician working for the Lady Ridgeway Hospital was set on fire on Wednesday night at his Nawala residence. Houses of two other doctors in the Kurunegala District were stoned. Similar incidents were reported from Gampaha and Gokarella.

The crowd which protested against the doctors strike at Kuliyapitiya had allegedly caused pandemonium in the hospital premises and the doctors threatened to withdraw even the emergency services if the crowd did not disperse immediately. Kuliyapitiya is in the North Western Province where the doctors's strike was sparked off after the chief minister took the issue to the courts. 

Kurunegala Hospital Director Dr. Ananda Gunesekera said there was tension after the Kuliyapitiya incident but the doctors were maintaining emergency services. He said the doctors had asked him for security but there was nothing much he could do. 

The GMOA officials allege politicians had let loose thugs on them in different areas while police protection was also minimal. They said that some politicians had even prevented them from conducting medical clinics for patients outside hospitals. 

How the case got worse

1996- Identifying the problems between the Central and Provincial administrations, a policy was formulated 

March 24 1999- Cabinet approves the policy 

June 12- GMOA decides to go on a token strike in the Wayamba Province saying the policy had not been implemented.

June 13- GMOA threatens islandwide strikes if the government fails to solve the issue.

June 14- GMOA launches strike 

June 15- Meeting with the Health Minister while on strike. The GMOA says the minister agrees to submit a cabinet memorandum the next day. The strike was suspended till June 17. Interim Order issued by the Appeal Court preventing the Public Service Commission and the Health Ministry from interfering with the appointments of Medical Officers to administrative posts.

June 16- Cabinet Sub Committee was appointed to look into GMOA demands. Memorandum was not submitted, oral submissions were made by the Minister.

June 17- Islandwide strike by GMOA. The President issues the Essential Services Order under Emergency Regulations but GMOA decides to continue with the strike. Leave of all medical staff cancelled.

June 19- Government Dental Surgeons launch token strike in support of the GMOA. Government calls in retired doctors, municipal medical officers and AMOs and RMOs to work in hospitals and conduct clinics outside hospitals. 

June 20- Dental Surgeons decide on a full-scale strike. 

June 22- Colombo District Court issues enjoining order restraining the GMOA from continuing the strike. GMOA forms a new trade union and continues the strike.

June 23-Minister requests other trade unions not to join GMOA strike. 

June 24- Doctors are asked to sign a letter stating that they are on normal duty if they wish to receive their salary.

June 25- Colombo District Court issues an Order to arrest 12 GMOA leaders. GMOA holds talks with UNP leader Ranil Wickremesinghe. Talks with government leaders called off at last moment. GMOA indicates it will agree to end strike if the president agrees to negotiate. But the President says they should report to work before any talks are started. The President is scheduled to leave for Nepal. The medical crisis drags on.

Demo against minister's son-in-law doc

Some one hundred people protesting against the doctors' strike demonstrated outside the residence of Minister Batty Weerakoon in Colombo yesterday afternoon.

The demonstration was against Dr. Charith Fonseka, son-in-law of Minister Weerakoon. Ms. Weerakoon told The Sunday Times that both the minister and her daughter were out of the country. 

Borella police were informed and two policemen came to disperse the crowd. But the two policemen were ineffective against the crowd, she said.

Asked how they managed to disperse the crowd, Ms. Weerakoon said "these are foolish people" and after a one and a half hour demonstration the crowd dispersed on their own.

Dr. Fonseka was among the 12 doctors against whom the Colombo District Court issued arrest warrants on Friday. However, it was said that Dr. Fonseka was not a committee member of the union. 

GMOA sources said there was a demonstration in front of the past president's home. The present assistant secretary's house has also been stoned.

The protesters are reported to have had with them a list of names of the doctors and apparently it was an a old list which included the name of Dr. Fonseka who had been a committee member in 1997.

Meanwhile more than 35 incidents of threats and attacks on doctors were reported within the past few days from various parts of the country.

Did they kill them?

Angry relatives and the public have attributed four deaths that took place during the week to the on-going doctors' strike.

Despite claims by government doctors that emergency services are being maintained and that the ongoing strike will not be the cause of death or any other complication, the recent deaths have provoked allegations that the striking doctors are acting in an 'irresponsible if not inhuman' manner. However some people blamed the government too for not finding a quick solution.

Although it cannot be clearly proved that the deaths were due to the doctors strike, the inconvenience caused to patients during the past two weeks has turned the public against the doctors. 

Julie Margaret (71) was one of the victims of doctors' strike, her family members claimed.

According to relatives, Margaret having got the wheeze was first rushed to the Kalubowila Hospital on June 14. When they asked for a trolley, the attendant at the hospital had turned them away saying there were no doctors. Seeing a woman doctor in the premises, Margaret's daughter-in-law Jayanthi approached her. 

The doctor having examined Margaret confirmed that the patient was serious but she allegedly she could not give treatment though the patient could be admitted if they wished to. Jayanthi had pleaded with the doctor to either give some pills to reduce the wheeze or to prescribe some drug to be bought from a pharmacy. 

Why not go to the pharmacy instead of coming here. Either admit her or take her away,' the doctor allegedly shouted. After much pleading, Jayanthi said she managed to get the pills from the hospital itself.

Realising that her mother-in-law would receive little or no treatment, Jayanthi decided to take her back home. Later she was taken to a doctor in the area but developed complications the next day and was taken into the emergency unit at the Panadura Hospital immediately. But the patient died around 9.30 a.m. 

Margaret's sons and Jayanthi believe that lack of attention at the Kalubowila Hospital was the main cause of death.

The problem did not end there. Margaret's family had problems in taking the body home. The hospital called for a post mortem. But the family members opposed. Margaret's family was asked to at least bring a letter from a private doctor or from the Police stating that she was ill. Finally the family had to seek the assistance of the Hospital Police post to remove the body without any letters or the post mortem.

Margaret's son who was angry over the whole issue said, the doctors were not prepared to take responsibility for their negligence. He said, "if the Kalubowila Hospital had promptly attended to my mother, she would be still among us."

Meanwhile Panadura's District Medical Officer Dr. Sarath Silva said, "we did our best to save the patient but we don't know what took place at the Kalubowila Hospital."

The physician, a member of the GMOA, who examined Margaret at Panadura hospital said she was unconscious when she was brought there. 

He said: " it is possible that the doctor who examined the patient at Kalubowila was an Assistant Medical Practitioner (AMP) who do not take Emergency cases." 

Among the other victims was four-year-old Ishani Kaushalya who died at the Kurunegala Hospital. However, Hospital Director Dr. Ananda Gunesekera said Ishani was suffering from a blood disease thalassaemia and had been receiving treatment at the hospital. He said the death could not be directly attributed to the on-going strike. A post mortem has been called for on Ishani's death. In recent weeks, there have been reports of serious shortage of a drug required to treat thalassaemia patients.

In Batticaloa, 38-year-old Anthony Sagayma, a mother of two died on Wednesday due to a heart attack, reports said. Dr. Rukshan Bellana, GMOA Branch union secretary in Batticaloa said, "it is the fault of the husband and the patient." The patient who was brought to the hospital suffering from a chest pain had been told to get admitted. But both the patient and the husband refused and went back home." Perhaps they were thinking that proper treatment won't be given in hospitals because of the strike.

Meanwhile the couple had met a doctor known to them who prescribed a pain killer and another pill and advised that the patient be admitted to the hospital. But no interest was shown. Later in the afternoon, the patient had got an attack and on admission to the hospital she was dead.

The other death was at the Chilaw Hospital where a woman died of hepatitis. Family members believe the death was due to lack of medical attention. But GMOA doctors there denied responsibility. Many patients who are deprived of the regular clinics and OPD treatment showed their anger and agony over the ongoing strike. Whatever the problem, the doctors should settle it with the government instead of making us suffer more, one patient said, echoing the feelings of thousands.

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