First, Do No Harm? Strikes In Health Care — Dr Ginsky Chan

Systemic problems require systemic solutions, and many demands simply cannot be met within unreasonable timelines. There are, nonetheless, actions that can be taken now.

Here is an oversimplified anatomy of most of the organised strikes in health care: years of poor working conditions for health care workers (however you may define ‘poor’) leads to the raising of concerns from those on the ground.

The initially unofficial concerns gradually progress into official demands and finally peak with the threat of a labour strike. Decision makers will then respond with counter-threats, ranging from pulling the ethics card (“Primum non nocere”) to termination threats to, in some cases, police brutality.

Do a quick Google search and you’ll find the same old, same old, globally. What is different, however, is the extent to which the demands are met.

Let us start by addressing the ethics card first. Contrary to popular belief, “First, do no harm” being in the Hippocratic oath is a Mandela effect. Regardless. if that particular oath was taken during medical graduation, “First, do no harm” makes no sense.

Medicine cannot be practised without the risk of harm. I have to prescribe warfarin to a patient with atrial fibrillation even if it risks causing fatal bleeding. I have to perform chest compressions to a patient with asystole even if some ribs may fracture.

Of course, they are to be done with the right dosages and techniques respectively, but I cannot refrain from practising medicine solely on the basis of ensuring no harm first.

What does evidence tell us about strikes in health care? Here is the conclusion that Essex et al. (2022) drawn from the systematic review and meta-analysis of 17 studies: “Based on the data available, this review did not find any evidence that strike action has any significant impact on in-hospital patient mortality”.

It is interesting to note that we, who sacrifice sleep and mental health to improve patient outcomes, get shoved with the ethics card by the group of people who prefer to tax liquid nicotine instead of banning it entirely.

Granted, the generational end game and the Hartal are two different issues, although they fall under the jurisdiction of the same group of people. Based on the list of twelve demands by Reformasi Kesihatan Malaysia (for the sake of this discussion, let us assume that they do represent the demands by all health care workers), four relates to career stability and progression (items 1, 3, 8 and 12), three relates to better pay (items 2, 6 and 9), two relates to improved working conditions (items 4 and 5), two relates to a safer feedback system (items 7 and 11), and item 10 is a recommendation to increase government revenue. Excluding item 10 (because it is not a cause for strike) leaves us with:

  • Career stability and progression.
  • Better pay.
  • Improved working conditions.
  • Safer feedback system.

Are the demands reasonable? In other words, realistically, how fast can the government meet these demands so that health care workers would call off organizing a strike?

At this point, let us immediately exclude the discussion on promises following a town hall meeting, press release, threats of disciplinary action, and the like, for obvious reasons. At the time of this writing, there is no official word on whether and how the decision makers plan to take action (again, plans to have plans are not counted).

Assuming (based on historical data) that the four demands above will not be met, here is a philosophical question to consider: is the failure of the government to meet the demands because the government cannot meet them or would not meet them?

Career stability and progression involves creating more permanent and public service (JUSA) positions (among others), both of which are associated with increased salaries. Better pay involves not only increasing monthly salaries, but also claims and allowances. Improved working conditions, as elaborated by Reformasi Kesihatan Malaysia, involves hiring more health care workers and upgrading health facilities.

These three demands demand large financial resources, which unfortunately, are finite. Here are some things to consider when making a demand: noting that money has to come from somewhere, whose money should be channelled to health care workers? Pensioners, scholars, or politicians?

We can go one step higher: should we channel funds from the Ministries of Transport, Tourism, or Education to the Ministry of Health (MOH)? We can also take a step down. If we are raising user fees in health care facilities, how do we ensure equity, where the rich willingly pay more and the poor do not incur catastrophic health care expenditure?

Besides finance, time is another finite resource. While we agree that providing better pay may improve morale, how much should salary be increased? If pay raise is limited to doctors, what about nurses, medical assistants and hospital cleaners? Improving health care facilities is desirable, of course.

The question is, should the government invest in catching up on childhood vaccination coverage post-pandemic (because children should be prioritised) or build cardiology services in more hospitals to increase access to heart stents (because ischemic heart disease is the number one killer in Malaysia)?

Should money be allocated to buying prescription books and printing blood investigation forms, and denied to better computers and hiring software developers to support the digitalisation of health care, or vice versa? Numbers and decisions have to be evaluated for cost and effectiveness, and they require time and expertise.

The bottom line is this: Systemic problems require systemic solutions, and many demands simply cannot be met within unreasonable timelines. There are, nonetheless, actions that can be taken now.

Two commendable examples are the ‘Proposed Ranking Criteria to Prioritise Absorption into Permanent Service’ proposal led by the Malaysian Medical Association (MMA), and the collaboration between HelpDoc (under MMA Schomos) and MyHelp (under the Integrity Unit, MOH) in providing a safe space for whistleblowers.

Making demands is important to provide a voice for the unheard. Making constructive demands, on the other hand, increases the chances that the demands are met.

To echo Iles (1997), here are three rules in “Really Managing Health Care”:

  • Agree with them precisely what it is you expect them to achieve.
  • Ensure both you and they are confident that they have the skills and resources to achieve it.
  • Give them feedback on whether they are achieving it.
  • Otherwise, we might find ourselves barking up the wrong tree.

Dr Ginsky Chan is reading public health at the London School of Hygiene and Tropical Medicine.

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.

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