Time Junior Doctors stopped playing the fool

Dear Junior Doctor X
Many thanks for telephoning me after my article last Monday. It has given me a rare opportunity to hear the point of view of doctors-on-strike. Yes you are right. My figures for House Officers in the UK supposed that these were equivalent to the Junior House Officers in TT.

In fact it is the Senior House Officer who is equivalent to the Junior Doctor in TT. This ups the British Doctors’ salary in 2002 from approx ?18,000 basic plus 20 percent to 70 percent allowances to ?21,000 plus 20 percent to 70 percent allowances. It also brings these doctors into the tax range of 40 percent after the first ?28,000. Very recently an additional 4 percent has been added to the doctors’ remuneration. I am not certain however as to if this represents a rise in the indented cost of living or a rise in the basic salary. Most important for our purposes, I do not as yet know how British doctors’ salaries and increases relate to salaries of other health personnel, to salaries of other professionals in the Public Service and to the lowest salaries in Britain.

It is this picture which is relevant plus the overall economic situation of what is after all not only a developed country but one which has had a considerable start in “development”. But then, as you yourself state, comparison with British or US salaries is not the salary issue. It is, according to you, in the first instance, the repayment of the study loan. It is the equivalent of this that you wish added to the present doctors’ salaries de facto annulling your pay back commitment. In other words, behind the Doctors’ Strike is the demand for free University education for those who choose to be doctors. What you argue is that present junior doctors are being discriminated against, or victimised, since before this medical tuition was free. I do believe that you were genuinely surprised to hear that this was not so except perhaps for a short period when, as a result of the oil boom, TT aimed at free university education. In the case of most older doctors, fees were paid for by their family.

Before the establishment of UWI, costs included travel to the UK or Canada (McGills) and overseas board. On return doctors depended on their family to set them up if they were in private practice and in any case scrunted respectably — given their status — for many a year. No doctor and few professionals expect to “take off” until midway through their career. A fair amount of the present conflict is therefore about extraordinarily high expectations fuelled I’m afraid by ignorance of the past. I hasten to add that this is not only a medical disease — it is widespread in the country.

Globalisation

You do however have a point. There has been a sharp rise in university fees as a result not of government wishes — whatever the party in power — but as a result of World Bank-IMF policy. This has been to treat the university, like health, as primarily a ‘business’ which should ideally pay for itself. University fees therefore have increasingly been calculated with reference to the real cost of training. This has had an impact not only on fees and therefore on your pay back package, but on the social composition of the student corps and indirectly on the present series of strikes.

Your other salary complaint was couched in terms of the salary of the WASA CEO. I suspect if we spoke today it would be the Petrotrin CEO. Here we are likely to be in agreement. I do not believe that it is either morally justified or socially wise for anyone to be paid salaries of $50,000 and $70,000 a month at a time that Laventille claims a 70 percent unemployment — and over three quarter of all households live on less than $4,000 a month. This gap in salaries is one of the main reasons for the lack of social cohesion in developing countries and the resultant instability. But there is another reason why I am against this. It represents the present tendency to privilege the technocrat over the intellectual and management over professions. In line with this I remain against RHA’s. These too, let it be known, were foisted on us in the form of “conditionalities” in a Save Mount Hope IADB loan. You see, Junior Doctor X, I am not as far away from your preoccupations as you may think. However, and unfortunately, we are unlikely to rid ourselves of the RHA’s. We must look beyond these and with Energy money we can. If we are to look beyond in Health, however, we must hit hard another of the modern trends: medicine as business and medical studies as investment. It is here we disagree.

I need not add that none of your grievances justify this series of strikes. It is inadmissible that industrial action by doctors aim at shutting down the nation’s hospitals, deliberately increasing suffering, risking deaths and augmenting the medical costs of an already under-budgeted health service. You will note that I have nowhere taken into account charges of a confrontational minister or confrontational RHA’s. The tendency to collapse problems into personalities is a way of trivalising problems. Where there have been three doctors’ strikes in a row, we cannot afford this. The supposed personality of either the minister and, let’s be honest, the confrontational personalities of a gaggle of MPATT doctors, is neither here nor there to the real issue. That real issue remains the health policy.

The public hospital

The corner stone of any health policy here, as in Europe or Canada — note I omit the USA — is the public hospital. No possible equitable and overall health care policy can be implemented outside of the crucial nature of the public hospital even where private hospitals play a part in health policy, as in France. Here, as in Europe, the tradition has been that citizens and often residents in a State, have the right to free or nominally priced medical attention in public hospitals. It is the quality of this treatment which signifies equality both in the treatment of patients and its usage by all sectors of the community. Where this quality does not exist, the poor get bad or no treatment, the middle class is ruined with medical bills and doctors are caught in the conflict of interest as between public and privatised.

The first step in policy therefore is the revamping of expansion and equipment of the public hospitals. To the former priority for health care for the young, and the need for a healthy workforce on which the country’s economy depends, add our changed population profile. An aging population is reflected in the incidence of certain diseases, eg, cancer, heart, diabetes, arthritis, Alzheimers. The modern treatment of these can be expensive both with regard to surgery. There is, in addition to the age profile, the increased incidence of serious mental illness not the least in part due to the incidence of drugs. I would be very surprised if say our schizophrenic rate is not abnormally high. These are only a few areas that will need our attention. These alone are enough to be challenge and excitement. This expansion and revamping of the health services in turn demands increased specialisation as it does equipment, and maintenance.

One of your complaints, Junior Doctor X, has been that of lack of opportunities for specialisation. As in the case of university fees, this is in no way a right. It depends on the expansion and needs of the public hospitals. There is no reason for taxpayers’ money to be spent on paying for doctors to specialise in order to serve the privatised health sector. Doctors’ interests therefore are generally the same as the interests of the rest of the population. Isn’t it time then, dear Junior Doctor X, that, well forgive me I am elderly — Junior doctors stop playing the fool.