Is it ethical for health workers to strike? Issues from the 2001 QECH general hospital strike

Summary

Between 5th and 19th October 2001, a general strike in which virtually all workers at the Queen Elizabeth Central Hospital (QECH) were involved was effected. Hospital workers' grievances included low remuneration and poor work environment. The strike resulted in the virtual closure of the QECH, as the 1500-bed hospital was maintained less than a hundred in-patients. The outpatient department was closed. Patients that were still in hospital were being cared for by volunteer workers who included; the Red Cross, medical and nursing students and their lecturers. The two-week strike at QECH has left an almost indelible mark in as far as tertiary level health care delivery in Malawi is concerned. We report on the conduct of the hospital workers strike and discuss ethical issues in the light of the socio-political context of Malawi. While many people suggest that damage has definitely been done and felt, the ethical issues involved remain contentious as ever.

Introduction

Malawi has four public tertiary care hospitals of which the largest is the Queen Elizabeth Central Hospital (QECH) in Blantyre. The other referral hospitals are Zomba, Lilongwe, and Mzuzu. The QECH, a 1,500-bedded hospital is the teaching hospital for the University of Malawi College of Medicine, Malawi's only medical school and also hosts the Blantyre campus for the Kamuzu College of Nursing (KCN). The hospital operates at about 120 per cent capacity and functions as the ‘district hospital’ for Blantyre. There are between 10 and 20 deliveries conducted each day, at least 20 admissions are made each day to the medical and surgical wards and over 40 paediatric admissions. The bulk of clinical work is provided by clinical officers ¹. The hospital is also served by about 15 intern doctors, 8 medical registrars and about 25 specialist doctors. From 5th and 19th October 2001, the hospital experienced a general strike in which virtually all cadres of workers were involved ^2–7. We report the conduct of the strike, its implications and ethical issues pertaining to the general strike in as far as health workers are concerned.

Political History

Malawi attained political independence from Britain in 1964 having been under British rule since 1881. For the next 3 decades after independence, the country had one-party dictatorial rule. Political dissent and industrial action such as strikes were firmly discouraged. For the most part of the 30 years immediately post-independent, Malawi had a State President for Life and any attempt to stage a strike or public demonstration was construed as intention to bring down the government and therefore, tantamount to treason. The maximum penalty for treason in Malawi is death.

Significant political change was experienced between 1992 and 1993 when general civil disobedience in form of street demonstrations, riots and strikes were used as tools to put pressure on the government to effect political change. In June 1993, a National Referendum was carried out in which Malawians were to choose whether to continue with the status quo i.e. one-party dictatorial rule or to change to plural politics. The main result of the National Referendum was that Malawians chose to change their political system to political pluralism. With the coming of political pluralism was the rebirth of democracy and recognition and respect of individual and group rights. For once in many years, Malawians had the right to form associations, political or otherwise. The right of collective bargaining and provision to wage industrial strikes was effected in Malawi's statutes. Between 1994 and 2001, Malawi has witnessed more strikes as compared to those witnessed between 1964 and 1994.

The QECH Strike

Between October 5th and 19th 2001, a general hospital strike was in session at QECH, Blantyre. Virtually all hospital workers i.e. clinical and nursing; administrative, catering and laundry, security and others refused to work. As has been observed elsewhere⁸, four main issues ignited the strike and these were dissatisfaction with the amount of; house allowances, monthly wages and risk and professional allowance. The disfranchised hospital workers had argued that they deserved better remuneration as their services were essential. Comparison was made to the Judicial Services where employees have better remuneration packages, as compared to health workers. The government (employer) on its part argued that it was not possible to meet the demands raised by the workers as doing so would have upset the 2001/02 national budget that had already been approved by the National Assembly in August 2001.

During the course of the strike the 1,500-bedded QECH only managed to serve 196 patients mostly in the Burns Unit, Orthopaedics Department, Malaria Research Project ward, and paediatric oncology ward. Other patients were left to find their own care and many had been either encouraged to leave or discouraged from staying earlier. Over 500 patients from QECH were admitted at Mlambe Mission Hospital, which is under the Christian Health Association (CHAM) some 12 kilometres from QECH. Mlambe has capacity only for 250 in-patients and had only three doctors. While the professional health workers were on strike, 104 volunteers, 68 of whom were from the Red Cross, 36 others being nursing and medical students and their lecturers from the University of Malawi provided clinical, nursing and support services at the QECH.

The ethics of the strike

The big ethical question is; is it ethical for medical doctors to strike just like everyone else as was the case at QECH, which implied withdrawing treatment and healthcare to the patients entrusted to them? One would argue that such action undermined the right of patients to healthcare and the profession's duty to protect life and health. If we indeed agree that it is ethical for doctors to strike, then we ought to ask ourselves how should the strike be conducted? If we are against medical strike, then which other viable options do health workers with grievances against the employer have other than strike.

According to World Medical Association declaration of Helsinki, it is the duty of the physician (health worker) to promote and safeguard the health of the people. The health of the patient will be the first consideration of the physician (health worker)⁹. The main aim of medical practice is to save life, preserve, promote and manage health. It is generally understood that health workers should always desist from harming their patients¹⁰ and their actions should always be in the best interest of the patient ¹¹. On the other hand health workers that are employed on agreed remuneration packages have the right to be paid and they have the right to express dissatisfaction and protect themselves from unfair treatment and exploitation ¹². However their own rights are limited by their responsibility to save life and promote health as laid down by the medical profession's code of conduct. It is suggested that there is a need to do a thorough risk benefit assessment, before health personnel decide to embark on strike. Is the strike in the best interest of health care delivery system? Patients ought to be notified and be given prior warning about the strike, so as to minimize harm. The Constitution of the Republic of Malawi recognizes that workers should be fairly remunerated and the provision for strike is enshrined¹³. Just because a thing is legal is not necessarily that it is ethical in all circumstances.

When two rights are in competition or conflict, as was in this case, the right to be adequately remunerated and right for the healthcare the impasse could be solved by resorting to what we call re-evaluation of moral values. Not all-moral values have the same weight and scope; there is hierarchy of ethical norms and principle. Although moral values are hierarchical in nature, they are intermingled. For example, the right to life does not have the same weight as the right to privacy. Therefore the right to health care (and implicitly life) on the part of the patient may be considered overriding the right to better remuneration of health care workers. This is not a universal perception among health workers and it is a matter of controversy in many circumstances.

In the context of a strike, one should ensure not undertake anything that could result in causing harm directly or indirectly to the patient. Any struggle undertaken by medical personnel that violates patient right to health is unethical. The struggle should be centered at improving overall working conditions and environment in the hospital. The problem with this understanding is that it is almost impossible to stage a strike which is not painful and does not hurt the patient as such would in essence defeat the whole effect of the strike. One could rightly argue that, the only ones who could better defend the plight of the patient are the health workers. If they forsake their patient who can then defend them? Therefore if the health workers want to improve their working conditions let them also fight for the living and care conditions of their patients. For the working condition of a health worker is the living condition of the patient, both are two sides of one coin. A health worker and a patient are not the same and yet they cannot be separated; one cannot be, without the other. Therefore government cannot improve the living conditions of patients without improving the working conditions of the health personnel.

The duty and responsibility to protect life is among the first in hierarchy of values. Hence in a strike an attempt should be made to leave a skeleton staff. Some might say this could undermine the effectiveness of the strike. Others might argue that the absence of a skeleton staff could undermine the integrity of the health workers involved in the strike. It might also be argued that to put in place a skeleton staff could do more harm to the patients than good, because the small and less motivated staff could exhibit negligent behaviour being induced by over work, fatigue and stress but also carelessness.

If the government and regulatory services say that it is unethical for medical personnel to strike, because medical service are in category of special services ^14–16, where and how can the health personnel express their grievances when they discover that their professional services and good will are being abused in the name of professional ethics? If their work is crucial in our society, why do society not give them what is due to them?

Alternatives to strike

If the medical strike is difficult or impossible to implement without endangering one's reputation and work, why not try other means? In the strike under discussion, the Malawi Human Rights Commission offered to mediate between the workers and the employer, Ministry of Health and Population (MoHP). While efforts of a mediator may be crucial, such efforts require commitment from both the employer and the health personnel to accept and respect judgment and advice. Mediation should be based on the principles of dialogue and compromise and not domination.

If the government (employer) and regulatory bodies such as the Medical Council of Malawi and the Nurses and Midwives Council of Malawi show disfavour towards health workers' strike, are there any channels available where the personnel can channel their discontent and grievances? The Malawi Congress of Trade Unions (MCTU) and the Civil Services Trade Union (CSTU) appear not to be suitable for the handling of grievances from the health sector. We consider the health care delivery system very much unlike general employment and work situation. We consider the Medical Association of Malawi (MAM) and the Nurses and Midwives Association of Malawi as better placed, but technically as yet unavailable, to assist health workers with grievances. When MAM last held a general assembly in 1998 and as at December 2001, there were just about 15 registered members. Its influence of the health sector workforce is minimal. Other options are hospital lobby groups or friends of health personnel, who could lobby for the interest of the workers. Such facilities for community lobbying on behalf of hospital workers are currently not available in Malawi.

There has also been the suggestion that health workers may go on strike by withdrawing their services towards the employer that will not harm the patient ¹⁷. The shortfall of this approach, at least from the perspective of those people on strike is that, while these services may be withdrawn from the health sector, they are unlikely to cause immediate pain to the employer or society for them to take corrective action.

Final Remarks

Deciding to go on strike has been an issue of great concern among hospital workers ^18–20. Health workers have been caught between two viewpoints. On one hand, they have considered themselves as ordinary workers, with no special privileges, but with right to strike. On the other hand a professional model with implication to resist the call to go on strike has been suggested. For the first time in Malawi's history, the country's major tertiary hospital was virtually closed due to a general strike. While previously, the health profession had been considered a vocation and sensitive to human life (of patient) that view has been challenged ^21–22 As long as health workers receive no special recognition in as far as their compensation is concerned, there is increasing likelihood that they will behave as ‘ordinary workers’, having no second thoughts when going on strike.

The QECH experience has also challenged the role that the Medical Association of Malawi (MAM) and the Nurses and Midwives Association (NMAM) play in the welfare of health workers. Both associations were not involved at any stage of the strike. More importantly, there did not take part in resolving the impasse between the health workers and the employer. We believe time has come when these two associations must assert themselves and take up their rightful role in the health care delivery system of Malawi. If the fail to take up the task, then we doubt as to the reason why they should exist at all.