My Response to the Response to Astaphan’s “Health Problems and Solutions”

As many of you may or may not know, over the past years I have become very concerned about the state of health of our Federation. For those of you who have taken the time to study my in-depth article, The Secret to a Healthy Nation, you would have noticed that I have taken pains to document in excruciating details where I think we are going, where our internal and external challenges lie, and what we need to do to improve the physical, mental and social health of our nation. This article was based on a speech I gave at Operation Rescue’s fundraiser on October 3, 2015.

What you may or may not know, is that Dwyer Astaphan is my cousin and also one of my patients, whom I have grown to understand, appreciate, respect and love, as he is a kindred spirit and deep thinker who is intimately familiar with the goings-on in the country and who is constantly searching for how we as a people can improve our lot. He is uniquely positioned in this role as he comes with a wealth of experience and understanding, being a former minister of government and now a social activist. Although he has been fiercely critical of the previous administration of which he was a member, and especially of their leader, his single minded focus was the betterment of our people, from the least among us to those at the top. Although I have been sceptical of words that come out of the mouth of politicians, be they past or present, our interactions over the years have given me opportunities to discuss the good, bad and ugly in our Federation, and has given me occasions to question his motives and expectations of us, and I can truly say he is one (ex)politician I now trust.

It is no secret that over the years I have been frustrated with the trajectory the health sector was taking in terms of staffing and resources, and on many occasions, I would vent my frustration and express my concerns. To my embarrassment, I can remember once, during a consultation with Dwyer, I broke down in my office in tears exasperated by the enormity of the disconnect between 1) what we technocrats and front line-workers knew and could achieve if we were given the right tools and resources to succeed, and 2) the lack of foresight and initiatives by our policymakers back then in helping us to succeed. There was an incident that occurred about three weeks ago that prompted me again to vent my frustration in Dwyer’s presence, and I suspect this served as a catalyst that moved him to publicly express my and his concerns via the social media in his article entitled, Health Problems and Solutions.

I gathered that some of my colleagues were offended by some of the statements he made in the article, and yesterday an opinion piece expressing some “disgust” at the article was posted entitled, Response to Astaphan’s “Health Problems And Solutions.” Given that my venting in frustration may have been the root cause of Dwyer’s article and the response it got, both on the ground and in the social media, I feel it would be irresponsible of me to remain silent on a matter raised, and it is in the light and spirit of more accountability and transparency that I am moved to elaborate some more on the issue.

Firstly, with regards to the Cuban-trained doctors, I have worked with many of them over the past decade and I can truly say that although a few of them have raised eyebrows and have become a liability to our health system, and some are weak in their clinical acumen, there are many who stand out out as exceptional in their drive, knowledge base and passion for the profession. One Cuban-trained doctor that has stood out for me is Dr. Terrence Drew. He worked with me for some months on the Medical Ward before going off to continue his post-graduate training in Internal Medicine/Nephrology in the USA. As a matter of fact, I wrote one of his letters of recommendations, and I had no reservations then, and no regrets now in having done so. My only disappointment was that on completing his training in Internal Medicine, he chose to use his new skills in politics rather than in the practice of medicine proper. I had expressed this to him, and he once remarked to me in private that he felt that he would be able to be more of an asset to the health sector by being able to help formulate policy at the top given his understanding of medicine, the challenges we faced, and his exposure to the strengths and weaknesses in the health care systems, both in Cuba and the USA. I still feel that he was genuine and sincere in what he told me, and I honestly feel blaming Dr Drew for the decisions he made to get involved in politics, is grossly misplaced. (Please see Dr. Bichara Sahely Comments on Issue Regarding Internist at JNF Hospital.)

I gather from inside sources that his resignation and signing of contracts may have been done in haste, and they may have been some legal issues and ramifications to his actions then, the consequences of which he may not have fully appreciated. Being that as it may, I honestly feel that not giving Dr Drew the opportunity to be part of the health team on the ground fully engaged in the public sector, is a gross miscalculation that is compounding an initial error of judgement with another. Many of us start off innocent, naive and impressionable, and make judgement calls that were not wise in retrospect. We all have been there some time or the other, but many of us have been given the opportunity to learn and grow from those experiences. It would be a gross waste of human capital and resources if he is not given the opportunity to be formally engaged with the public sector, and I am urging his supporters on his side and those on on the other side to pressure the powers that be on both sides to do the right thing, and to encourage both parties involved to put aside their political differences and reach a just solution, while acknowledging the lessons learnt along the way.

With regards to Dwyer’s concern on the state of preparedness of the other Cuban-trained doctors, it must first be said, as he acknowledged, that we are grateful to Cuba for opening their doors and playing a major role in the provision of specialists to our nation, and the training of our locals in the general and specialists fields. I have worked with many of them and I am pleased to say that the relationship has been for the most part cordial and professional. The concern I have, and I gather some of the Cuban-trained doctors also have, is that the majority of them have been trained in primary health care as GPs and many of them are put in positions to work in areas that require more specialist oversight and guidance. I do not question the drive and the desire to serve, but what I question the most, is the desire and drive, by a few, to learn and communicate in order to discover their weaknesses (which we all have), and the desire and drive to capitalise on their strengths (which we all have too).

The policy makers and administrators in the Ministry of Health need to urgently do a needs assessment and SWOT analysis to determine what our strengths and weaknesses are, where there are opportunities for improvement, and what are the current and potential future threats to the health sector. We must also determine which areas need more specialty guidance and procure the expertise where needed, and make sure that what the patients need for accurate diagnosis and treatment are always available and accessible. We must make health preventative and promotion strategies the foundation of any policies going forward, and this is a strength our Cuban-trained graduates have brought to the table.

I have to keep reminding myself when I am put in compromising situations that my employers are the taxpayers of the country (our patients) whom I am called upon to serve, and not the hospital nor the government. If we are not our patients’ best advocates, I do not know who will be. It is our duty and responsibility to serve our patients foremost by empowering them with knowledge and skills, identifying barriers in their way, and above all, motivating them to live a healthier life guided by responsible stewardship of their bodies, families and communities. It is the policy makers and administrators duty and responsibility to equip us as best as they can with the tools and resources so that we can serve our patients to the best of our abilities. Our job is not to make the life of our administrators and policy makers easier, but it is, au contraire, the job of our policy makers and administrators to make the life of us, the front-line workers, easier so that we can better serve our patients. The sooner we are all on the same wavelength, I can guarantee the healthier our patients will become, the happier and committed our health care providers will be, and the more rewarded our politicians will be at the polls (although this should be a benefit, and not the driving force).

The incident that gave me reason to pause and take stock, and prompted me to vent my frustration recently was the sudden and unexpected death of one of my private patients, and this one incident have brought out all at once to the fore, for me at least, the major deficiencies in our health care system. Dwyer has done an excellent job in his assessment and synthesis of my frustration over the years, and although there were a few inaccuracies there and also in the response to his article, both have thrown the spotlight on the breadth and depth of the challenges we faced and continue to face.

This is not a time to cast blame and create division among the medical fraternity, as now more than ever, we need all hands on deck, if we are going to improve the standards of care and delivery of health in our Federation. Let us learn from the mistakes of the past, capitalise on our strengths, explore every opportunity for improvement, and deal swiftly and decisively with any threats, be it at the bottom and at the top of the chain of delivery of this most essential service.

I will leave with you with a passage from an article I read many years ago, which helped connect the dots of understanding and reasonable expectations from all involved – including me, the health care provider, along with the policy makers and the general public. It is a passage that grounds me and I hope will 1) raise each one of us to a higher level of awareness, understanding and appreciation of the challenges we face, and will 2) help each one of us empathise with the other as we begin to understand each other’s role as we find the best solutions for all concerned.

Who is entitled to what? Healthc Financ Manage. 2003 Sep;57(9):74-7.

“The problem of allocating resources reaches beyond public policy in health care. Allowing a physician to focus on the patient and a hospital to focus on who comes through the hospital door lets them ignore what is going on down the street or across town.

That is not a criticism, but simply a recognition of reality. Our strengths are often our weaknesses. The single-minded devotion of health providers to their patients makes them inadequate judges of the total system. Lacking the luxury of individual focus, public policy must consider the total moral landscape of public needs. That landscape has shifted in the past 10 years as we have increasingly recognized that we cannot provide everything to everybody. We must recognize that the macro-allocation of healthcare resources is not the cumulative total of all individual care.

We cannot provide unlimited, unrestricted health care if we are paying limited taxes and insurance premiums. Pooled resources are always limited resources. Once we honestly admit that health care is not an open ended system, the whole dialogue changes. All stakeholders cannot possibly optimize their care in a pool of limited resources. The challenge is to make the public understand that this is not bad news.”