26 Sep 2011

Giving birth should not be a death sentence!

A  former assistant commissioner of Epidemiology and Surveillance in the Uganda Ministry of Health wrote an eloquent opinion piece discussing the ethics and morality of the Uganda health systems in light of its appalling record on maternal health.
Below I reproduce the opinion piece:
Nurses and doctors being led to Mbale CPS after she was arrested from Mbale Referral Hospital

shock and disgust
I read with consternation, shock and utter disgust, the story in the Sunday Monitor of September 18 about a pregnant mother (RIP Nambozo) who died following a ruptured uterus and subsequent bleeding after being neglected in obstructed labour for over 12 hours at the regional referral hospital in Mbale, allegedly because she could not afford Shs300,000 demanded by the medical workers.
As a health worker who started a medical career at Matany Hospital in Karamoja, a hard-to-reach area by all measures of imagination, and rose to a senior level position at the Ministry of Health headquarters, I feel ashamed about what my professional colleagues did, if the Sunday Monitor report is correct. For the record, we as medical professionals, have long been taught to practice medical ethics and that is why medicine is a vocation and those who cannot stand up to this calling should never have joined the profession or should quit it immediately to avoid bringing this noble profession into disrepute.
Medical ethics
Medical ethics is a system of moral principles that apply values and judgements to the practice of medicine. It encompasses its practical application in clinical settings as well as work on its history, philosophy, theology, and sociology. Historically, medical ethics may be traced to guidelines on the duty of physicians such as the Hippocratic Oath that all doctors swear to uphold when they graduate from medical school, as well as the early rabbinic and Christian teachings. By the 18th and 19th centuries, medical ethics emerged as a more self-conscious discourse.
Since the 1970s, the growing influence of ethics in contemporary medicine can be seen in the increasing use of Institutional Ethics Review Boards to evaluate experiments on human subjects, the establishment of hospital ethics committees, the expansion of the role of clinician ethicists, and the integration of ethics into many medical school curricula. Six of the values that commonly apply to medical ethics are:
1) Autonomy - the patient has the right to refuse or choose their treatment;
2)Beneficence - a practitioner should act in the best interest of the patient;
3) Non-malfeasance - “first, do no harm or primum non nocere in Latin, which was the language of instruction in the early years of medical practice ;
4)Justice – Which concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality) ;
5) Dignity - the patient (and the person treating the patient) have the right to be treated with dignity; and
6) Truthfulness and honesty - the concept of informed consent, which gained importance after the historical events of the Nuremberg trials carried out by the Nazi military in Germany without the consent of the trial participants and the Tuskegee Syphilis Study that denied Penicillin to African Americans in the US even when all evidence showed that Penicillin was the best drug at the time to treat syphilis.
If the Sunday Monitor story is correct then in the Mbale incident, 4 of 6 values (2, 3, 4, and 5 above) were grossly violated and the explanations of the medical superintendent and hospital administrator to try to justify their actions, which to say the least can be best described as their negligence or lack of action are at best lamentable and should be condemned in the strongest terms.
MDR for maternal death review or audit
The World Health Organisation requires that every maternal death should be audited. I have for long held the considered view that every maternal death should be a reportable event such as Ebola, or Yellow fever. While I do not know the true circumstances that led to the Mbale regional referral hospital disgrace, what was reported can only be described as ethically unacceptable and repugnant, notwithstanding the poor pay of health workers and the poor working conditions that the government continues to ignore.
Giving birth is not a death sentence!
As a people who care about any life lost that could have been prevented, we demand that the Ministry of Health, the medical practitioner’s council and other relevant bodies thoroughly investigate this case, and take disciplinary and criminal action where necessary. Further, the minister of health should provide a full report to Parliament on the measures to prevent such incidents and many more that go un-reported.
In future, it should be mandatory to investigate any maternal death, whether it occurs at home or at health facilities, like we do for outbreaks or epidemics of Ebola, Maburg, Yellow fever, cholera, polio, measles, etc. with a detailed post-maternal death evaluation report to be provided to local and national level leaders. Any maternal death in this era is just unacceptable and we as a nation must say we have had enough-we cannot continue to lose between 400-500 mothers for every 100, 000 live births. Giving birth is not a death sentence!

What is happening to health profession in Uganda?

One week ago, the press in Uganda reported a case of a pregnant mother (who was a practicing school teacher) who died from hemorrhage from Mbale Regional Referral Hospital. This latest deaths attracted condemnation from all sector of the Ugandan community.
The following letter to the editor from a public health specialist is an example; read on and weigh in with your own thoughts.
A typical Ugandan hospital maternity ward.

I write to condemn the behaviour of the medical personnel whose negligence led to the death of a teacher in Mbale last week. Medical personnel are bound by medical ethics and they are expected to respect those ethics. An emergency obstetric case brought to the referral hospital at 8am and left for 12 hours unattended to until she died is the highest degree of negligence. How shall we prevent such deaths in the future?
I personally believe medical work is charitable work. Some medical personnel consider their work unpleasant and of high occupational risks. A TB patient may cough blood right into your mouth. During difficult delivery, you may swallow the fluids from the womb. During surgical operations, you may get HIV through a needle pricks. They wonder whether the occupational risk they face is equivalent to the money they earn. The economy is hitting the medical personnel hard as well. Some may even be failing to send their children to good schools.
Government needs to review the pattern of expenditures in this country. The possibility of having excess money enough for all the services in the country is distant. The option we have is to prioritise our areas of expenditures so that the salaries of the people working in the health sector are reasonable. To reduce maternal deaths and improve the health of our population, let the government consider very seriously the pay of medical personnel.
May the soul of the teacher rest in eternal peace!
Dr Michael Amone Liri,
Public Health Specialist