By Lasantha Pethiyagoda –

Prof (Emeritus) Lasantha Pethiyagoda

Almost everyone in Sri Lanka knows that very often, public hospital wards have patients sleeping on the floor under other patients’ beds or in corridors even at the best of times. Wards wallowing in squalor and disrepair, with flies, cockroaches and mice, with rusting iron bed frames, narrow beds with torn and frayed Rexene covered mattresses, cracked floors and broken ceilings, creaking and rusty fans with thick layers of dust, perpetually leaking toilet taps and wet floors with dark greenish algae and brownish splashed feces stains adorning walls with cracked and peeling tiles are still not uncommon.

Public hospitals largely serve the needs of the general population, mostly rural, and often urban. Major towns have large hospitals, often designated as “teaching” hospitals. Wards are administered by senior doctors who have passed a doctor of medicine or doctor of surgery post-graduate exam, having served as registrars after becoming fully qualified medical practitioners.

Major towns also have sizeable populations who are able to cobble together large sums of money from fixed deposits, sale of property or jewellery etc if desperately ill and requiring expensive interventions urgently. Rural populations do not qualify in large enough numbers for “consultants” to set up shop as “private practices” outside their duty hours in public hospitals.

Most businesses operate in the evenings, with hordes of desperate patients milling around “channeling” centres in order to try and save their relatives from an untimely death from treatable conditions for which demand far outweighs supply in the public health system, or timely intervention is not assured due to systemic logistical inadequacies or lack of funding.

State of the art modern hospitals have sprung up in major towns and the national capital to cater to people who can afford to spend a few thousand rupees to see a specialist for a few minutes or stay in a private room for a hundred thousand rupees for a few days. It is fairly common to be billed a few hundred thousand rupees for a range of “services” during a few days’ stay. The “consultants” who see around fifty patients an evening, earn around a hundred thousand rupees income a day on top of their government salaries and perquisites like duty free motor vehicles.

These same consultants, unless they have retired from public service, are usually in charge of the overall administration of a male and female ward in their specialization at their respective major regional public hospital. With all due respect to the few honorable individuals who maintain their wards in a good state of repair and hygiene, the far larger majority of these multi-millionaires prefer to keep their government public hospital wards in the appalling state described above.

I have a question for the reader: If public hospitals are clean, well maintained with courteous staff and comfortable accommodations and toilets like in the private sector, will the private sector (of which these consultants are partners) still have thumping profits? Therefore, to an unethical and greedy individual who imagines that their qualifications are an open permit to profiteer from an ever increasing trade, would it not be in their own best interest to ensure that the status quo remains one of stark contrasts between private and public?

Sri Lanka has been sliding down deep and fast into an economic quagmire over several decades. Thus, most citizens (ie 99.9% of them) do not eat balanced and nutritious meals; they are stressed in their underpaid jobs; (real incomes are insufficient to counter price increases in basic essentials) they have various issues with injustices, unfairness and a duplicitous society. Many have taken to alcohol or other addictions with substance abuse to try and suppress their woes. With galloping inflation and shortages of essential consumer goods, these people have a far higher propensity to become ill or dependent on maintenance drugs and regular medical interventions to keep themselves alive.

It is in this context that demand for health services is at an all-time high (even regardless of covid). Medical practitioners know these basic realities only too well. Politicians have ensured that those who are unethical are rewarded. From corruption at the highest levels of government, to cronyism and nepotism, grossly unfair, unethical and unjust practices are tolerated or encouraged. Manufacturers and producers use unethical and often illegal means to gain more profits, jeopardizing the health of consumers. This is true for packaged shelf food, restaurant meals, dry groceries, vegetables and fruit, farmed meat animals to various agricultural produce.

Medicine is a noble profession. It used to be a calling that gained immediate respect and admiration, not so much for how many high marks one scores in order to be selected for medical studies but in the knowledge that practitioners genuinely strive to heal, with compassion and genuine caring for the welfare of the patient being uppermost. Quite contrarily to not doing harm, and doing good, choosing the best outcome for patient health and wellbeing, balancing options that favour patient interests (ie good health), most doctors would seem to be no different from the other business people mentioned above.

One could argue that medical officers work under much stress, with inadequate infrastructure, shortages in equipment and limited facilities with various woes themselves. Choosing medicine as a career entails the hardships argued about; it is chosen not as a lucrative business venture with the investment part forming the education and training in medical school, but essentially for the desire to serve people and be part of their well-being. The exalted status that is conferred to smartly clad men and women, twirling their stethoscopes along busy hospital corridors with poor desperate peasants looking up to them to be their saviours does not mean they should be regarded as demigods.

Any respect from the public must be gained. How often does one encounter an apologetic doctor meeting grieving relatives of deceased patients admitting to a fault that led to their demise? Instead, don’t the medical team cover for each other and close ranks, so that medical negligence is never an issue that relatives get to know about, regardless of prospects for litigation? The only explanation given to relatives is that they tried their best, but could not save the patient. Is that always a true and accurate depiction of reality? It could be ethical to comfort a terminally ill person saying that they would somehow make it, while removal of life-support in cases where the prospect of life is deemed almost nil, for the larger good (ie to save other critically ill patients with available limited resources) is acceptable and just.

Private hospitals are known to be ruthless in extracting their full fees from dying patients or relatives of deceased patients. Senior doctors, being partners in these businesses are complicit in these unethical practices. Thus, they cannot be adhering to the Hippocrates oath or indeed any pillars of medical ethics. It would be interesting to see how these medical business people deal with their own conscience.

Public hospital wards have very prominently displayed Buddhist symbols (ie images of the Buddha) for desperate patients and their relatives to pray or ask for mercy from the Buddha, not being aware that the Buddha had never promised to save people, unlike gods of theistic religions. One could argue that the psychological effect of relief has health benefits in such circumstances.

Here I would like to add in conclusion, that a false sense of reassurance from vainly praying to people’s respective deities and assuming that fate eventually deprived them of their loved ones seems to be the only relief when doctors and hospitals seem to be no different to any opportunistic vendor flogging their goods on the dusty streets of Sri Lanka.