HEALTH SECTOR IN NEED OF SURGERY

It was a year of questionable baby deaths, imported doctors, viruses and protests. The world was on the alert for a new deadly disease called Severe Acute Respiratory Syndrome (SARS), which first showed late last year in China’s Guandong Province but rapidly spread in the new year due to international travel. Dengue made its usual appearance, but this year it became a source of dissension between the Health Ministry and South doctors who claimed there was a cover-up of the actual number of Dengue cases. There was red eye, leptospirosis and the usual flu/cold making the rounds in TT this past year.

But it was a bacteria little known to most of the population which left the strongest impression on the health sector. Indeed, enterobacter bacteria exposed all that is wrong with the sector, after an outbreak at the Mt Hope Women’s Hospital was publicised in early September. The Health Ministry sought to address the chronic shortage of doctors in the health sector by looking overseas. The first batch of Cuban doctors and nurses arrived in July and in September they were followed by United Nations Volunteer doctors who were recruited through an agreement with the United Nations Development Programme. The presence of these foreign doctors and the process through which they were registered  rankled local doctors’ representatives who criticised the Health Ministry for seeking to bypass the local Medical Board. Relations between doctors and their employers, the Regional Health Authorities, did not improve due to the very slow pace of negotiations. The rift between former Health Minister Colm Imbert and the Medical Professionals Association of TT was carried on in the media with both sides accusing each other of untruths.

Doctors impasse
The doctors impasse of 2002 spilled over into 2003 after the contracts for junior doctors expired on December 31. Doctors began staying away from hospitals and health facilities managed by the Regional Health Authorities, with senior doctors refusing to teach, supervise or accept medico-legal responsibility for junior RHA employed medical officers. Outpatient clinics at Port-of-Spain General Hospital were closed until further notice and the Eric Williams Medical Sciences Complex and PoS Accident and Emergency Departments were taking emergency cases only. Other patients were advised to visit their health centres. SFGH was described as “hardest hit” because 80 percent of its House Officers did not report for work. Several patients in North and South had to be referred to private facilities with the Health Ministry paying the cost for treatment. An issue which complicated the negotiations was the fact that the doctors’ representatives, the Medical Professionals Association of TT (the break away Medical Arm of the Public Services Association), was not a recognised union and could not negotiate collective agreements. Imbert said MPATT was trying to gain recognition to negotiate while their application (sent in November 2002) was still before the Registration, Recognition and Certification Board.

The doctors’ representatives (members of MPATT) were eventually allowed to negotiate on their behalf because it would have been impractical for all the RHA doctors to negotiate individually with their employers.  On January 19, Labour Minister Lawrence Achong put an end to further protest by doctors when he was granted an ex-parte injunction prohibiting doctors from taking industrial action at any time.” He said the action was taken because of “continuous and interrupted access by the public to health and hospital service operated by the RHAs.” The injunction caused some senior doctors to “resign” supervisory positions they did voluntarily. Although doctors had to return to work, service at public health institutions remained curtailed. They regarded the injunction as a “big stick” approach and demanded a resolution of their terms and conditions of employment.

At the end of January and for the interim, the RHAs offered doctors letters indicating an extension of their contracts until negotiations for new contracts 2002-2003 were completed. However, junior doctors were reluctant to return to work. The Inter-Ministerial Committee on the Health Sector, chaired by Minister of Public Administration Dr Lenny Saith, met with the doctors’ representatives on February 5 to resolve the impasse. The RHAs were mandated to continue talks with the aim of settling new terms and conditions; all terms and conditions of the new contracts would be retroactive to the date of expiry of the old contracts and doctors were to return to work “forthwith.” The injunction against the doctors was lifted on February 11. 

Three weeks after the intervention of the Inter-Ministerial Committee, doctors were complaining  about only one meeting taking place with the RHAs and the other two cancelled. However, on May 8, doctors agreed to the “major points” of the RHA proposal including a basic salary of $8,600 and allowances for junior doctors. The issues of compensatory days, overtime rate and gratuity were referred to the Ministry of Labour for mediation.

A consequence of the doctors’ protest was former Health Minister Colm Imbert’s announcement that the Ministry planned to institute the necessary checks and balances to monitor doctors who reported sick at public hospitals but undertake private work. He said this was a serious conflict of interest. No disciplinary action was taken against any doctor. As the end of year approached the RHAs offered full contracts including the terms sent for mediation to doctors. Time will tell how many doctors will sign.

SARS
Late November 2002, a new illness emerged in Southern China. It was called SARS. In 2003 SARS infected 8,000 people, killed 800 and adversely impacted on many Asian economies. The disease started in the Guandong Province and further spread was linked to an ailing visitor from Guandong who stayed at a hotel in Hong Kong during late February. The spread of SARS in Hong Kong to Singapore, Vietnam, Canada, Ireland, the United States and Germany was linked to the index case. TT was on the alert for travellers from countries which had detected SARS. One of the first actions taken by the Health Ministry was to bring legislation for SARS to be a notifiable illness. It is mandatory for doctors both at public and private institutions to report any probable or suspected cases. In May, the Ministry established a technical committee to oversee this country’s response and examine the possibility of all health care workers wearing specially designed masks as a form of protection against the disease. The Ministry advised anyone with respiratory infections to go to the Accident and Emergency Departments of their respective hospitals. Health workers were to isolate these cases, as well as persons with the cough and colds. They were to be sent to an assessment area. Health workers were to be equipped with protective wear against infection. The Ministry bought seven infra red thermometers and distributed them to air and sea ports. Although several people were warded for respiratory illnesses during the high alert for SARS, TT was fortunate not to have had a case. The World Health Organisation declared the world SARS-free in July.

Imported doctors
On January 3, Minister Imbert said his Ministry had received Cabinet approval “to take whatever steps necessary to fill all vacancies for medical doctors through the use of foreign doctors including Cuban doctors.” He said the decision was taken to forestall a complete shutdown of the health sector. The public was very receptive to the idea because they felt the brunt of the impasse between the doctors and the Ministry/RHAs and were disillusioned  enough with the local doctors to say “bring the Cubans.” The first group, 30 nurses and six doctors, arrived on July 24 totally oblivious that they would be at the centre of the ongoing feud between the Minister and local doctors. Ironically, just one month earlier, MPATT was receptive to the idea of Cuban doctors coming to relieve the chronic staff shortage, and even called the “proactive approach” a “welcome change from the ‘jail the doctors’ approach.” The association hoped the vacancies would be advertised regionally and internationally.  When the issue of registration of Cuban doctors arose, the war of words between the Health Ministry and doctors escalated. 

Doctors questioned the Minister’s intention to amend the Medical Board Act to establish a panel appointed by him comprising five members and headed by the Chief Medical Officer to issue special temporary licences to foreign doctors. The Medical Association and MPATT vociferously opposed this move because the change would remove this function from the Council of the Medical Board. On July 9, Imbert told the Senate the amendment was an interim measure until the repeal of the 43-year-old Act. He said the legislation would deal with the inaction of the Council of the Medical Board “against any doctor accused of negligence of malpractice.” Imbert said this is completely alien to legislation in other countries such as the US where Medical Boards can investigate allegations against doctors. The amendment also addressed the recognition of UWI medical graduates, who no longer enjoyed recognition by the General Medical Council in England. The Medical Association rebutted the Minister’s statement saying the Council could be sued if it failed to investigate any complaint received. Despite this, the amendment was passed and the six doctors in the first batch of Cubans were registered.

Since the Cubans arrived, MPATT was at the forefront questioning the standard of the personnel hired. One of their major arguments was that the medical personnel could not speak English properly. The Health Ministry had maintained from the onset that all the Cubans had a high level of English. Contradicting this, however was the fact that a few of them had to be sent for additional language training. MPATT wanted to know how much Government was spending on the Cubans’ accommodations, their salaries, and who would provide medico-legal coverage for them. They accused the Ministry of giving preferential treatment over locals and other foreign doctors since the Cubans were receiving an allowance during the three weeks of orientation “at the taxpayers expense.” Imbert steadfastly dismissed MPATT’s statements in the media. At the end of August and into early September, Cuban doctors and nurses were sent out to health centres and hospitals to start work. The total pay package the doctors are getting was also made public in the House of Representatives on September 5. Imbert had maintained that the salaries the Cubans would be getting “is of equal or lower value than their TT counterparts.” He said that they were not entitled to a rural incentive allowance, continuing education allowance, guaranteed overtime or housing allowance.

Attention shifted from the Cubans to the UN volunteer doctors, who began arriving on September 19. A total of 100 doctors are to be recruited under the UN Volunteer Programme. This has made TT the first country to have so many UN volunteers of one occupation. MPATT has accused the Ministry and RHAs of using “a subversive process of hiring UN doctors to occupy posts.” MPATT said no attempt has been made by the authorities to regularise the positions of doctors who have been in acting posts or advertise vacancies. He said the presence of Cuban and UN doctors would facilitate the establishment of specialised teams to deal with the backlog of surgical cases. Imbert announced that an Ophthalmology team was established to deal with cataract cases. He said with the arrival of more UN doctors other teams would be established. At the end of 2003 there are 72 Cuban doctors and nurses and 60 UNVs working in TT.

Enterobacater
Neonatal Consultant Dr Jennifer Delamore was first to call the attention of the authorities to the increase in enterobacter infections at the neonatal unit at Mt Hope Women’s Hospital. A routine swab of ten babies on September 5 showed they had varying stages of the bacteria. This was a 100 percent increase from the norm. Enterobacter is a nosocomial (hospital acquired) infection which can cause a variety of infections including lower respiratory tract infections, skin and soft tissue infection, lower urinary tract infection and intra abdominal infection. It is called an “ICU bug” because among its predisposing factors is prolonged hospitalisation particularly in Intensive Care Units. Premature babies are especially vulnerable because of their undeveloped immune system. The neonatal unit was shut down and all the babies evacuated to another area. A private company was contracted to thoroughly clean and sanitise all areas including the unit, post natal, labour and  delivery departments. Following the enterobacter outbreak, the Health Ministry mandated its quality manager to investigate conditions at the neonatal unit; a parallel investigation was to determine whether 15 deaths in August were due to “unsanitary conditions.” Minister Imbert threatened that “heads will roll” if anyone was found responsible for the conditions. This did happen, but the blame fell solely on the Vice-President of Quality, Jenny Gobin. Her suspension in October and dismissal the following month is the result of an internal investigation done by the NWRHA.

Everything seemed back to normal at Mt Hope when it resumed operations at the east wing on September 16. While the area was cleaner, a doctor disclosed that the unit was not properly equipped. In a press statement, chairman of the North West Regional Health Authority (NWRHA), Dr Patrick Watson said “stringent measures have been reinforced with respect to access to the units and delivery of quality care.” He assured that the unit was fully operational and all units were open to the public. Enterobacter seemed to be under control until November when Anisa Ramdial told the media  her seven-week-old baby girl died on October 7 from the bacteria. She also claimed several other babies had died at the hospital. Ramdial said doctors told her the infection came up to the neonatal unit from the delivery room. Nazeema Narine also came forward to say she believed her baby also died of enterobacter. The NWRHA denied Ramdial’s claim, saying the deaths of babies at the unit could be attributed to various factors because of their premature state. However, the NWRHA appeared to be hiding something when days later, Medical Chief of Staff Dr Esau Joseph disclosed that the bacteria was detected in babies born to two women admitted to deliver babies at the hospital. Another major cleaning exercise was done at the neonatal unit a week after Ramdial’s complaint was highlighted in the media. New Health Minister John Rahael announced there would be no cover-up following investigations into the latest outbreak of enterobacter. Earlier this month, Rahael announced plans to relocate the Women’s Hospital to the Eric Williams Medical Sciences Complex (EWMSC).

At a media briefing on December 23, the Ministry released the findings of the investigations done by PAHO and Dr Petronella Manning. The reports highlighted how poorly prepared, equipped and maintained, the nation’s ICUs are. The PAHO report said the ICUs were not even designed to serve this function. Enterobacter has caused heartache to women whose babies have died, and fear in expectant mothers. Despite the fact that hospital infections are part of the hospital environment, many have chosen to boycott Mt Hope.

Protest
No year-end review of the health sector would be complete without noting workers taking protest action. It is a means used by  workers to have their concerns addressed. The doctors were not the only group to show their exasperation with the RHAs. The North West RHA saw its daily and monthly paid workers protesting, while the South West RHA had to deal with the protest by emergency medical technicians with the Emergency Health Service. In September, the non-payment of increments totalling $10 million caused scores of workers to position themselves in front of the Health Ministry’s Head Office on Duncan Street to demand a meeting with Minister Imbert. At the September demonstration, PSA president Jennifer Baptiste-Primus blamed the incompetence of the NWRHA and Ministry for the delay in payment. Imbert did meet with the workers and gave the assurance that money had been identified to pay the arrears by the end of the month. He also agreed to meet with the PSA regarding permanent appointment of temporary workers. The workers were prepared to protest again (on September 25) when they saw the deadline date approaching, but this plan was shelved when they received word that processing of payments had started.

The protest by daily paid workers represented by the National Union of Government and Federated Workers (NUGFW) began in May with a group from Sangre Grande Hospital, who used their lunch hour to tell the RHAs they are were fed up with the prolonged negotiations. By July, lunch hour protests were planned for all health facilities. NUGFW President-General Robert Guiseppi described negotiations with the RHAs as “going nowhere slowly.” He said the employers were not negotiating in good faith and cited the five-cent increase in Cost of Living Allowance. Emergency Medical Technicians and dispatchers said they were tired of complaining through proper channels so they stopped work for four days, starting Monday June 30. This caused a virtual shutdown of the National Emergency Health Service. EMTs said the old vehicles they were using malfunctioned daily and put their lives and their patients’ at risk; they also protested a shortage of vehicles since the service began two years ago, and working without contracts.
Days after the protest began, Health Minister Colm Imbert announced that a new salary structure was approved by the Public Service Negotiating Committee for EHS workers, and the SWRHA was instructed to implement the new terms and conditions with immediate effect. Workers were also promised new ambulances.

On December 4, Minister Rahael signed an agreement with UNDP for the delivery of 40 new ambulances, starting next month. There is no doubt the health portfolio is one of the most demanding of any Minister. Colm Imbert learnt this during his less than two years in office in which he tried to push ahead the Health Sector Reform Programme and make changes. His tenure would get mixed reviews. The past year in health has not been all bad — health centres opened, the Chronic Disease Assistance Programme was introduced in February to provide free medication to pensioners with diabetes, hypertension, glaucoma and some cardiac disease. It was extended in June to include people over 60 thereby providing coverage to approximately 135,000 people.

The Health Ministry is finally taking action to deal with the long surgical waiting lists. Special projects for cataracts, prostates, heart surgery will provide assistance to those awaiting surgery until a long-term system is devised. TT is exploring the Western Canada Wait List project to adapt it for the local setting. The five-year national HIV/AIDS Strategic Plan received US$20 million in financial support from the World Bank and the coordinating committee to oversee implementation of the plan has been appointed. The new year is expected to challenge the Minister as it is never boring in the health sector.