Two weeks ago, the , on July 27, 2018, carried yet another article by Kusal Perera slamming the medical profession. In this piece, Perera argues that increasing the number of medical doctors by establishing new state medical faculties will be useless because the doctors they produce will occupy redundant administrative positions in the public sector. Perera attributes “the continuing decline in the health service” to medical doctors holding administrative positions like the Medical Officer of Health (MOH), a position that he suggests should be done away with, and be replaced by trained paramedical workers.
While elements of Perera’s argument are compelling, such as his condemnation of the autocratic nature of the medical establishment and his critique of public sector doctors engaging in private practice, Perera’s social positioning and his deep-seated contempt for the medical profession blinds him to the critical role played by the MOH in the preventive health sector.
The MOH is a vestige of the health units system introduced in British Ceylon by the Rockefeller Foundation who arrived on the island in the early 20th century to deal with the hookworm scourge on tea plantations. Disgruntled by an uncooperative Planters’ Association, the Rockefeller Foundation shifted its sanitary efforts to the Western Province where the inaugural health unit was set up in Kalutara in 1926.
The health units system gradually expanded to cover the entire island. Serving the demands of imperial medicine, medical doctors were assigned to health units where they worked towards promoting maternal and child health and preventing the spread of communicable diseases. Thus medical doctors did not usurp the MOH position in the 1970s as per Perera’s argument.
At present, the country is divided into 330 plus MOH areas, each led by a MOH.These areas are further split into Public Health Inspector Areas, which, in turn, are divided into Public Health Midwife areas, each (ideally) covering a population of ~3000 to 5000. The MOH teams up with a public health nursing sister, public health nurses, public health inspectors and public health midwives, to deliver preventive health services in the relevant MOH Area.
The MOH is not a glamorous position in the medical hierarchy which places hospital-based specialists at the apex. Yet, these doctors are essentially the linchpin of the preventive health sector, coordinating between MOH public health teams and district level health administrators. They oversee service delivery at the community level, including maternal and child health, family planning, and communicable and non-communicable disease prevention, while carrying out medical consultations at maternal and child health clinics. They also play a crucial role in disease notification, the School Health Programme and other community-based health education initiatives, and are responsible for food sanitation, and occupational and environmental health.
Admittedly, many of these functions are not carried out optimally owing to crippling staff shortages at all levels. Cadre positions lie vacant in many remote and rural areas. In the Northern Province, for example, field midwives often cover two public health midwife areas, with grave implications for public health. As Perera points out, the Government needs to invest much more in this system.
Perera suggests that we do away with the MOHs as it is “a wholly irrelevant position in community life.” He attributes the rise in dengue to the incompetency of MOHs. It is unclear on what basis he makes these claims. It is well recognised that dengue is a product of rapid and unplanned urbanisation compounded by a crisis in garbage disposal. The health sector cannot do very much about the spread of dengue without the necessary support from government and non-health sectors. It is farfetched to attribute the failure of the preventive sector vis-à-vis dengue, the resurgence of leprosy, and even a lack of sanitary facilities,to MOHs being doctors.
Moreover, Perera’s allegations do little justice to the many socially minded MOHs who do not engage in private practice. While working in the health sector, I have met a number of dynamic MOHs working tirelessly with limited resources. In addition to running primary care clinics and overseeing the work of public health inspectors and public health midwives, they have been responsible for initiating various health promoting activities within their respective MOH areas. Examples from Jaffna District include the promotion of organic home gardening and the use of a nutritious mix of grains and cereals (‘saththa maa’) manufactured locally to address malnutrition, which is rampant in the Northern Province. While Perera labels such activities as completely irrelevant, he unwittingly contradicts his own position that prevention is better than cure.
Also notably absent in Perera’s analysis are the successes of the preventive health sector in spite of medical doctors holding positions of administration. For instance, its role in the much proclaimed low maternal mortality ratio and, more recently, WHO certification for malaria elimination. Despite such achievements, financial allocations to the preventive sector have declined over the years as more and more funds are channeled toward curative care. Rather than focusing solely on doctors, Perera should expose the Government’s role in Sri Lanka’s health sector crisis.
Perera’s criticism of the medical profession and private practice is valid. However, his writings are confused and often unsubstantiated. For instance, during the SAITM crisis and student boycott, Perera’s antipathy to the medical profession led him to undermine the students’ call to protect ‘free education.’ In fact, he supported the government’s efforts to privatise medical education by taking a questionable position on SAITM.
His latest article (Daily Mirror, August 10th 2018), an attack of the Sri Lanka Medical Council, suggests that the joint statement of Deans of state medical faculties on SAITM was manipulated by the Federation of Faculty of Medicine Teachers’ Associations (far from the truth in most if not all medical faculties). Perera is unable to see that the establishment of for-profit medical degree-awarding institutions like SAITM could jeopardize medical education in the country.
Many of the positions Perera articulates in his articles, including the denigration of MOHs, smack of Colombo-centric middle class elitism; trashing the public sector, including state hospitals and universities, is standard dinner table conversation in Colombo. In his pro-people analysis, Perera seems to have forgotten the ordinary families who rely on the public sector, including the MBBS qualified MOH (not a private sector specialist), for their maternal and child health needs.
Yes, medical doctors are not the ‘saviours and guardians’ of the health sector, and they should embrace other healthcare professionals instead of obstructing their entry into the health sector. Yes, the maldistribution of medical officers should be addressed rather than placing them in administrative positions in Colombo. Having said that, however, Perera should be wary of trends in other parts of the world where physician administrators are increasingly replaced by MBA degree holders and others of that ilk who are trained to maximize cost-effectiveness and profits in the health sector. Second, Perera should think twice before supporting ‘task shifting,’ a particularly neocolonial approach that has its basis in the assumption that poorer communities in rural and remote areas can be served by a ‘low cost’ paramedical healthcare workforce. Finally, I urge Perera to separate his contempt for the medical profession and the Government Medical Officers’ Association from his analysis of the public health sector in order to offer a more informed critique in his writings.
[The writer is attached to the Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna]
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