By Dr. Fintan Sheerin
24th June 2014
As I think of yesterday, I am reminded of the title of one of Morrissey’s songs, November Spawned a Monster. For me it might be better titled Monday Spawned a Monster! I am not sure, though, who the monster is and whether it is one of the actors in the events of last night, or the underpinning structures which form the background for our actions as health professionals.
The day started well, with three of us visiting a school in Kasungu and meeting with special needs teachers who maintain a resource room for children with disabilities. The meeting was positive and we were made very welcome. It was notable that, although the resources are limited, the teachers work with an enthusiasm, knowledge base and dedication that are admirable. Indeed, the lack of resources is a problem everywhere and, in anticipation of this, Dale and I had brought four large suitcases of medical supplies, many of which, whilst officially past the ‘best before date’, remain viable and usable for many more months. As health care professionals, we are very aware of this fact but note that, despite this, these are routinely discarded to waste in our own countries. The decision whether or not to bring them was essentially a dilemma as I had wondered whether expecting Malawian people to use items which were not deemed usable amongst our Western populations was in some way devaluing the former group. In the end, knowing that the supplies were still safely usable, I decided that the need of the local Chilanga people took priority and met with the ethical principles of non-maleficience (do no harm) and beneficience (actively do good). And so, following the meeting at the school, Dale, Eloise, Suzanna and Shayla visited a designated clinic in Kasungu and delivered the medical supplies in the presence of a large number of local people and health care professionals. It was clear, from their invited tour around the clinic, that resources were indeed scarce and that these materials were a considerable addition to the empty shelves in the treatment room. Following the handover, the girls left feeling very positive. As we returned to Makupo village, the positivity of the morning was tinged with a sense of uncertainty as all afternoon meetings had to be cancelled on account of a local funeral.
Out of the depth I cry to you… (Psalm 130)
The uncertainty reached a nadir of negativity in the late afternoon following a telephone call which left me feeling utterly devastated. A medical official in the clinic contacted us to say that they could not use the ‘expired items’ and asked us to come and collect them. It had been clearly indicated that the medical supplies were beyond their ‘best before date’ but this man indicated that he was worried about the risk to his job if such items were found in the clinic. So, in the face of having no resources, it was deemed appropriate to refuse recently expired but viable resources! In real terms, this could be the difference between a person bleeding out from a wound or being in a position to stem the bleeding! I don’t know, but this did not make sense to me and the central issue influencing this decision appeared to relate to the need to protect one’s back and not to the saving of lives. It led me to question where Hippocrates’ medical imperative of non-maleficience and that of beneficience were in reaching the outcome of this decision. Have we reached the point whereby the protection of the professional and institution is considered to outweigh that of protecting the person? In the light of this event, I found myself at the lowest and most emotional point on this Malawian trip, such that I became very angry and tearful as disbelief and disillusionment grew.
In reflection today, this is not a uniquely Malawian problem but may be emerging here due to globalising commercial and professional forces which are recreating here what is already extant in our Western countries. Thus, in Ireland, the fear of litigation and allegations of professional misconduct have increasingly become the context within which health care is being provided with the need to assign blame when something goes wrong. This is reminiscent of the infamous medical model in which the person, as human being, is reconstructed and objectified as a patient, bereft of his/her identification as a human being. Illich has written extensively about this in his books, Disabling Professions and Medical Nemesis, and has suggested that this objectification of the person creates dependence, disempowerment and loss of individual identity: dehumanisation. This is the result of the development of a bureaucratic approach to health care which, he has further posited, is essentially a major iatrogenic (physician-originating) threat to health. It may be considered that this is evidenced in the creation and maintenance of a small elite of powerful professionals and a much larger mass of disempowered people: oppressors and oppressed.
Despite the negativity that characterised the earlier part of the evening, there was to be yet another twist in the emotional rollercoaster. One hour later, we were approached by another medical doctor who shared our view on the medical supplies and who expressed a desire to obtain them so that he could use them to treat local people in his own clinic. Whilst his actions, in many ways, countered the gloom of the previous hour, there remained in me a disquiet which is leading me to explore and challenge the roles that each of us play in sustaining policies and practices which lead to waste in our countries: both material and human.