#a5000

Research is one of the weakest and limited activities in the country. Specially healthcare related research and publications are almost unavailable. Yet, all health institutions in the country have an abundance of data. Collating them, correlating them and writing publishable papers is the next step to understand and improve the health care functions, disease patterns and so forth in the country.

#a5000 is a personal initiative of mine to foster and mentor research within ADK Hospital to produce good research papers and publish them. This is more like stepping into unknown territory for me. But worth having a go.

The grant name #a5000 stands for Afaal’s MVR 5000 small research grant. This was the initial idea and the beginning. Ironically  not many people were impressed and perhaps when I did write that, the readers here would feel the same. Well. my take on that is, who is funding any research now? How many philanthropists in the country take research seriously? And if I can get a few papers written and published, this will be a beginning. Nothing happens if you don’t try!

On June 1, 2017, I went ahead and brought out the first call notice for research proposals. I  did get quite a lot of acknowledgements for the initiative. The call had a one month time frame for proposal submission. For the first week, there was no indication from anywhere in the organization that a proposal will come. Eventually, I got good news. One of our staff met me and said that she will put a proposal. Relief. At least one proposal will be an achievement for an environment without much research culture.

On 29th June, a day before the deadline, my email inbox had a mail with the subject “a5000 research proposal.” Then came a second and a third before the end of the deadline. My hunch was right, nothing happens if you don’t try!

After going through the proposals, I decided that this year all three proposals will be funded for the grant. And as planned, today I awarded the grants to the researchers. This initiative has got some fruit on the first attempt. And now, I feel more proposals will be made for the next round. I am confident more people are interested, and I intend to continue this work.

Three grants were awarded to conduct the following studies.

  1. Neonatal outcome in emergency versus elective cesarean deliveries.
  2. Smoking history of patients in relation to disease conditions.
  3. Patient perspectives on quality of nursing care.

I aim is to stay determined to make this endeavor a success. An initiative that will foster and mentor research and a culture of evidence based learning in the hospital and beyond. Perhaps in future, the grant amounts may grow and perhaps the framework of grants may change. Perhaps other philanthropists may contribute to the work in improving the grants.

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Wolf in a sheep’s clothing

At a time when the advocacy for better health of people of the country are increasing and a number of activities are being carried out both socially and economically to curb detrimental consumer products, the industries play certain tactics to counter such measures.

In this article I will look at a certain aspect under scrutiny by the health professionals of the country. The increasing talk and established facts of the harmful effects of energy drinks. So lets look at how the industry plays in front of our own eyes on countering the potential harm it gives to human health.

Here are some steps that the regulatory authorities have taken to reduce the risk of such products.

Awareness creation:

Awareness creation on the harmful aspects of energy drinks, though are conducted, it is very weak at present. It’s just that every add carries a small text that says it’s harmful, more like that’s done with formula milk. This message is displayed in the least attractive way so that people won’t really read it. Well I don’t think that has any effect on the person consuming it.


As can be seen in the above picture, the surroundings are more attractive and the little ticker message is just insignificant.

Policies:

Many good policies to address the non communicable disease burden of the country are made. The most recent NCD plan has specific goals to reduce the consumption of energy and high sugar drinks. Sadly these policies are not aligned. The industry always look into ways to reducible and undermine such policies. This is not necessarily in the Maldives, but world over. For example in the U.K. the popular EFL Cup will be in the name of an energy drink starting 2018.

Here in the Maldives, we see that the industry is exploiting the vulnerabilities of the government events and capital projects. A few examples is the sponsorship of the biggest talent show franchised by the government media company by an energy drink. And also tricking the public in the form of an endorsement by making the Health Minister of the country to give away the prizes with the brand name. Another such company is making the biggest youth sports park in Hulhumale under their name.

There needs to be a mechanism to politely refuse such infiltration by the industry. We do moan the increasing number of young deaths in the country. At the least the government should attempt to align their own policies to what these they do. Ah and also just for a second think about the ever increasing curative health expenditure for NCDs which now is becoming unsustainable.

Taxation:

Recently the People’s Majlis passed legislation to increase the taxation on energy drinks in the Maldives. Now this is a welcome move in more than one way. For those critics this was just a ploy to increase government revenue. It is alway good in my opinion, to have high taxation on products that are harmful to human health. It is also widely known that with increased price, the consumption of such harmful substances goes down. This has a positive impact on improving health and reducing the expenditure on health, both for the state and out of pocket.

If you look at the statistics, in 2016, about 6.4million liters of energy drinks were imported to Maldives. This amount is from 41 different brands of energy drinks that are currently available in the market. With the rise in taxation, the obvious outcome should be that the price of these products will go up in the market. Perhaps not always. Reason, some of these are sold at a good margin that such a change will not have an immediate effect on the  price of the product. In other cases, the industry may even look at the loop holes in the legislation and exploit it. Now here, the legislative change in the taxation of drinks came to those that are classified into the energy drinks category. Other sugary drinks, or the so called processed soft drinks did not have a hike in tax. Perhaps an amendment with good intentions.

Irony is, what if all energy drinks suddenly become soft drinks? This is not something that came to my mind out of the blue, but happened to tumble on a very interesting piece of labeling. I have a picture too posted below. This happens to be the new label of a prominent energy drink, which is in the process of being brought for sale in the country, or it may already be here. What is evident is this label is made specifically for the Maldives market as can be seen written on the top left hand corner of the artwork.

I will leave the questions to be asked to those who have to. And also let others to imagine what the outcomes of this be. I hope and wish that the authorities are on top of this type of matters and take appropriate measures to stop such infiltration. It is very easy to change the label, what is difficult again is that we in the country cannot measure weather the quantity and the ingredients that are on the label match what is inside either. This could even be a soft drink? Well I find it hard to believe. The readers can make their own judgments.

As citizens, lets be aware of these type of matters and act safely and avoid consuming food and drinks that are harmful to us.

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Maldives should ban the sale of tobacco to all those born from 2007 onwards? Smoke free generations.

Smoke free generation is a very interesting concept where countries are looking at future generations that are smoke free. Efforts to protect future generations from the harmful effects of tobacco, people born from a certain year will not be able to buy tobacco.

In the year 2012, the Tasmanian legislature passed a motion calling to ban the sale of tobacco to anyone born after the year 2000. This measure was proposed by an Independent MP, Ivan Dean who was a former police officer and Mayor. Mr Dean said that the ban would prevent young people “from buying a product that they can’t already buy” and  “this would mean that we would have a generation of people not exposed to tobacco products.”

If this becomes law, those people who turn 18 in 2018 will not be able to buy tobacco thus reducing the initiation of tobacco use. This generation will the lead to better health status without the harmful effects of tobacco. It is believed that this idea was initiated from Singapore, and Singapore and Finland were also considering such laws.

In 2014, Tim Crocker-Buque, a specialist registrar in public health medicine, passed a motion to the British Medical Association, to completely ban the sale of cigarettes to all people born after year 2000. According to him

The 21st-century generation don’t need to suffer the hundreds of millions of deaths that the 20th-century generation did.

About 80 per cent of people start smoking in their teenage years and they end up addicted usually for the rest of their lives.  Banning sales of cigarettes for people born after a certain year means we don’t penalize people who are already smokers which might be very difficult morally and ethically.

This motion was passed by the BMA and is now being further lobbied with the Department of Health to be bold in publishing a new tobacco control strategy.

And more recently, Russia has emerged as a country proposing this action. Defending the policy submitted by the Ministry of Health, a member of the Russian parliament’s health committee, Mr Nikolai Gerasimenko said that

This goal is absolutely ideologically correct

Youth tobacco consumption in Maldives can be considered significant as well. The Demographic Health Survey conducted in 2009 showed that 19.8% of never-married males in the 15-19 years age group were smokers and in the age group of 20-24, 42% of never-married males were smokers. According to the survey the prevalence for females were not presented because less than 25% of the females in this age group reported themselves as smokers. I have replicated the table (15.10 Cigarette smoking) from the published survey report easy reference.

The Global Youth Tobacco Survey, 2011 showed that 11.2% of students aged 13 to 15 were tobacco users of which 7.9% were using some form of smoked tobacco.

In my personal opinion, the above rates would be higher at present, at least from the anecdotal evidence that is very apparent. A survey is required to get the real extent of the problem.

Going back to the idea of discussion, the smoke free generation, I believe with all the current tobacco control measures struggling to be addressed, implemented and or enforced, it is time we follow footsteps of the champions in tobacco control. With youth smoking as high as 42% in some age groups, it is important we address the matter before it starts. A smoke free generation should be the next step we push to take. We should start to lobby and be courages enough to push such a motion through the policy and law making bodies for the sake of our children.

My view on proposing 2007 for the cut off year is simple. This year the children born in 2007 will turn 10. In three years time they will start to experiment with smoking and other tobacco as evident from the Maldives statistics above. And this cohort of children will turn the legal adult age of 18 in 2025. If this can be implemented successfully, Maldives can become the champion of global tobacco control by, to mention a few,

  • Saving lives
  • Increasing life expectancy
  • Improving national productivity and
  • Reducing the national financial burden for non-communicable diseases

Well, we can make our children, and those who follow, tobacco free generations.

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An accident waiting to happen! #RoadSafety

The United Nations Road Safety Collaboration marks this week as its fourth global road safety week (8-14 May 2017). Given the fact that speed is the main road traffic killer across the globe, the UN’s slogan for the week is Save Lives: #SlowDown where it seeks to increase the understanding of dangers of speed and also generate actions to save lives by improving measures to address speed.

Well in the small, confined and congested roads of Male’, the amount of road traffic accidents keep increasing. More vehicles, more speeding, more practices that may lead to traffic hazards are all to be seen. Ah, and also the increased traffic jams and the impatient horns that beep, bark, honk and what not are the norms of the road now.

In this post I want to highlight a practice on Male’ roads that relate to heavy vehicles. A practice that is becoming more and more common. Perhaps, an accident waiting to happen!

Early last year, in February, I posted the following post on FaceBook with a photo

This is a major road safety risk. Today I came across this lorry on a very busy road with lots of traffic. Can hardly move and everyone on the road realising the risk tried much to keep distance from this vehicle. Wonder why such unsafe practices are allowed. Without the back flap of the lorry cradle this poses a huge potential hazard for all on the road. And would this be a road worthy vehicle?

Some people commented to concur on my concern and also shared similar photos. When I posted that post, I did get a direct message from a government official who claimed to be from the relevant authority asking me to share the picture with the registration plate visible. I did share the original photo. Well that’s that.

Overtime, I have had an eye open for this practice, and this keeps increasing day by day. The graphic below is a compilation of some photos of vehicles without the end flap of the cradle. A lot of dust goes into the eyes of the people on motorcycles behind the vehicle and sometimes even debris fall onto the ground. I am concerned that this could one day turn into a major accident on the road.

I believe that such vehicles should not be road worthy and regulatory authorities should enforce vehicle owners to conform to better safety regulations. Also, those who are doing this should always keep in mind the danger that they are posing to a number of other people. This kind of complacency should not become the norm.

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Sorry, cigarettes should only be sold in packs! of 20.

Each Party shall endeavour to prohibit the sale of cigarettes individually or in small packets which increase the affordability of such products to minors.

WHO Framework Convention on Tobacco Control – Article 16, Clause 3.

It is very common that when you get into the corner shop, almost every shop will have a couple of brands of cigarette packs on the shopkeeper’s table, just in reach. Those who walk into the shop will quickly take some coins and handover to the shopkeeper and say the name of the brand and the shopkeeper will give a stick out of the box. In some instances, I have seen that the person walking in won’t even say a work but just throw the coins on the table and the shopkeeper immediately takes what the person requires. That’s how easy it is to get access to a cigarette in this country. For example in India

Many smokers in India, including minors and students, prefer buying loose cigarettes because they are much more affordable than the whole pack.

Saptarishi Dutta, Quartz India

Sale of loose cigarettes have other problems as well. They include

  • They are affordable to youth and hence becomes a factor of encouragement for non-smokers to experiment with smoking.
  • Displayed, sold and consumed without health warnings.
  • Also, it may be a barrier to quitting because of the tendency to buy that last cigarette before quitting, which in fact never becomes the last.

According to a study conducted in February 2014 in India, it is revealed that sale of single cigarettes is an important factor contributing to early experimentation, initiation of smoking and also persistence of tobacco use. The findings also state that single stick sales promoted sale of illicit cigarettes and nutralizes the effect of pack warnings and effective taxation.

A naturalistic observation study done in California (1994 of which the relevance is valid up to now in my opinion) showed that single cigarettes were sold significantly more often to minors and minors paid more for these single sticks.

Where are we on this in Maldives? Well the tobacco control act of 2010 as we all know is weak. So far only one regulation has been ratified since then. Most of the regulations related to tobacco trade has been pending since 2011-2012, none ratified though reached the ratification stage over three governments. Those regulation drafts would now be outdated and called for a review. The regulation that was passed has its own challenges and is very weakly enforced.

As per single stick sales, I remember well that this was a clause in the very first draft of the law around 2006. The clause (like many other strong clauses) never made it to the law when it was passed through the parliament. All this is left for regulation. The ban on single stick sales was also included in the draft of the trade related regulations pending ratification. Well no point talking about that now I guess …

Despite the above “challenge”, during the recent tax debate on tobacco at parliament, the issue of a single stick sales ban came on the floor. Aha, now this is a little light of hope, perhaps. Immediately when this happened, the tobacco control bodies in the country have embarked on pushing this agenda. Though we need to quickly push it into the debate before the issue dies down, as of it never occurred before. You know that happens.

The most effective single stick sales ban have come with a control on pack sizes. The gold standard in most of the effectively implemented regulations seem to have a single stick ban combined with a pack size regulation of not less than 20 sticks. We should not accept anything less. And as of now, that is what the regulatory authorities will propose as far as I know.

A single stick cigarette sales ban will be a huge step towards curbing the epidemic. I just hope policy makers have the will to do this, and be away from the influence of the industry who will blatantly oppose this as they have in all other countries.

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The Flu

A month has passed since all of us, specially in the health sector had a hectic time battling the flu outbreak that happened in March. A time with a lot of public panic, mixed information, social media controversy and all that went with such a situation.

At this time I thought to reflect on the efforts that we (ADK Hospital) put into to try and contribute the control of the outbreak. Though the data and actions described are very much as it was implemented by the Hospital, my own views and interpretations are included to bring the perspectives of my thinking.

Surveillance

Surveillance is an integral part of any healthcare system. All healthcare institutions are required to report certain notifiable diseases to the HPA as part of the mandatory reporting requirements and hence data flow is always there. In this instance of the flu, some individuals in social media and also some news agencies stared mention an increase in the speed of flu, H1N1 specifically and there has been deaths associated with it. Even in non outbreak situations, such diseases will have some  patients whose severity of condition will be different and the outcomes are different. Also important to note is that even best health systems may not always be able to prevent an outbreak from happening, yet, perhaps could manage such events more effectively and efficiently depending on the available resources and know how.

In case of the recent flu outbreak, as can be seen from the graph below, the number of people who sought treatment for flu-like illnesses started to increase from the first week of February. The numbers continued to be higher and by mid March the numbers reached a peak and then reduced. By end of March the numbers came down to and the whole of April normal levels were maintained. For ease of reference I have marked the important dates on the figure and also coded it into three zones of green (normal), yellow (higher) and red (alert level 3 period).

Flu clinic

Immediately after the HPA’s declaration of outbreak response level 3 on 13 March 2017, we decided to set up a flu clinic and also as quickly as possible to locate it to place outside the hospital. The first day of the clinic, we started is outside at the open area of the hospital. Though some may think that this is not a very ideal way to establish a clinic, I took this form a learning experience at Singapore General Hospital during the SARS outbreak. They did an initial screening for temperature and other vitals at the SGH lobby and provided protective masks for those with symptoms before they entered the hospital proper. Perhaps no harm in attempting to get something like that done ourselves. However, unfortunately the weather wasn’t too kind on us. We moved the clinic to H. Sosunge, thanks to Maldives National University, who very kindly agreed to share the premise for the cause.

There were few things we made sure that happened in the flu clinic.

  1. We made sure that every single person who came to the clinic seeking care were attended to whether a local or expatriate, and that a series of steps followed in the care. Initial registration by an administrative staff, screening of the vitals by nurses, consultation with a doctor and basic medications given on the spot, all free of charge. In order to ensure that we had to close up the hospital’s main general OPD for the entire duration of the clinic in order to relieve staff. We conducted the flu clinic from 14-22 March 2017 before winding it down and streamlining it into the normal hospital operations.
  2. Continuously monitor the care seeking behavior of people during this time. This was done to keep us alert to the fact whether we should further increase the efforts or whether we needed alternate strategies. During this time, a concern for us was that we are only seeing people who come to the clinic, but what about those who may not be able to come. Some maybe hard to reach! This is where we decided to undertake a mobile clinic. We decided to go to the people, let people access to us near their homes, and even in some cases the flu clinic staff went to the homes of the sick to ensure we covered a good reach. I have to also highlight the readiness of the Maldives Red Crescent society. They did a wonderful job doing the door to door data collection for sick people so that we can reach and provide care.
  3. Making sure we published data in some way for public to know what we have been doing. In this regard we made an effort to publish the flu clinic’s work every day just after the completion of the clinic. We thought that this would be a good way to keep the information flowing and also to encourage people who may want to interact to do so too. We did this through social media mainly on Twitter and Facebook platforms. Above is the last set of flu clinic data we published before closure.

After 9 days of continuous efforts, we saw that the number of people who came to seek care at the flu clinic started to drop and hence based on this trend, we closed the flu clinic and returned back to the hospital and streamlined the services into our normal routine.

Awareness creation

Making people aware goes hand in hand with any services we provide. Specially in an outbreak situation, it is important to intensify the awareness work. Though the national authorities were doing a good share of awareness messages, we decided that it is only right that we chip in as well. Our team made awareness material on signs and symptoms of the flu, prevention matters, detailed awareness flyers related to vaccination. Eventually we did static flyers and animated videos as a contribution to include HPA and MRC as partners so that it became a collective effort.

This is an area we have a lot of room for improvement. Perhaps one aspect of service that we will have to uptake in future and device continuous process to create awareness generally.

Vaccination

Vaccination was the topic of interest. So much of criticism on the healthcare system for it did not have good stocks or general availability of influenza vaccine. I agree and rightly so. Influenza vaccines were a controlled vaccine, at least up until this flu outbreak and were only given to those going to Umrah and Hajj and in some cases those who were specifically prescribed to be vaccinated, by a doctor. The outbreak lead to finding ways of quickly finding stock and making it available, which eventually happened. I hope and believe that, from now on influenza vaccine will be readily available in the market. As I know almost all importers are now given license to import and store the vaccine.

We started vaccination on the 15th of March and it was only to a controlled group as per the directive published by the national authorities. We kept to the same guideline. However, we did provide vaccination for people who came with a prescription. This we believed would ensure that those who may be out of the controlled criteria, but may genuinely need might not get access. However, we observed that this was not necessarily the case. More and more people got the prescriptions. Many people called me complaining that doctors at ADK Hospital did not give the prescription on their request. Well, of course we have specific instructions that prescriptions should only be made available to those who fall into a higher risk category and not just for perfectly healthy people, at least till the national guidelines changed. I personally talked to some patients who came with prescriptions, from everywhere and anywhere. Some patients told me that they got the prescription by paying a doctor MVR300.00 or sometimes MVR500.00 (I cannot confirm how true that it, but that’s just what people said). Many prescriptions had statements such as “parent want to vaccinate the child”, “issued on patient request” etc. Well, so much for the prescriptions. Eventually, we decided to open generally. We had our own differences of opinion on this and some very heated discussions too. But then, we had to do that, and some of us believed that is the way to go. By end of April, some 10,980 influenza vaccinations were provided from the hospital.

The queue

On 26 March 2017 it was chaos. Just chaos. A long queue started way before the vaccination time and by 1:00pm the queue was all the way up to the Henveiru grounds. This was an underestimation, I agree from our side. I had to make decisions quickly. Well, I decided to release the tokens before the vaccination time that was still two hours away. I couldn’t bear to keep the people waiting like that for that long on the road in a never ending queue. After al we can only release also certain number of tokens for the day, and knowing that there was more people in the queue than the amount of tokens we can issue, it only made sense to release the tokens too. No point keeping people just because we set a time. Well this wasn’t a solution at all. The next day, the queue was that long by 9:00am. But we were a little bit more prepared to monitor the situation. It was early morning around 6:00 am I was informed of the forming queue. Well the vaccination starts at 3:00pm. People though took on the word we put to them previous day that we will not be content to make them waiting in queue for long long hours. So by 9:00 am we released the tokens for the day.

Next day, by 3:30am the queue started. Now that means if we waited to release the tokens at the time of vaccination at 3:00pm, that’ll be a waiting queue for 12 hours. We released the tokens at 6:00am. We did stick to this time to release tokens till we winded down the exercise few more days later. The dilemma here was when people started to demand a time for release of tokens. Our aim was to start releasing tokens just at the time of starting vaccination so people do not have to come two times, one to take the token and two to get vaccination. For some reason, this happened automatically when queues that long formed. What we realised was, if we say that we will release tokens at 3:00pm, the queue is there 6 hours before, full and even more. People simply refused to go even if we told then that this is the end of the queue. Well, an experience to learn from, perhaps we should learn more on the behaviour of people in such situations as well. I did get a lot of good feedback from the people who queued up, good load of all sorts of criticism and some harsh remarks and shouts at my face too. I was there everyday managing the chaos. There was one night that people in the queue continuously called my phone since 3:30am. Different people from different numbers. Saying that they were there, to come and release the tokens. Well that’s the type of work that we have to do eh! All I get out of this whole exercise is how patient people were, how cooperative most people were, and above all many people thanked us personally and the very few who just gave a pat on the shoulder. That’s enough, more than enough satisfaction from doing the work. I still keep reflecting on that, trying to learn, figure out ways in which we could perhaps do it better.

Burden of the flu

Well I’ll just refrain from writing too long on this topic, but I feel that in order to complete this post, it is appropriate to present this in some way. I will just add the infographic published at the ADK Hospital website for information here. You may click on the image for a larger version.

Volunteers

It will not be just to complete this post without saying something about volunteers here. In fact we did not make any formal call for volunteers. It came from a conversation I have with our Director of Nursing. She came to me saying that the flu control measures we are undertaking is making our staff a bit stretched and asked me what solutions we could use to somehow address it. Just as we were brainstorming, I told her to see if she can get a few nurses who may not be working at the time, but willing to help out temporarily to give some relief to our staff. In the meantime we can also ask other staff members to see if they have friends or family who can come for short period to help out if they are willing to do so.

In a short period of time after that conversation, a Viber message the Nursing Director posted on a group belonging to nurses went viral. It was shared in many viper groups and eventually went on to newspaper headlines that we were looking for volunteers to assist in the flu control efforts. All for the good. I call it beautiful. Specially because volunteers did approach us. Phone calls, SMS, Facebook messages all came from people who wanted to volunteer. We did have to politely decline since we didn’t require so many. The lesson though is that people have big hearts. They are kind and willing to help out. A good sign. I do appreciate the work of all those volunteers, their willingness and enthusiasm was something to acknowledge and applaud. Thank you all.

The staff

I have never doubted the commitment of our staff. And they passed with flying colours in what they showed and how they worked. I sensed that everyone took pride in what they did. Despite the heavy load and long hours everyone managed a smile at the end of the day. They kept questioning what more they could do? They were always ready for the next call. “Let’s do it” became the motto, it was all action. As a person who works with them day in and day out, I cannot be any more proud of them. Kudos to the hard work and showing that we can count on each other. Just keep it up.

____________

By end of March, the number of people who sought care with flu-like symptoms reduced and we kept a continuous tap on the trend. It went down below the average and stayed slightly lower than that of January before the increase in cases. A good sign and perhaps a result of good work done buy everyone involved. What I’ve written here is based only on the work we did and data is also from ADK Hospital. What is written is an account of our efforts and in no circumstance undermines the great and noble effort of the entire health sector. We cannot compare the work everyone did, but of course compliment the work.

Every emergency, outbreak or abnormal situation that we face gives us an opportunity to learn. And this outbreak also is no different. In hindsight, I can say there are many things that can be improved. As for us, we could improve our own surveillance mechanisms and be proactive in our actions. Play a bigger and better role in public health perhaps? maybe at the least publication of information on disease and trends so that we are more proactive.

Learning is continuous …

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Our strange society

When I look at our society and the way we act, sometime I feel strange. Don’t you? When I was studying in developed societies, I find that there are some beautiful societal values that are practiced everyday, values that are the norm. When I look back at those, I think to myself, “Why are we like this?” I will share a few experiences and observations here.

THANK YOU

Thank you is a very common term used in the western society. For example, when you are traveling on a bus, I have always experienced that passengers say tank you to the driver despite that fact that the driver was just doing his job. In our society, although some people do say thank you often, majority of the people just don’t bother. We do not readily say thank you. Did you ever say thank you to your taxi driver? Very few people do and if you do, the driver most of the time does not know how to respond. Wouldn’t it be nice if the culture of thank you becomes the norm? Start saying thank you to your mom, dad, family, neighbor, shopkeeper, driver, receptionist etc. Lets make it a habit. Definitely it will start to create a happier and more respectful society.

HELPING EACH OTHER

Another thing I learnt was that people help each other. Especially for example in traveling getting on or getting down from a bus, train etc, if some one is having heavy luggage, a pram with a kid, or is a senior citizen, someone else will volunteer to help them. Everyone is willing. When I came back home, I remember an experience I had. A lady with two small kids was going to get onto a ferry to Villingili. She was struggling to close the pram while carrying the little child. But no one bothered. Everyone wanted to get on to the ferry as quickly as possible. I offered to help, but she was reluctant initially, but then I folded the pram and put it up on the ferry. I saw the look on her face, she didn’t know to say thank you perhaps. I thought that she must have been wondering that I was abnormal. Small things matter in society. Aren’t we getting taught such values? It should start form home, schools and then should become the norm in society.

ZEBRA CROSS

A zebra cross is meant for pedestrians as we all know. All vehicles are supposed to give way when someone is on the zebra cross. If you do this in Male’, few things happen. First, the pedestrian gets really confused. Many times I have had this experience. Some pedestrians just look at you in amazement as if saying to you “are you crazy? why are you waiting?” Secondly, someone may hit your vehicle from behind since most people don’t even keep road rules in their mind while driving. Its just that we do not bother at all. Sad isn’t it?

YELLOW LIGHT

One day when I was taking my elder daughter for a ride, she asked me “dad, why is it that everyone are speeding up when the yellow light comes on? I told her “perhaps they might be in a hurry, want to pass before the red light comes on.” Then she replies to me “well we were taught traffic lights in school, and the point of the yellow light is to indicate that the red is going to come on soon and hence to slow down.” So true, but I just didn’t have a further explanation. That’s more like the norm on the roads even the kids notice and give a bad example. Unfortunately none of the traffic lights in the island work anymore.

Well there could be many more examples like this, and things that we really do not bother to correct. More work needs to be done on instilling values in the society. Starting from each nuclear family, household, school and flowing to the community. I just think to myself what can we do to change this? Don’t you? It’s just too strange a society …

Thank you for reading …

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Apology, disclosure and trust

First published: December 15, 2012 (FaceBook)

Over the years, many Maldivians travel abroad to seek health services. Many a time, these people seek services abroad for those that are readily available in the country.

But why?


I believe that this is due to the fact that people have lost trust in the system.  We need to go through a shift in paradigm in order gain the trust of the people. The first step towards this shift is to start believing that we have a problem.

In my interactions with quite a lot of patients, issues that they have raised are not really medical. Following are views from patients that I have been told many a time.

  1. Patients believe and know that no health system is perfect. They also believe that there is a high risk in any medical intervention and of course, doctors and other health professionals can make mistakes. They could sometimes be negligent as well. Most patients do understand this fact.
  2. Most patients think, and rightly so, that the health providers are not willing, or are reluctant to share with patients any mishaps or complications that happen during a procedure. They believe that they should know and yes they should. A few patients told me that there is simply no disclosure at all.
  3. No one among the healthcare providers cares to offer an apology let alone compensation for any mishaps or complications due to the provider’s mistake. Most people will accept an apology, a genuine apology.
  4. Hence, people think that the healthcare settings in the country are clod places, not open, no communication, no dialogue and to a large extent no participation of the patient in care. All these factors, over the years have lead people to loose trust in the system.

Recently, I posted the following question on both my Facebook and Twitter accounts just as a small assessment of how people feel about medical mishaps.

In an event of a medical error or complication, what would you want or expect your doctor to tell you?

Most of the responses revolved around wanting to know what happened, wanting and apology and empathy. Following are some of the responses received.

Doctors, medical staff and hospitals never say sorry or apologize in such an event. Experienced personally few times.

Apology would be a good start. It always calms the atmosphere. Explain the current state of the patient and what are the possible options to overcome the said complication. Constantly keep the by standers in the loop.

When you’re a patient, you trust you’re in good hands, but even the best doctor or nurse can make a mistake on you. Just learn how to say ” I am sorry “.

In the event of a complication, the truth, and in the event of an error, an apology.

As you can see, this is where we healthcare providers have failed to create the link between the patients. And this is where we can start to build that trust with the patients.

I recall a conversation that I had with a very prominent local doctor on this matter. We had a discussion on apologizing and compensation. His response to me was, when you apologize, you are accepting your fault. You cannot do that can you?

With a mindset like that, we will never be able to get the trust and respect of the very people we serve everyday. I believe we should start to work on this, be bold, be accountable, be open and be honest. How the events unfold will not let us down.

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Smoke free public places

This article was first published on Facebook on December 4, 2012

Efforts to curb the tobacco epidemic in the Maldives have been put for a long time. In the Maldives, in the 1980’s, some regulations were passed to ban smoking in some public places, such as governemnt offices, sport facilities and so forth.

One of the key measures to curb the tobacco menace is to declare public places smoke free. This is addressed in the Framework Convention on Tobacco Control (http://www.who.int/fctc/text_download/en/index.html), Articles on Protection from Exposure to Smoke. Maldives, being a Party to FCTC, require to develop and implement a legal framework to control tobacco.

In year 2010, the Tobacco Control Law (15/2010, http://www.mvlaw.gov.mv/pdf/ganoon/chapterII/15-2010.pdf) was passed by the Majlis and ratified by the President after years of deliberation. The first draft of the Maldives Tobacco Control Law was made as early as 2005. The current Law, compared to the initial drafts, is a much weaker piece of legislation.

Although this may be the case, the Law is currently in force and regulation on smoke free public places under this Law will come into effect from January 1, 2012.

So what are the public places that are and or will be declared smoke free?

There are two sets of places, one, those that are specifically stated in the Law and two, those that are specified in the Regulation (R-41/2012, http://www.health.gov.mv/PDF/Tobacco/Dhunfathuge%20Isthiumaalukurun%20Manaa%20Thanthan%20Kanda-alhaa%20Qawaaidhu.pdf).

According to the Law, Chapter 1, Article 3, the following are smoke free public places. (not an official translation)

  • Workplaces and parts of workplaces as specified in regulations made under this Law
  • Cinemas and meeting halls
  • Public vehicles, places and or part or parts of places used for transport as specified in regulations made under this Law
  • Hotels, cafe’s, restaurants, part or parts of places of food production and or sold as specified in regulations made under the Law
  • Mosques, health facilities, educational facilities, child minding facilities, open areas within the premises of these places including any other building within the premises.
  • Government offices
  • Sports facilities, courts, grounds and stadiums
  • Any other public place as defined and stated in regulations made under this Law

Hence, according to the Law, the Regulations should identify and define public places, part or parts of public places that will become smoke free.

Apart from the places already defined in the Law, the main areas of definition in the Smoke Free Public Places Regulation are

  1. Smoke free public places as specified in the Law  with an inclusion of a 10 feet perimeter surrounding that gates/doors that give access to these premises from the road.
  2. All premises of governemnt offices including, independent institutions and public and governement share holding companies.
  3. Oldage care facilties including the open areas of the premise
  4. Rehabilitation facilities and centers including the open areas of the premise
  5. Childrens’ parks and oter places where children regularly go to play (such palces will be marked with signs to indicate the smoke free status as the regulation comes to force)
  6. All ferry’s and ferry terminals
  7. Vessels that are not deemd ferrys, but are used as ferrys for passenger transport on instances where it is used to for passanger transfer. (a tricky situation and hard to implement, but worthwhile)
  8. All vessels and vehicles used for transport of passangers and cargo
  9. All airconditioned cafes’, restaurants and food services facilities
  10. All oter cafes’ restaurants and food services facilties apart from the designated smoking area within the premise (these places will have to have a designated smoking area as specisfied in the regulation and need a permit to do so)
  11. Places where people gather for goods or services on a temporary basis including those where people have to wait in a queue (e.g. ATMs, ticket counters etc)
  12. Open public places where a large number of people gather (a bit vague but intended to mean places like Sultan Park, Fish Market, Artificial Beach and the like. These places will be marked with appropriate signage)

These demand reduction measures are included in the Law and Regulatin based on extensive research and best practices from countries who are successfully implementing such measures. It is though the people who will adhere to this Law. Undoubtedly, these are the signs of a modern developed society where smoking bans in public places are much more extensive. Lets hope that Maldivians will also follow suit.

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Births – a basic comparison

Deliveries by type at ADK and IGMH

Births are a common occurrence at the hospital. In fact in the Maldives, the most births occur either at IGMH or at ADK Hospitals. During the first six months of this year, a total of 2119 births, of which 855 (40%) occurred at ADK Hospital and 1264 (60%) occurred at IGMH.

When we look at the modes of delivery the combined rate of normal deliveries for both hospitals stand at 52%. The rate of normal deliveries at ADK is 46% while the figure for IGMH if 55%. When assisted deliveries are taken the rate stands at 0.7% with the ADK Hospital’s figure at 0.2% and at IGMH 0.9%.

In the case of vacuum deliveries, the combined rate for both hospitals stand at around 4%. However, a further breakdown shows that this figure is higher with 9% of all deliveries requiring vacuum at ADH Hospital while only 1% required the same at IGMH.

Cesarean sections can be said to be on the increase in the country as a whole. The combined cesarean rate for both hospitals is 43% for the referred period. Also the comparison between the two hospitals also does not differ with 44% and 43% at ADK Hospital and IGMH respectively. Over a year back, the cesarean rate for ADK Hospital was around 35% and although we do not have proper figures, anecdotal evidence suggests that it was the same case at IGMH as well.

This comparison was done as part of an analysis of services provided in the Maldives for the purposes of the ADK Hospital’s development project currently being undertaken. It is unfortunate that these types of analysis are not done more often. This little analysis already gives some light to the situation of deliveries and the modes of if for the two major hospitals. It gives a learning opportunity for both hospitals, to see where each other is doing better or worse and to look positively and identifying and improving any shortcomings.

The available data allows more indebt analysis that can be used as further evidence for quality improvement. The Hospital intends to conduct similar analysis for different specialties in future. Unless evidence and information use increases in healthcare, quality cannot be improved. There are indications in this very basic analysis, where ADK Hospital can attempt to further improve and also to identify areas for patient education as well.

However, it is not enough for hospitals alone to do patient education on matters such as this. There needs to be national guidelines and recommended rates of Caesarean sections for the country. As I understand, the WHO standard for Caesarean sections is 10%. This is a figure way below the Maldives average. In fact this is a rate that no country in the world probably would achieve at this day and age. Perhaps, WHO should look at revising this rate and also this matter is now on the books of that organisation.

For the Maldives, we need to gather experts and brainstorm on the reason for this higher rate of Caesarean sections. In some countries, it is said that Caesareans are comparatively higher in private sector where doctors are incentivised to conduct surgeries and hence produces a supply induced demand whereas in the public sector salary based employment, there is no incentive to do surgeries. However, in the Maldives, there is no difference among the sectors as can be seen from the data.

More needs to be done of patient education and encouraging families to opt for normal deliveries. Obviously the natural process of birth will have many advantages compared to a more risky surgery. Also, in case women opt to take up Caesareans due to pain, in the modern world normal deliveries can be pain free with local anaesthesia or epidurals. Also new concepts such as water births could also be tried out.

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