Working Environment for Doctors in Maldives.

First of all I’ll request you to go through the 1^st  page of this blog to get an overall idea about the subject.

I could not get enough time to sleep since last few days and hence had not enough time to write anything.  But now the article is presentable so I am publishing it over this blog.

The environment which you’ll get as a doctor, if you come to work in Maldives will be as such:

1.      Working hours are usually eight hours per day for 5 days in a week which means a total of 40 hours in a week is required to complete normal working schedule. You become even 10 seconds late and someone may react on this leniency. Usually reporting time is 5 – 15 minutes before actual start of duty. No matter it’s raining or whatever or that you were called from mid of your sleep at 04:00 AM after which you could not fall asleep for another one hour and hence may have got up late today. You have to report at 08:00 AM then you have to reach before it. I have actually sometimes left brushing my teeth or freshening up in the morning to catch this reporting time. Of course felt bad the whole day about it….but who cares about that!!!

2.      The administration (of course comprising of those so called community health workers who are now called community health officers or community health supervisors in accordance with their capacity to command the management and anyway whatever they call themselves, they don’t do anything anyway except holding meetings about how to eat up all the funds) can one sided declare that your working hours now will be not 40 but 48 hours a week. You cannot do much about it. As I explained earlier in my 1^st page here, all the conditions in the contract they give us here are able to be revoked by their side without our opinion on it.

3.      Other than these 40 or 48 (or maybe someday they’ll declare that  70 hours are needed as minimum in a week) hours as the case may be, all the time you are on call. Being on call means you can be called from anywhere and you are supposed to run to their health centre to see that particular emergency (as they call everything from a hair-fall to itching). You will be entering the total time you took in giving consultation to that patient in a book which will be 20 to 30 minutes and for this you will be entitled for Over Time (OT) which will be calculated as [basic salary /total hours of work scheduled in a month] – [15% of it] X [time you spent in hours]. When you try to calculate this all you’ll find that it is almost not worth waking up and disturbing your whatever activity you were indulging into at the time of this call to get OT for half hour or so. But since your contract says you have to attend all calls immediately and that too in proper dress code including formal wear and a shoe (yes, these stupids have mentioned even this in the contract) preferably within 10-15 minutes, you have to do all this. They must be believing that by wearing formal clothes and shoe doctors become wiser or else I personally fail to find any worthwhile logic.  It is believed that the locals don’t think of you as a doctor if you are not well dressed in formal.

[P.S. - When you’ll come to Maldives and will get a chance to visit their offices and all, a strange sort of formal wear is on display here.  You close your eyes after reading the entire combo and then imagine, you’ll find it interesting. Half Shirt in some glazing color or dark brown, a tie which is not tied daily but which comes all made and attached to an elastic string to wear around neck just as school children in our country use sometimes, pant worn above ankle joint as preferred in Islam, a shoe of any kind, green betel leaf in mouth or some deodorant sprayed around.  This was for men. Women mostly in veil. But by their clothes every corner of their body is exposed, every contour accentuated as clothes are skin tight from top to bottom.  This is the official look of men & women. They looked real funny creatures to me earlier but now I have developed a resistance. ]

4.      You are not supposed to leave your station. Translation: Going inside the Ocean water to see corals is also called  leaving station for which you are not allowed officially.  So, you may be seeing the ocean everyday but going inside is so complicated [some health worker has to be requested. Then your In-charge has to be requested. He may even call his/her higher officials after which you cannot always succeed in getting permission to go inside water.] that you may actually hate the idea of touching the beaches.

5.      In case you fall ill and you are the only doctor over that island, as is the case in 90 percent postings, then you need to try to treat yourself  first. Suppose you consulted a specialist over phone on the matter and you are suggested to visit a higher center for investigation etc, you first apply on paper to the In-charge about it. You may get an answer about your permission to go to the higher center  after a day or may be even two days. Up to this time you need to work as usual. You’ll tell ‘I m having pain lower abdomen’, they’ll say ‘ok. Take rest doctor.’. Then again some so called cough & cold kinda emergency will come and again you need to repeat that you are actually sick. And they’ll listen to it and say that come for 5 minutes and see the patient after which you can take rest. This thing will go on like this for the entire day. You may better decide to sit in your chamber to minimize your torture eventually because all the time going to your residence and coming back will kill you even before you would like it to happen. So, by the time you get the permission to at last visit that higher center and your travel arrangements are made, you may be either better already or your disease may have been aggravated to another level by now. One of my doctor friends here got Dengue and by the time they allowed him and arranged for him  to go to Indira Gandhi Memorial Hospital in Male’ which is the only tertiary care hospital here in the country, he was already in convalescence. God’s mercy upon him that the serotype was not a lethal one. Or else a anything could have happened. No need to say that after completing his contract, he has not gone back to continue.

6.      But suppose the condition when one of the Maldivian is sick…..then? Then irrespective of the sickness [cough, cold, body ache, weakness, fever….or likes] that fellow is brought to the emergency room. You do something and send him/her home. Apparently tomorrow again the same patient will visit you in visibly better condition. Then….the patient will come to you after 5 days to ask for sick leave for 7-9 days including two days when he/she could not come to you to show + the day you saw him/her in so called ER + the recovery time of 2-3 days + 2-3 more days when the patient didn’t think of going to class or duty due to laziness. And you can turn as red as you would like but you have to issue this medical Certificate and curse yourself for signing such a thing. If by any chance you deny to give it [management will always tell you to decide on your own about all things although never is this case], he/she may become aggressive and shout. You have to live there unharmed I think? Right? So, you better give it without resistance.

7.      The most demanding of all is: You are a doctor so you have to treat all [medicine, surgery, ortho, ENT, eye, Gyne, Obs, Pediatry], everybody [Child, women, child, men, child] and every known disease on earth….and this all with total accuracy of doses and all. Imagine getting a small sick child on your first day of arrival with seizures and you have no bloody idea of how much Diazepam per kg body weight has to be given and how. They all will stand around you and start conversing between themselves in such loud voices that it becomes difficult to concentrate or even talk to a specialist.

8.      Most of the time, even after knowing that the doctor can in no case understand their language or reply them,  One of the relatives will stand in front of you [with smelling foul breath] and start telling you in louder than loudspeaker voice about his anger on your incompetence or dissatisfaction about the treatment or even about some local event. You are astonished, frightened and in shock…that what to do in such case?  And the locals will smile on your misery. Forget that the local staff or translator will come to your help. They love spectacles.  Like this they deal with any foreign staff. Be it doctors or laborers. There is actually not a big difference in a Maldivian mind between both.

      In all, the gist of the matter lies in; This is a tough condition tackling even the littlest of things here. All the local staff and people, no matter how friendly they seem when you talk with them, will support the locals. Mostly because due to the incestual tendency in marriages here everybody over an island is a close relative. They breed within their family [The interpretation of Family as we see in non-Islamic world with no offence intended because it’s not in every religion or community that step siblings can marry between themselves] and hence the support for each other and hence the absence of secrecy over an island. Everybody knows everything about everyone here. All elders pairs contains 50 percent of pairs which are married twice or thrice in their life. So, children are of different category. One may be from one father, another may be from another and third one may be from the same father but different mother altogether and all living in the same house doing whatever they want between themselves.

Anyway, their system of marriage is none of our concern. Although all this little somethings have an impact over the environment we get here to work in.

Another Clipping from a News Channel.

Doctors quit over intimidation

The resignation of three doctors from the largest private hospital in the Maldives has brought its gynaecology department to a grinding halt, according to a hospital official.

Ahmed Afaal, the managing director of ADK hospital, said all of the doctors in the department quit over the past two weeks, claiming their work environment is not safe due to threats and pressure from members of the public.

“Doctors face a lot of pressure and persecution from patients,” he said. “Most of the time, doctors are treated very inhumanely, and this makes them lost interest in their work.”

Due to the rise in the number of threats against doctors in the Maldives, the ministry of health issued a press release in early June. “Qualified specialists are refusing to work in the Maldives, saying they don’t want to work in such a terrifying place,” the statement read.

Doctors in the Maldives are predominantly recruited from India.

According to Afaal, over 60 patients visit the hospital everyday for labour and emergency services as well as caesarean facilities.

Hospital records show that more that ten per cent of patients visit the hospital for gynaecological services.

“We are working to begin the services once again,” said Afaal explaining the three resignations had led to fewer patients. “But it’s hard to recruit professional doctors.”

At the moment only one gynaecologist is employed at the hospital and he has been suspended following an investigation into the death of a mother and her baby, said Afaal.

The mother and baby died following a caesarean section which led to protests outside the hospital.

His passport was confiscated under a court warrant issued by criminal court.

A 26-year-old mother who gave birth recently at ADK hospital expressed concern over the temporary termination of gynecology services, saying “many women will have to suffer”.

In the Maldives, only two hospitals in the capital city Male’ offer basic facilities. The largest hospital Indira Gandhi Memorial hospital recently experienced a shortage of equipment such as x-ray machines and CT scan machines.

Dr Rajshekar Kalgudir, ADK hospital medical superintendent, said pressure from the public was a recent phenomenon, and at times, either the patient or their family openly threatens doctors. 

“Sometimes they might ask for 100 percent guarantee in the cases,” he said.

Kalgudir said this kind of behaviour had only been exhibited by Maldivians. “If this continues…many more doctors will quit,” he said.

“Patients and their family should have faith in doctors,” he said. “We’re trained to care, not to harm.”

Some old News Clipping of some Maldivian News Channel

http://minivannews.com/society/expat-doctors-deserting-maldives-5021

Expat doctors deserting Maldives

By JJ Robinson | November 23rd, 2009 | Category: Society | No Comments » 

 

Expatriate doctors are deserting the Maldives because of poor facilities and uncertainty over their pay, according to a doctor working at Indira Gandhi Memorial Hospital (IGMH).

“We’ve lost five expat doctors in the internal medicine department in the last four months,” said Dr Ibrahim Shiham. “Only one has been replaced, and from an island so not a new recruit.”

Foreign medical staff are vital to the country’s health services and comprise 85 per cent of the country’s doctors, according to Shiham, most of whom come from India with some from Nepal and Pakistan.

Many are showing reluctance to renew their contracts, Shiham claimed, because the latest round of cuts to government salaries have added to the uncertainty that followed the efforts to standardise civil servant renumeration in January.
“What actually happened was a lot of pay scales were streamlined, and doctors’ basic salary, including allowances, was ultimately down 30 to 40 per cent. So what [the government] did was invent another allowance to take it to the original break-even level. But the extra allowance has no legal standing, and in theory doctor’s salaries got a major decrease.”

With their salaries “propped up and not in the rulebook”, many expatriate doctors “started talking about leaving and looking for other opportunities,” according to Shiham.

“People who’ve been working [in IGMH] for 14-15 years have begun leaving in the last four months,” he added, when their contracts come up for renewal – something he says was rare in the past. “They realised that once they sign the contract there’s not much they can do [if the allowance is withdrawn].”

Deputy Director of the Health Ministry, Abdul Samad Abdul Rahman, said three specialists and six medical officers had left the Maldives in the last two months, and that replacements were declining offers because of the lower wages. CEO of IGMH, Zubair Mohamed, meanwhile told daily newspapers Haveeru that departures from the hospital were a “normal occurrence” and that “doctors are always leaving because their contract has expired.”

Because of its reliance on expatriates staff, particularly from India, the Maldives is also competing with the burgeoning Indian medical sector to attract staff.

“Even in Indian government hospitals, which have to compete with the private sector, a medical officer in Delhi undergoing training would get 52,000 Indian rupees, around 16,000 -17,000 Rf,” Shiham said.

Moreover, Male in particular was proving an unattractive destination for foreign staff because of high living costs and the need to leave families behind. The lack of facilities was also professionally unsatisfying, a particular issue for attracting senior staff, he explained.

“Here [at IGMH] I am only able to do 30-40 per cent of what I am trained to do because of a lack of facilities – out on an island, maybe five percent. Even equipment for kidney biopsies or needle for taking bone marrow samples. Doctors’ skills are underutilised and referrals overseas are common practice.”

Impact

The loss of medical staff is placing pressure on those who remain and affecting the amount of time doctors have to see patients, Shiham said.

The rule is we see four patients an hour, 15 minutes for each,” he said. “If we start seeing a patient every 5-6 minutes, then the patient is not being seen properly, even if he might be happy he’s seen a doctor. The level of documentation will also go down, and that will later attract a lot of litigation. The patient loses, the doctor loses and the system loses.”

Appointments were starting to being made through contacts, a situation Shiham describes as “embarrassing.” The pressure to thin the growing queues of patients was also leading to staff being recalled from other critical roles.

“I cannot stomach it when a medical officer is pulled off ICU (intensive care) to see a few more flu patients just because people are starting to shout outside. We don’t have a doctor on duty 24/7 in our critical care unit,” he said.

Doctors in Maldives....Job in Medicine & the Reality

First let me introduce myself. I am a doctor currently working as a Medical Officer  in Maldives for their so called (because almost everything is only so called in this country of selfish lying stupids) Ministry of Health & Family (which has changed it’s name from Department of Health to Whatever  for 3 times in last 2 years) .

So, for the sake of my still running contract, which is not ending any sooner than 6 months, I wont give my actual name up in this blog.

The whole purpose of writing this blog is to make people like me (doctors)  aware of the things going on here before they decide about coming & working here, in case they are interested in coming here at all in the first place.

First let you clear any fogs if you have in your mind about this Republic of Maldives: This is actually no republic. A form of Anarchy prevails here. This a totally Islamic country and forbids you to talk about any other belief/religion with public or even carry out any ritual of your specific religion, other than ISLAM. They have even mentioned it in their contracts here that you can not bring any statue or picture of any Gods or any other religious books here, Can't show them in public even if you own any such thing and never tell anyone about any such religion or ritual. Even if someone enters your room where you live and sees anything in connection with any other religion than Islam on display, it's enough to start a legal proceeding against you in their local court which doesn't have any lawyers as such. These are unpardonable acts here and you can be prosecuted if found to be indulged in any such deed.

 

Now coming back to the topic of my blog......Just now when I am sitting in a small consultation room, waiting for a sillier than silly patient to come and literally tell me what he wants in the name of treatment, I can hear the laughs and jokes of the Maldivian staff sitting over the reception counter of our Hospital. Actually I would like to site you some examples from my experience here and let you enjoy it: 

Chronology:

In-charge: As they call the community health workers here who are made in-charge of  Health facilities and govern all the decisions of doctors or other issues arising in any health facility. Totally uneducated people. Mostly 9^th class pass and then trained for some quackery in Colombo, Sri Lanka. They spend their entire time on duty calculating how can they eat up funds given to them for the health centre or the hospital.

Doctor: We. We the doctors (MBBS or MD or MS or whatever; this is not their botheration). A doctor is a doctor and can treat everyone, starting from a neonate to a geriatric patient including Gynecology & Obstetrics in between somewhere. This is the demand from you to treat them all and treat them well. No matter you are a GP, a specialist or a super specialist. They can say an Anesthetist to write prescription for a 6 month old baby with cough & cold and start shouting if the baby doesn't get well in a day or so.

Nurses: All the south India trained, majority of nurses who don’t know which drug has to be administered IV and which IM. You be watchful, they can put milk in IV line and put Diclofenac Injection as syrup anytime in anybody's mouth if you are not repeatedly asking about the administration of your prescribed drug.

Patient: It can be someone who comes at mid noon or midnight out of his sleep for getting his/her weight and BP checked or someone who will tell you lies just to get a medical certificate so as to avoid some duty or exams. They always tell the wrong stories. Majority of them don’t take medicines and throw away your prescription as soon as they get it. 

Translator: Someone whom you tell a lot of sentences which are to be translated to the patients and she translates them all in 4 – 6 words. You are left looking like a stupid after she sums you up.

Scenario 1:  Patient called the In-charge at around 01:15 AM one day. A call came to me that some emergency patient is coming. Run towards the health center. I reached there. The In-charge reached there. Now we are waiting for that emergency patient to come in half sleeping half awake state. Ultimately the In-charge decides to call back the number which had called him about that patient. We are informed that the patient is on the way. So we switch on the lights and all and wait.

A small child (3 years of age) is happily laughing in his mother’s lap and is being brought (this is the emergency patient by the way). Our conversation starts:

Me- What brings you here at such a time? What’s the emergency?

Mother of Child- He is having cough & cold.

--Since how long?

--A month…. May be more.

I try to keep my anger down. They woke me up for this when I have to get up and report for duty at 07:00 AM again.

--I write down medicines and the case is finished.

They don’t bother here that doctors are human. The general behavior of people towards doctors is as if they are using some slave as per their convenience and are surprised to hear that those slaves are human. The most of nonsense will wake you up at 02:00 Am like small abrasions or little pain over hand muscles since a week…. Things like that.

Maldivian population is not dumb. It actually is hostile towards anyone who is from outside. Be it a labor or a doctor. God forbid if you fall in a situation when you yourself need help, they’ll not help you. Even if help will come, it may be too late for you. So, if you can take a risk of guaranteeing your well being and no need of any sort of help for 1 year, then only think about coming here for the same period.

The first thing you’ll get from them is cheating. As a doctor you’ll approach some agent or even the ministry itself. They’ll send you an offer letter. And guess what, it will include the false promises to lure you in. As soon as you receive the work permit & reach Male’, go to the office of Health Ministry, you’ll come to know that a few things in the offer letter were wrong. Even the salary they have told is not right. It’s not easy for us who calculate our association with them in accordance with the promises they have made in their offer letter. As normal human beings, we calculate that this much we are going to get...this much we can try to save....so we will be back in our native place after this many years having enough for our that particular purpose for which we have set foot abroad in the first place.

But for them it is so easy to cheat you. And that too shamelessly. Just now I have came here. They told in Male’ that salary will be 15% less than told in the offer letter. Can you imagine the situation when you were promised a salary of Rs. 50000 for example and suddenly it becomes Rs. 42500 and that too after you have left your original place of work and landed up here already. They know that after a doctor has reached Male’ it’s not easy to just back down and return that’s why they dare to do such things.  

Their offer letter says that they’ll give us accommodation for free but after coming here it became’ we’ll give you a certain amount of money (MRF [Maldivian Rufiyaa] 1500/-) per month and you find a place for yourself to live’. I found the cheapest one available was costing me MRF 3500/- and no less. Now I live there only. A significant amount of total salary has to go in rent now. 

Here as soon as you come, the first of horrible things will happen when the ministry will confiscate your passport and keep it with it for your entire contract period. Just to stop you from getting away from Maldives. They know that by the slave like treatment they’ll give us, we would like to go back immediately. 

No one is happy here. Only a very few, who are here since long, are ok or tolerant of these people.

They change the clause; like ‘total working hour per week’, ‘accommodation rules’, ‘rules of leaves which you can get’, ‘rules of Over time’ and any other rule for that matter; all by themselves. Their contract is one way. They prevent  us from showing this contract to anyone because it can expose them.

The most important thing is, you can never make them agree to any of your pleas. They will do as they’ll think. Their believe is supreme. This is another fact that they don’t know how to read English or can’t calculate anything properly as there is no proper education in this country.

Uneducated people ruling over us is the hindrance we have to cope with each and every time we do have any significant issues. I personally feel helpless. 

Doctors posted over island health centers are the worse affected.  There are no proper facilities available there. Water which comes in supply, you’ll be having difficulty distinguishing it from the toilet tank’s water as the same smell will be in it too. To drink; there’s stored rain water only. You can find a mosquito larva happily floating in it every now and then when you collect it in a transparent bottle. Even brushing teeth and gargling is difficult as the water you get is so smelly that it’s sometimes better not to wash face and brush than to do it. Nauseate as much as you want, there is no way out till termination of contract due to earlier described reasons. 

The process of breaking a contract needs minimum serving of 6 months and so much of economic loss such as total refund of work visa fee + refund of ticket money which supposedly they give when we come here (I haven’t received the refund for my ticket even after 45 days of my arrival here) + 1  month’s salary as fine. This entire thing becomes so heavy that usually people control themselves and stay here for 1 year and go back swearing never to come back to work here again. Leave the issues of 24 hour electricity and cable TV things. Those are your luck.

It is not easy to feel humiliated & cheated every single morning and still carry on.  Yes, I agree that there are some professionals who either get even worse conditions at home or are in fact very big hearted that they can continue here for more than a day. Very few.

So, in all this place is not easy to cope with. And when as an MBBS you get a salary effectively equal to 55000 in Indian Rupees and from there you have to pay rent and food as well, there is nothing much left as savings. Yes for specialists things are marginally better. But these people make you feel as if they own you. Modern form of slavery only. 

Cases come from this to that. You need to consult a specialist sometimes. But these people start shouting over you that why don’t you treat from coma to seizures just because you are a doctor. And the basic population is full of incestuous relations. They marry between themselves without any feeling of close family and all. So, there are a lot of genetic pathologies which we don’t see anywhere else.

And most important of all, majority of them don’t have any small amount of respect for you. As soon as some sickness befalls them, they become aggressive towards the doctor. Quite a few instances of beating the doctors are there now.

At the moment 3 cases are in different courts of Maldives where the doctor can get a life term or even worse fates.

Here is excerpt from someone’s blog who lives in Maldives:

“Ok I live in Maldives,  recently I got a mail from one of my friend asking where I am, I said I’m Maldives and he replied me he is also in Maldives and he gave me the address and company name so i met him. I was happy to see him in Maldives and he has come one day after getting married with his wife. Since he had a situation that he wanted to go some where he has come here without any ideas and any commitment. He is happy with salary but the company provides a very small allowance for both of them and cant even think about a private accommodation. By the time I met him it was 1 week in Maldives. For this one week they have moved to over 5 places. Finally they have got a jut a room with no bath room but the bath room is out side of the room and have to share with the people who live there. He has some Indian people living in the house. And all of them sleep and eat in the same hall, so they have to go home early. I was so worried about this issue since the day I met them. Other thing is finding accommodation in Maldives is not easy. Since this couple is  newly married, they need some freedom to enjoy the life, need some privacy to have fun. Now we are searching for a better place for them, hope they will get it soon. I wish for them a good life.”

So, By all this you can imagine the things going on here.

Almost everybody has a similar story…’they cheated with the contract’…’they cheated with the salary…said it would be $1000 for example and now when we came here they are giving only $ 600/-‘….or things like that.

I will be regularly writing & updating this blog page. My sole concern is that no one should come here in darkness as I or a lot of my colleagues came in.