Malaise in our public hospitals Pt 1

Malaise in our public hospitals Pt 1

Ahmad Sobri in Malaysiakini | May 22, 08

AHMAD SOBRI is a surgeon who has served in both the public and private sectors in Malaysia for 20 years. He is currently based in South England and his interests include resuscitative techniques including reanimation. His work also includes health policies, planning and finance.

When Dr Chua Soi Lek first came to office, he apparently called for a meeting of all senior officers and when asked about the priority of problems at the Ministry of Health, he reportedly was inundated with numerous comments about the dastardly troubles private hospitals had created and how they and their devious doctors were leeching the poor Malaysian public and something had to be done urgently.

 

The gullible Chua, ever willing to show off the political strongman that he conjured himself to be, wasted no time in implementing the shelved PHFSA and together with his DG, bamboozled it recklessly utilizing the BN’s brute but now mercifully clipped majority in Parliament, brushing off all objections against the Act just so he can show who’s boss.

Needless to say despite all of Chua’s and Merican’s big talk and assurances, the first victim who got thrown into jail was a registered doctor, a stark reminder of the previous government’s callous and appalling methods of governance.
 
New health ministers are almost always a shoo in for our machiavellian Health Ministry officials who have become rather slick in cornering incoming, inexperienced and invariably unknowledgeable ministers into making silly decisions. All ministers are political animals and make distorted decisions essentially because the minister is fed only half the story or the story he generally likes to hear. And so it is with the new health minister Liow Tiong Lai.
 
While Tanzanian President Jakaya Kikwete was going on an all out war against witchdoctors (read bomohs, sinsehs, etc) who were gorging out eyes of albinos and the Brazilians were calling in the army and possibly Cuban doctors to help battle the mortal incidence of dengue in that country, back in Malaysia, the hapless Liow had thrust upon him a meaningless business turf battle between pharmacists and doctors as his first task. The Brazilians must have wondered about the priority of the Malaysian health minister and cannot be faulted if they thought that Malaysians had indeed licked the dengue scourge and were actually moving on to bigger stuff.
 
Far from it. The dengue fever outbreak in Brazil had infected 55,000 people, and killed 67 Brazilians so far this year with half of those killed by the mosquito-borne illness being under 13 years old. But Malaysia’s “Disease Control Director”, Hasan Abdul Rahman reported a proportionately higher mortality ratio of 9,889 people diagnosed, with 26 of them dead for the first three months from January to March alone of this year. Maybe we have something to learn from the Brazilians or more likely our stats are out of sync.
 
But these problems will pale into comparison as the new and inexperienced health minister has made a second momentous decision. That of shipping unfortunate children with congenital heart disease to Devi Shetty’s “world famous” heart center 2000 miles away in Bangalore, the Narayana Hrudayalaya. Even Chua, known to be a brusque decision maker refused to take this decision. But the new health minister had no qualms sending these children off….or was he pushed into make this decision.
 
When the NST published their under-researched cum marketing piece for the IJN on the lack of heart surgeons and the need for critical care for paediatric cardiac surgical patients in a center spread on 2/4/08, they didn’t quite delve into the factors as to why this country has not caught up with the rest of the world or at least India, despite the government spending millions to curb the rising incidence of heart disease.

Paradoxically, after 50 years of Merdeka, we are in fact sending off patients overseas for treatment just like the Mauritius, Ghana, Nigeria, Sierra Leone and Bangladesh to the Narayana Hrudayalaya Institute of Medical Sciences (NHIMS) Do we not have the expertise? Elementary. It is just poor management of our resources.
 
Five gov’t heart units 

The government has five heart units. The unit in Penang was established in 1995 at a cost of RM30 million, followed by Johor Bahru in 1997 for RM40 million and Kuching in 2001 for RM55 million. A new unit was set up at Alor Star when the new Sultan Bahiyah Hospital was being constructed midway causing the hospital to have serious delays in its opening and another at Serdang Hospital which has been designated as the ministry’s heart center for the Klang Valley. Surprisingly despite the government spending millions on infrastructure, little attention was paid to manpower leaving many of its units underutilized or not operational.
 
hospital patients in bedThere are no paediatric cardiac surgical services at government hospitals save for a small number being attempted by an expatriate surgeon in Kuching. The Penang unit, although busy in the beginning, had its work slowed down when the initial surgeon resigned. It further attracted controversy when expensive and untested cardiac equipment bought for millions of ringgit ended up as a white elephant.

It was in the news again in 2005 when surgeons left the unit in droves when belligerent anesthetists there tried to take control of the cardiac surgical ICU which has always been the domain of cardiac surgeons throughout the world. The unit was then briefly run by an Indonesian born doctor who surprisingly was awarded a JPA scholarship to do his training. However patients complaining at the greatly lengthened waiting list reportedly as a result of the new surgeon being unable to do bypass surgery there saw the ministry moving some of its doctors from Johor Bahru to cover the unit. The Indonesian surgeon, in a bizarre move by the MOH, has been transferred to head the Serdang unit.
 
The Unit at JB was initially run by a British trained Malaysian surgeon who left for Singapore leaving the unit now running only on a single theater at times. The Kuching Hospital unit is one of the better run units. One of the reasons for this is the high level of commitment of doctors there and the support financially by the local community.

Despite the lack of manpower, the ministry is planning to open more units in other areas such as Ipoh, Kuantan and Kota Kinabalu. In KK alone, the MOH announced last month that it will be spending RM70 million. Even planning administrators in the ministry have argued that that there should be a period of consolidation instead of splurging more capital until manpower problems are soughted out. But these reservations have apparently been over-ruled by the surgeons and anesthetists. It is always nice to splurge … if it is not your own money, especially if it brings you fringe benefits like more overseas trips for “lawatan sambil belajar”

There are in total 23 units doing cardiac surgery in the private sector. One in Alor Star, four in Penang, one in Ipoh (apparently now defunct), nine in the Klang Valley, three in Malacca, one in JB, one in KK and one in Kuching. Only the Adventist Hospital in Penang and Gleneagles in KL do paediatric cardiac surgical cases in significant numbers. The rest are essentially adult units. Most private units are solo run by individual surgeons. As a result they do small numbers. However the Penang and Malacca units cater for quite a number of foreign patients especially from Indonesia.
 
National Heart Institute (IJN)

In the early eighties, the HKL was the only heart unit the MOH had. It was controversially corporatised to IJN soon after Dr Mahathir Mohamad had his heart surgery. Many then thought that perhaps corporatisation of this service will soon see Malaysia self sufficient in this particular area but as always in the Malaysian scene, corporatisation comes with strings attached. IJN’s founders made a deal where all heart cases in the central region must be solely given to them. They didn’t want any competition. And if you believe a monopoly corrupts, then there must be some truth to this considering IJN’s phenomenal surgical costs.
 
But despite being a monopoly they couldn’t hold on to their surgeons. One paediatric cardiac surgeon resigned to go to Gleneagles while two more found cushy jobs in Saudi. So it has gone back to the same routine of trying to train more surgeons. Despite the high volume of cases it does, it apparently lacks space which may be resolved when its new building is commissioned.

Interestingly, IJN offered to run the Serdang Hospital Heart Unit for the ministry but this deal was obstructed by the ministry’s own surgeons. You sometimes wonder if everyone in this area is really working for the common good of patients, or for themselves, at the expense of the general public. The ministry and their political masters, the MCA, are doing nothing.

Training programmes 

So why are we not training enough heart doctors? There are three university heart units based at the UH, HUKM and HUSM in Kubang Kerian respectively. But the volume of surgeries and procedures done are small, especially in Kubang Krian despite the disproportionately large incidence of coronary, valvular and congenital heart disease in Kelantan. The UIA in Kuantan apparently has been enthusiastic about setting up a heart unit there but again there was a problem regarding manpower and commitment by some of its specialists and of course the unending destructive rivalry between the MOH and the universities. The price you pay if you don’t have your own hospital.
 
hospital heart surgery patientsThe first open heart unit this country ever had was the one established as early as 1969 at the University Hospital by NK Yong who took up the post of Foundation Professor in Surgery when the UM’s Medical Faculty was first set up. He had trained at Kentucky University and despite virtually no trained staff he performed Singapore’s first open heart surgery in 1965 after painstakingly assembling and training a cardiac team for two years following his return from the US in 1963.
 
His presence at the UH saw the emergence of new surgeons such as Saw Huat Seong and the late Razali Hashim. The unit was further strengthened by an expatriate surgeon from the Christian Medical College in Vellore, George Cherian. But all this came to an end when Razali passed away prematurely almost 20 yeas ago. Saw Huat Seong is in private practice in Singapore, George is in Kansas and NK Yong is of course retired and is now a famed wine connoisseur. The heart unit at the UH today is more renowned for fist fights and slapping incidents with no trainees forthcoming.

While heart units around the world progressed by leaps and bounds, the UH unit stagnated and in fact regressed. The country’s pioneer unit fell victim to medical politics and to the tantrums of the remaining surgeon when heart disease was the pre-eminent killer with irresponsible university authorities just looking on, doing nothing or dabbling in trying to sell off university grounds.
 
UKM, which initially suffered a similar fate when it set up its unit a decade ago, has progressed much better and proposed a training programme for cardiac surgery last year to the ministry but it has yet to get off the ground. Again medical politics and unbridled, cumbersome, attritional professional jealousy has been the bane that threatens the progress of heart treatment in this country. The MOH and university authorities are in particular guilty of not dealing with these problems firmly, instead pandering to the whims and fancies of individual specialists against national interests leading Malaysian patients now possibly to that dusty road to Bangalore.

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