Doctors aren't saints

A man goes to the doctor with an ailment. The doctor cures this ailment and asks to be paid. The man refuses to pay, and says that doctors, by virtue of becoming a doctor, have special moral obligations to patients and society and asking for payment for his services brings into question his humanity, his morals and the oath to honor the profession. He goes on to caution that such demands would ruin the faith of the public in the profession and portray doctors as being inconsiderate and materialistic.

It is unfortunate that the current strike by doctors is viewed in such a perspective, that a strike is incompatible with the medical profession. It is disappointing that the Human Rights Commission denounced the strike by suggesting that doctors were trying to hold ransom the rights of patients for material gain when it wasn’t so. The strike was limited in that doctors attended emergencies and care was provided for inpatients. As advocates of human rights the commission should rather question why policy makers allow unnecessary suffering of patients by improper allocation of healthcare resources.

While it is true that doctors have special obligations to his patients and society, a person who choses to become a doctor does not make any declaration, implicit or explicit, that he/she will abstain from trying to make his/her life as fulfilling as possible and like any other individual they too have the right to pursue happiness. The actions of doctors should be judged by the same standards as those used for other professionals. When the Civil Service Commission fails to provide a just payment for their services, it is unfair to suggest that doctors should work under any circumstance. Several doctors, while employed full time as professionals, have been denied the professional allowance and exploited due to the commissions’ refusal to review its rules.

If doctors have special obligations, they can demand special benefits and go on strike, as long as the demands are reasonable and it does not undermine patient care. The provision of healthcare is a joint responsibility of the government, hospitals and doctors and each element should support the other.

THE PUBLICS' MISTRUST IN HEALTHCARE

Trust is a fundamental element in interpersonal relationships and the importance of trust within healthcare cannot be stressed upon enough. Patients present themselves to healthcare providers at their most vulnerable and must be able to trust both the institution and the individuals involved in their care. They must be able to trust that these individuals and organizations are competent and have their best interests at heart. At present this is far from true in this country. Most patients do not trust the institutions nor the individuals providing the care. They are weary and suspicious of any medical encounter. Numerous accounts of mismanagement, maltreatment and neglect by doctors are exchanged daily in the queues at IGMH or ADK. People would rather go abroad for the simplest ailment than get a consultation here at home. 

Several factors have contributed to the buildup of this mistrust. 

Firstly, as the face of healthcare, some doctors do not bother or are not trained in creating a healthy doctor-patient relationship that is crucial to the success of any treatment. Most Maldivian doctors are trained in South Asia, either in India, Nepal, Pakistan or Bangladesh, where a paternalistic approach to patient care is acceptable, practiced and used in training. The doctors know what is best and the patient should do whatever the doctors order, no questions asked. Procedures can be done on patients even without consent. There is no room for the patient to refuse treatment. On daily rounds it is common to see doctors scolding patients for not complying with treatment. The rights of the patient and proper ethical conduct are hardly an issue. Thus it is not surprising that such incidents are all too common in our hospitals where the doctors are either trained in or are from such countries. The possibility of trust in such an environment is impossible, especially when Maldivian patients in general ask more questions and are somewhat more aware of their rights (hence the popular belief among doctors that maldivian patients are ‘troublesome’ and ‘difficult’). 

Secondly, healthcare institutions and individuals do not protect the patients’ rights of confidentiality and treat their medical information as coffee-time gossip. It is all too common to hear doctors discussing personal details of their patients for their amusement, or lab technicians  discussing a patients’ paternity test. Healthcare professionals owe a duty not to disclose information against the patient’s wishes as medical confidentiality is an important feature of the doctor-patient relationship. 

Thirdly, healthcare institutions are all too keen to cover up medical mistakes and no framework exists to deal with such mistakes. Hardly any incident is thoroughly investigated and proper actions taken, and those wronged are not compensated. There are no professionals trained in legal medicine and those sitting on the ethics committee lack any training in the area.

Fourthly, there is no institution to regulate and standardize healthcare. The recruitment of expatriate doctors, who make up majority of doctors especially in the atolls, should be more stringent and registration at the Maldivian Medical Council should be followed by a licensing exam. Many are familiar with the account of a cook who used to work in one of the islands as a doctor for several years. There is a lack of standardized management protocols for common conditions, and adherence to those existing protocols is limited and not enforceable. There is no code of ethics or a code of professional conduct for doctors, which is a necessary tool for the regulation of the profession. Policy makers should consult healthcare professionals in making decisions that affect the health of the population in general. The recent changes to the appointment system at IGMH(which has fortunately been reversed), seriously violated a patients’ basic right to choose his/her healthcare provider, and only intensified the publics’ mistrust.  

In such a setting, where healthcare is not standardized or regulated, and where the healthcare providers are not bound by any obligations, legal, professional or otherwise, the publics’ mistrust towards healthcare is not surprising. It has resulted in the increased number of second opinions being sought and increased the requests for referral abroad. Failure to comply with treatment is commonplace. It has also increased the number of people turning towards other sources of treatment. 

Having said all this, I know of no doctor who wishes harm on his patient. Perhaps it is the combination of several factors rather than a single one that has led to this mistrust. Trust is a potentially powerful variable affecting healthcare decisions. And as such, both healthcare institutions and individuals should work to regain and reestablish this trust, by building a relationship in which the values and goals of both parties are clearer to each other, one of shared decision making, and one which promises to increase patient satisfaction and lead to greater understanding of treatment and illness. 

STATUS OF THALASSEMIA IN MALDIVES

Thalassemia, at present, is one of the most challenging hematological disorders . Patients with ß- thalassemia major need regular blood transfusions in order to live and the resulting iron overload requires chelation therapy.  The problems facing them and their parents are immense, challenging them physically, emotionally and socially. 

In the Maldives thalassemia affects about 0.16% of the population, and is found throughout the country, with the highest rate found in K atoll, most likely because an address in Male’ is given at the time of registration at the National Thalassemia Center (NTC).  Apart from K atoll, the highest rates are found in N, H.Dh and L atolls. 

To date a total of 670 cases has been registered at NTC. The number of new cases registered has not declined over the last five years, with about 28 new cases on average being registered over the last 7 years. Last year saw an increase to 39 in fact.

Considering that the country has two centers dedicated to thalassemia (Society for Health Education and NTC), and the government spends roughly $5000 per year per child for the treatment of a child with thalassemia above 12 years, this current trend raises the questions whether these centers are doing enough for the prevention of thalassemia. 

The current preventive program focuses on discouraging the marriage of carriers to one another, thus increasing the number of carriers throughout the country. And in Maldives where the social circles are small, the chance of intermarriage of careers is high. And their career status will not be a deterrence to getting married or having children. They will continue to take the risk and hope for that 75% chance of having a normal baby. 

The approach has not helped in reducing the number of new cases as most of the children with thalassemia are being born sadly, to those who know of their career status at the time of marriage, and to those who already have a child with thalassemia. This is an important observation that needs to be addressed in the prevention program as just the mere knowledge of the risk has not prevented couples from having children. 

The goal of the program should be to lessen the burden of thalassemia in at-risk families, accomplished not only by providing information about the risk but also providing options for dealing with it by helping at-risk couples obtain prenatal diagnosis and selective abortion, or by helping them to cope with the birth of an affected child. 

The current management protocol too needs revision to include oral iron chelators in the treatment. At present only a select few are being provided oral iron chelators at NTC as the treatment requires regular monitoring for side effects. Recommendations have already been made to the Min of Health and Family, in view of the considerable improvement in the serum ferritin levels in patients on combination therapy, to start the treatment at the regional levels, but its implementation has yet to materialize. 

The adherence to the current management need to be enforced more rigidly as reports of mismanagement are quite common at the regional and island level. Most doctors employed at the island level are not well versed with the disease and have different opinions regarding when to transfuse, how much to transfuse and on chelation therapy. 

And sadly the psychosocial impact of the disease is completely ignored in the management. Compliance levels are lowest at the adolescent age group and it is essential that they get the proper psychosocial support including a clear understanding of the disease. In a survey conducted amongst adolescents at NTC, 90% did not believe that they had complications despite not complying with treatment and having their serum ferritin levels well above the target range. The extent of complications have yet to be documented. 

A total of 140 of those registered have died so far, and from 1997 to 2007 each year about 8 children have died at the average age of 8 years. This young average age at death should be a matter of concern in a country where all aspects of treatment are free of cost and where treatment is readily available. No other single disease enjoys this level of commitment from the government and the statistics should be in favor of this support. 

As it is the status of thalassemia in Maldives is not encouraging and revisions need to be made in both the preventive and treatment aspects. Genetic screening should be accompanied by improved counseling. Effort should be directed towards prenatal diagnosis programs. Combination therapy for iron chelation need to be started across the country at regional levels and psychosocial support for both the affected child and family should be given. A comprehensive program encompassing public education, screening for carriers, genetic

counseling and prenatal diagnosis has markedly reduced the incidence of ,B-thalassemia major in

several countries such as Cyprus and replication of such a program in the Maldives is necessary to lessen the burden of this preventable disease.

‘Aadhaige doctarun’

In a few months’ time I will become a doctor and will go home after what has seemed like an eternity in Nepal. It will be one of my biggest achievements, as it is for any person who becomes a doctor. Training to become a doctor is tough. The amount of theoretical detail you have to know is enormous. The practical skill you need to acquire is demanding and challenging, more so because you are dealing with a human being. The social interactions you encounter, while mostly pleasant can be emotionally taxing at times. The burden of carrying the knowledge that your actions or inactions can have life changing impacts on people’s lives can only be understood by a doctor. To become a doctor is one of the noblest and selfless things you can do. And there is certainly nothing ordinary about it.

So why is that I will be labeled an ‘aadhaige doctor’ once I go home? Does any one hear a talk of ‘aadhaige lawyerun’ or ‘aadhaige teacherun’ or ‘addhaige engineerun’? Hardly ever. After all the hard work you put in, all you get to be is ‘aadhaige (ordinary)?’ Here is a dictionary definition of ‘ordinary’:

Ordinary:
·Not exceptional in any way especially in quality or ability or size or degree;
·Lacking special distinction, rank, or status

With all the knowledge and skill you have acquired, it almost makes you cry. The word ‘aadhaige’ in Dhivehi is used, for the most part, in this context to mean that you are ‘not specialized’. For a lack of a word for ‘specialist’ people have opted to use ‘aadhiage’ to differentiate the specialists from non-specialists doctors. As it is, the word is harmless and quite innocent if you don’t read too much into it.

And it may not be as upsetting if the public did not take the meaning of the word ‘aadhaige /ordinary’ to heart literally.

But words do convey meaning and if one examines the current doctor-patient relationships in Male’, the effect it has had on the general outlook regarding doctors is obvious-that a doctor cannot be trusted or knows little if he/she is not specialized. The public has to come to know that to become a specialist you first need to get an MBBS degree and that each specialist used to be an MBBS doctor.

The adoption of the word ‘aadahige’ and its effect on the doctor-patient relationship is as important as the reasons for the existing contempt for the health care system and its resulting failure to establish a healthy and productive relationship between the patient and the doctor. (This I will discuss later on)

Off topic

Here is a thought- will people be good when they go to heaven?

We are told that only those good among us will get to heaven. But only a few among those are good for the sake of being good. Majority are good only because they dont want to burn in hell for eternity. So once such 'good' people go to heaven and start doing whatever they wish because they can, will there be any order? Without the threat of the hell fire, is there any point of codes of moral conduct? Won't there be absolute chaos and anarchy?

Perhaps it will be safe to assume that no such thing would happen. But why not? As human beings we are the worst creatures to govern. Even Adam and Eve were cast out form heaven because they disobeyeyed God. Would we not be yeilding to temptations that we had resisted on earth? Would we not be feeling sooo free as to start doing each and every naughty little thing we were afraid to do?

Maybe when we go to heaven such temptations are removed from us so that we would be virtuous. We would all be wearing white robes and walking around like wise men. But once parts of my personality or characters that define me in toto are removed, does it not cease to be me? Would I , mutatis mutandis, be still me? Wont we all be akin to zombies?

A remark on Arts in the Maldives

As a maldivian, and as an aspiting artist myself (visit my gallery), I thought we were quite creative. In general there is good taste amongst us. I am thankful that we can distinguish readily the ‘katu’ and ‘ori’ type of styles. But when we take a closer look at the visual arts, there is a whole different story to it. We are indeed ‘katu’ and ‘ori’. Why else would we be making copies of Hindi movies and Hindi songs? (And really bad versions of that too) Are we so incapable of coming up with a good idea for a movie? Or a nice melody for a song? With the number of film companies and teenagers going around with guitars on their backs, you might think of that we were bursting with creative energy. Even in the popular business of graphics design, where one would expect to see new ideas, you could hardly come across a piece of work that inspires you to stop and admire for a while. Website designs are terribly disappointing. Posters, brochures and all such print media clearly lack any originality.

Maybe the whole creative process is aimed in the wrong direction- commercialization. I know of a vocalist who records a song (sung to a Hindi tune of course) and gets paid 1000/- for it. Making money is easy in the ‘Albom’ industry and the movie industry. And we as the audience let them get away with substandard performances, either because we think that ‘rajje aa balaafa evaru rangalhennu!’ Or that we are too rich so we might as well pay, or we just don’t care.

Maybe it’s the first response that is the common consensus. And that maybe the reason for arts in Maldives not to flourish to its potential. And perhaps the current condition is fitting to our current social condition: our inability (or reluctance?) to express ourselves. Art is supposed to portray what the artist feels, or think and if there is nothing for the artist to express, what results would be as blank as his emotions.

I recently came across the website of the National Art Gallery of the Maldives. One thing that strikes you when you browse through the gallery is that how ‘Maldivian’ all the art works look. Palm trees and beaches, underwater scenery of fish, native children playing, and fishermen going about their daily chores. Is this only what all Maldivians are about? I am sure there is more to being a Maldivian than carrying a fishing rod. That ideal has long been lost with the newer generations who know that even though we are portrayed as a nation of fisherman ( “mas veri kamakee dhivehin ge ley naaru”), we are not so.
We are a nation that imports almost everything- economic, social, cultural, and even academic. And one has to wonder why art has not had any impact on it by such influences. Why are we so reluctant to experiment and to change? Is it because the public will buy or see whatever that is produced without question?

We should not let our artistic expressions be limited to or be confined by what the society ascribes to as being ‘maldivian art’. New avenues need to be explored; new forms of art have to be introduced. Art has to be seen more as an outlet of creative expression than a commercial enterprise.

Note: I salute all Maldivian artists (but not those in the movie and song industry) for their inspiring works of art.

My Problems with Dhivehi Language: Part 1

While working at IGMH as a clinical assistant, I found the psychiatry OPD to of most interesting. People came with odd complaints, and the doctor would write off prescription drugs and write the diagnosis as anxiety disorder, depressive disorder etc. My interest was not piqued by the way medicine was being practiced, but by how difficult it was for the patients to describe their feelings.

How does an average Maldivian describe such concepts as ‘emotional trauma’ when there is no word/phrase for it? How about ‘soul’, ‘mind’, ‘self’ ‘psyche’ or ‘soul searching’? Let alone describe them as being ‘depressed’? Sure. There are words like ‘dhera’ and ‘hithaama’, but can they be used to describe the myriad of emotions like sadness, despair, anguish, angst, melancholy etc.?
A discussion of any topic on Oprah’s shows would certainly be a difficult if not impossible task.

'The limits of my language mean the limits of my world’ stated Ludwig Wittgenstein. While one can feel such emotions even in the absence of words to describe them, it has lead to the emotionally stale society that we are. Take a look at the atmosphere at one of our football games. The silence can truly be compared to that of a crowd listening to a sermon at Friday prayers. We love football. But we don’t dare show it. The only times the crowd shout is for a goal, and when the opposing teams’ goalkeeper takes a goal kick. A distant observer might as well think that the spectators are there by force. Or, go around the airport where loved ones leave or return daily. But hardly a shout of joy or a cry of sorrow escapes. We see Arabs (Muslims) hugging when greeting but I suppose that would only be frowned upon. Maybe the newer generations have noticed this and started greeting people with open arms (literally speaking), but then again they might be doing it just to be cool.

It is not only the emotional sphere that is limited by language. The way we think is clearly affected.
See if you can translate the following to Dhivehi without twisting your tongue.

- the idea of a thought
- proceeding to a conclusion by reason or argument rather than intuition
- abstract thinking
- the unexamined life is not worth living
- ethical issues
- moral values
- ideas and opinions
- I maintain that the cosmic religious feeling is the strongest and noblest motive for scientific research – Albert Einstein
- when sensation, attachment and possession are not, then love and compassion come into being – Krishnamurti

The difficulty is obvious. ‘Language is a crucial tool in the process of thinking. If we don’t have a language that is rich in vocabulary and language that has a subtle and complicated syntax, we are not going to be able to think in very complicated ways. Just imagine trying at the discursive level to carry out any kind of process of thought with a truncated or narrow vocabulary’. In comparison to most of the languages that we have borrowed from, Dhivehi language is very much impoverished in its vocabulary and its syntactical structure.

Are we capable of abstract thought if we don’t know what ‘abstract’ mean? Or of ‘scientific thought’ if we don’t understand it. If we (the lucky few) are not acquainted with English we might as well have been the dumbest people on earth. Sure. We are taught in the English medium. But the English is substandard. While over 98% or so of the population is apparently literate, there are few who read. The concept of commercial magazines saw an increase in reading before it started to become gossip columns. The reason also might be that there are few books available at the local stores which prefer to sell only textbooks. You might as well forget it if you want to buy a book on culture, art, science, religion or philosophy. When the government took their time in constructing a new building for the National Library, it seems few or no thought was put into stocking it with good books. A lack of writers in Maldives is also a cause for concern.
As is evident, the lack of words to describe such key concepts effectively hinders good communication and discussion of good ideas and development of critical thought.

The center for linguistic research has done little to address this issue. I remember a sign on the
operation theater of IGMH. It read ‘falhaa kotari’. One can only imagine what a patient being taken into the theater would feel after seeing that. Clearly the person who put that sign up did not understand the difference between surgeons and butchers. The center as the leading authority on language has failed to address the issue of the word ‘kaley’ (you) too. The community has effectively banned its use citing it as being rude. Even Soadhu, on Heyyambo, while not being able to say that it was okay to use the word ‘Kaley’ could not provide an alternative. So all Maldivians would have to go around speaking without a word for ‘you’. Imagine. The center, meanwhile, is busy teaching a Bachelor’s degree in Dhivehi Language when such key concepts are missing.

‘If evolution of language is not determined by its utility then what is it determined by?’ was a reply when I posted this in a language forum. Dhivehi as a language needs to evolve to meet the demands of the influx of knowledge and new ideas. The emergence of the practice of speaking in English by parents to their children is recognition on their part of such limits in Dhivehi language. Prior to writing this I was against such practice. But I want to be able to say ‘I love you’ or ‘I’m proud of you’ to my son, and to let his thinking develop unhindered by the limits of his mother tongue.

So what needs to be done? Translations of major work from all areas which define a society and which develop thinking; art, science, religion, and philosophy, is a must. The reluctance to borrow words from English, or other languages for that matter needs to be overcome. The Dhivehi language curriculum needs to be reformed and the distinction between language and Dhivehi literature has to be made. (What’s the point in making you read Dhon Hiyala aa Alifulhu at CHSE?) We have to be less arrogant about the mightiness and greatness of Dhivehi language by citing that ‘atoll’ is a Dhivehi word taken into English or by saying that we have terms for each stage in the development of a coconut that is all too commonly heard on debate competitions. We can still retain the so called ‘Dhivehi vantha kan’ even if we borrow from other languages like we have been doing so for centuries.