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Doctor, negligence and death

About four months ago on October 29, 2007, when Bangladeshi software engineer Masum P. Mohammad, flew back to Bangladesh to see his ill father struggling for life at the Central Care Unit (CCU) of LabAid Cardiac Hospital, he was in shock.

‘I saw my father lying on a bed, full of blood. I asked the nurse to show me where he was operated, and I was speechless to see the unhygienic condition he was put in. I stood there for the longest moment, not knowing what to say,’ he alleges. ‘That was when, I took out my cell phone and recorded the bed and the blood on which my father lay unconscious.’

‘My family was wrong to believe in the so-called expertise and skill of the hospital,’ says Masum, on the phone from his resident in Wollongong, Australia. ‘Today, I sit here, miles away from home and regret that I had not taken my father abroad for treatment and relied on the ailing healthcare system in Bangladesh.’

Masum’s father Late A.K.M Fazlum Haq was admitted at LabAid on October 25 under the treatment of Dr Prof. Baren Chakraborty, after he was struck by a sudden chest pain.

After Haq had a massive heart attack on October 26, he was given injection and later a ring was put around his heart on October 27. Later that week, Haq’s chest x-ray revealed dark areas over the lung, after which Prof. Ali Hossain was involved for the lung treatment. ‘On November 2 that day, Hossain told us, food was stuck in my father’s lung and he wants a Bronchoscope immediately.’

After the Bronchoscope Prof. Hossain provided cough samples for the Tuberculosis (TB) test in two different diagnostic centres-one in LabAid, and another in Monowara Diagnostic, at Panthopath, Dhaka. Three days later the result was completely different in the two hospitals.

‘LabAid results showed that my father does not have TB, and the Monowara Diagnostic test result showed that the report was actually positive!’ he alleges.

Masum explains that later they also learnt that his father had suffered from massive brain injury right after being admitted to the hospital, which was not detected by any of the doctors. ‘When he had a heart attack earlier, blood was stuck in his brain. So, he was not being treated for his brain injury during all these days. My father’s TB test was sent on November 3, 2007. My question is, why did it take so long to send the TB test for diagnostic, and why did it took so long to detect this TB? Even the TB diagnosis result was wrong,’ writes Masum in an email to New Age.

‘After he was given a medication, my father could not recognise us anymore. At that time we requested Prof. Chakraborty to call a neurologist to check my father’s brain, but again he did not bother to listen to us. Two days later, on November 11, my father was announced dead,’ he says fighting back tears.

‘Masum’s story is nothing exceptional,’ says Dr Quamruzzaman who heads the Dhaka Community Hospital in Malibagh and has himself been a victim of medical negligence through which he lost a perfectly-functioning kidney. ‘We have countless other cases of medical negligence and ignorance. But, it is important to realise that one of the biggest flaws of our health care system is that we have no accountability what so ever.’

Indeed, Masum’s case is not an isolated one. According to an investigation of a Dhaka-based NGO, Ain-o-Shalish Kendra, between January to October 2007 alone, there were over 76 death cases reported to be caused by medical negligence.

When Shafiqul Islam’s one-and-half year old baby Afia, under went an endovascular atrial septostomy at LabAid Cardiac Hospitals- an operation through which a catheter is passed into the heart to make the hole bigger so that it doesn’t close up completely, he was relieved. After the successful operation on December 25, last year, Afia was moved to Labaid Specialised Hospital and kept at the Neonatal Intensive Care Unit (NICU) under a ventilator machine as she had also contracted pneumonia.

‘I knew we would have to go for further treatment and I began to prepare papers for India,’ said Shafiqul to Banglavision Channel, which telecasted medical negligence victims last month.

But, two days after the operation, on the 27th, the ventilator machine at the NICU stopped working, alleges Shafiqul. He was asked by the hospital authorities to immediately shift Afia to another hospital with a ventilator machine. He went to two hospitals where he was turned away because their ventilator machines were not available and finally he found it in Salahuddin Hospital and Shafiqul went back to LabAid to take his baby. But he was further delayed for bill payment and when they finally arrived at Salahuddin in a Labaid ambulance, Afia was already dead.

Malpractice cases are numerous, and even affect some of the country’s senior-most and reputed doctors because they see scores of patients daily, giving each little time or thought, points out Dr Zaman. ‘It’s just the whole system that needs to be fixed.’

While an alarming number of cases go unreported and the issue of accountability is hardly in the agenda of health care sector in Bangladesh, Masum’s case has been exceptional in the sense that, he was the first to have raised his voice and reach out so far.

In the past three months, Labaid’s foundation and the health care system’s foundation has been shaken to a great extent, say the health sector insiders. ‘Nothing much is really going to change. But at least, for a change we a have sense of threat and perhaps we can expect at least the slightest degree of accountability,’ says a doctor at a Dhaka-based private hospital.

In the past three months, Masum has reached out not only the Bangladeshis but also an international community through emails, the recorded video of his father’s state released on You-tube and also a blog titled ‘LabAid’s real face’ which has had more than 11,000 visitors till date and also groups on social sites such as facebook. ‘Somehow, whether his allegations are true or false, it has triggered the health sector seriously. More and more patients are now speaking up,’ says a LabAid official, preferring anonymity.

‘We operate a huge system and we are truly dedicated to delivering the best possible health care service,’ explains an official of the LabAid Consultant management, preferring anonymity. ‘Mistakes happen and we work everyday to fill up the gaps and move to provide better services.’

In an e-mail to Masum, following the nationwide response and also six other negligence cases brought forward in a press conference, the LabAid consultant management wrote, ‘We are all aware of the unfortunate incidents you faced at Labaid which was basically the work of a few of our worst kind of employees and does not in any way reflect our service standard or customer service and behaviour.’

‘We, including our Managing Director, sincerely apologise for the incidents that occurred in your case and we hope we can now move forward. We have investigated the whole situation and have already taken administrative measures against those responsible. We sympathise with you and hope that you will also accept our official apology,’ reads the e-mail sent to Masum two months ago.

‘Afia’s case was also exaggerated. She was in a critical state already,’ explains Mesbah Aajad, Media Coordinator, the LabAid Group. ‘As for Masum’s case, mistakes do happen, but you do not take it that far and add more dimensions to it.’

According to Dr Mohammad Saiful Islam, Paediatric Surgeon and Dean of Faculty of Surgery, BSMMU, one of the biggest flaws in Bangladesh’s medical system is that there is no monitoring mechanism which checks whether doctors are administering wrong treatment which results in patients’ deaths. ‘The organisation that is to oversee such cases of negligence, the Bangladesh Medical and Dental Council, is now dead.’

‘In other countries there is a system in place which requires doctors to resit exams every five years or so as a way to reappraise his skills,’ says Dr Zaman.

Dr Zafrullah Chowdhury, the chairman of Dhaka’s Ganashasthaya Nagar Hospital echoes these concerns. In an interview with New Age, he says that the Bangladesh Medical and Dental Council should be responsible to investigate such cases but this doesn’t happen because of a ‘medical mafia’ that forbids doctors from testifying against their fellow professionals. ‘In Dhaka, certainly, you will not be able to find a case where even one senior doctor will be willing to testify to a gross malpractice by another,’ he says.

‘The question of a doctor’s negligence is intricately related to whether he is seeing more patients on a given day than he can handle,’ says Dr Zafrullah. ‘There are good and bad doctors just like there are good and bad architects or lawyers, but a good, skilled doctor can still give bad treatment because he prescribes medicine without giving a patient enough time to tell him the problem in detail.’

‘And make no mistake,’ he stresses, ‘that is negligence.’

Then why not lodge a case against such negligence?

As much as LabAid officials regret the cases and deny further allegations that has been born following the incidents, they ask why was not a case lodged against them, if they had been unfair to such extent?

‘The reason is that the law does not support Masum or anyone else’s case and this is a reality for the healthcare in Bangladesh,’ explains Obiadur Rahman, Co-odinator, Legal Advocacy, ASK. ‘Under the existing law, it is impossible for patients and their families to successfully take doctors to task for negligence or oversight.’

According to Obaidur, Masum had in fact approached ASK and they had sent a letter to the civil servants in the health ministry and an enquiry committee led by Dr. Mumtaz Uddin Bhuiyan was also formed to oversee the case. ‘Officially, we do not know if anything has actually been done, as of yet.’

In the eyes of the law, medical negligence typically comes under the ambit of Tort laws, since it is a civil offence as opposed to a criminal offence, says Bangladesh Supreme court lawyer Faustina Periera, in an interview with New Age.

The concept of Tort applies to an act which is a ‘wrong’ or ‘breach of duty’ as distinguished from a crime. The idea is that the doctor has a duty towards a patient who entrusts his health to the doctor’s care with the reasonable expectation that he will get a certain standard of treatment, even though there is no specific contract between them.

The Penal Code in Bangladesh allows a victim of negligence to file a case if the doctor involved did not possess the educational or professional degrees he claimed he had, or if he failed to take the patient’s consent before operating on him, as well as a slew of other fraud scenarios, explains Dr Pereira.

‘The doctor has an escape clause in Section 88 of the penal code which exonerates him from wrongdoing if his act was done in good faith with the patient’s benefit in mind,’ says Pereira. And that escape hatch of ‘good faith’ lets doctors off the hook in many cases, she explains.

Moreover, the concept of a civil offence is intricately related to the idea of whether the law sees the act of administering treatment as a service which a patient is purchasing, and if so, whether there are minimum standards of the quality of this treatment that a doctor has to meet, say legal professionals.

‘The monitoring system that is supposed to ensure that doctors and clinics are up to par are so riddled with corruption that it is surprising the health system works at all,’ says Rahman. ‘We file medical negligence cases under the same act that applies to reckless driving, imagine that,’ he says.

‘We need to enshrine a Consumer Protection Act that will detail the responsibility that a doctor has towards his patient, or any other service provider has towards a consumer,’ says Pereira. ‘Without an umbrella act, victims don’t have faith in the system, and we don’t have the confidence to tell them that they will get justice.’

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When silence speaks

In the winter morning, as he walked through the narrow roads of Baghdhuli village, memories of his father flashed before his eyes, time and again. Having lived more than twenty-seven years abroad, these roads still look familiar and the air that he breathes remind him, that he is home.

‘My friend and I went to the interior village near Pansha and walked a great deal. At one point, we stopped by a tea stall where a man covered with a muffler looked on at me,’ he tells me, as his eyes twinkle with a hint of pride. ‘“You are the famous artist aren’t you? You are Partho Pratim” he uttered ecstatically and I hold that moment close to my heart. This is my achievement in more than three decades of career, that people remember me, even when I have been away from home for so long,’ he says silently.

He has been the laureate of silence- his white face, striped jumper and unique and real-life expressions changed modern theatre and the concept of mime in Bangladesh and with passage of time, inspired a generation of performers across the world. Indeed, when we speak of the legendary artist Partha Pratim Muzumder, we can say with certainty that there has been no one like him across South Asia and he remains to be irreplaceable.

Having lived twenty-seven years in Paris, and moving on to become an internationally lauded mime artist, this past week, as Partha sits by the window of his friend’s apartment in Dhaka, he tells me about his regrets, about his life as a mime artist and his wish to make a difference.

In a career that began at the age of 15, Partha has performed in Europe, America, Asia and beyond. In France, the birthplace of mime, he has performed solo in more than hundred shows. The winner of titles such as ‘Master of Mime’ (by the Jogesh Mime Academy in India) and ‘Master of the World’ (awarded by Malaysia) and many more, Partha feels his struggles and achievements are yet to end. ‘I continue to struggle and learn more each day,’ he tells me.

There is an unmistakable hint of energy and enthusiasm in his eyes, his gestures and the way he talks. He seems to live each moment to the fullest and strikes up a great conversation with almost anyone. And I was no exception, in this case.

It’s around 11.30 in the morning and he is in a rush to go to the workshop where he is taking classes for the next twenty days. In the middle of all this, he does not fail to smile and greet me.

He tells me his childhood was full of colours and festivities. Born on January 18, 1954 in Pabna, Partha had indeed spent a lively childhood- in festivities and events, where his father Himangshu Kumar Biswas, a photojournalist, used to take him.

‘Some of the best memories of my childhood were spent watching cinemas, sitting on a chair by the projector. I loved the screen as it seemed to portray dreams and so much more,’ he says. ‘Moreover dances in different festivals fascinated me beyond words and I use to try to capture their moves.’

While he indulged himself in music, his sense in rhythm and physical movements only sharpened through keen observations. ‘I would imitate little things I would see- an old man, a clown and the films I watched. So soon, the table in our house would become the stage and we siblings would perform these random plays,’ he laughs.

Later, besides being enrolled in Dhaka Music College, a prestigious institute of that time, he also learnt mime craft from Jogesh Dutta of Calcutta. ‘It was during that time that I was adopted by Ustad Barin Majumder, who was a relative and who had recently lost his daughter.’ While being with a new family, Partha was further introduced to the world of art. ‘My passion only increased and I would practice in the indoor stage of the Music school for hours.’

And so started mime, he tells me. By 1974, Partha was known was all across the country through the various shows he performed. In 1975, his first solo performance was seen in LalKuthhi auditorium. Later he performed a number of times at the Shilpakala Academy. His gestures and smooth movements and ability to convey social messages touched hearts of many.

Partha’s stories of struggle remain to be awe-inspiring. ‘I had chosen the less travelled road after all,’ he tells me. ‘It was a challenge throughout my career to keep the audience to an art that is so limited and fast dying. It was certainly not a profession everyone else wanted me to pursue. Moreover, there was little scope and little financial support in this area.’

As Partha appeared on Bangladesh Television through adverts and programs, he became a celebrated artist. ‘I performed countless dramas in Dhaka University, medical colleges and many other institutes, most often conveying social issues and messages that remain unspoken.’

Finally after his production in Alliance Francaise, the French Ambassador invited him to hold workshops there and he began to grow a French connection- a nation where mime has lived through for the longest period.

His turning point came, when the French Ambassador asked offered him a three-year scholarship in Paris to pursue his career through training at a mime school. ‘Right when a huge door of opportunity opened up for me, I realised that I was not being supported by the government of my own home, my country. All that I required was a certificate that needed to be signed that I am allowed go abroad and it took me two years to have that. Those were perhaps my most difficult times,’ he says ruefully.

‘I continued mime nonetheless, as by then it had not only become a part of me but a part of my life and existence,’ he says.

‘Paris was an experience,’ he tells me. He attended the school of Etienne Decroux, the founder of corporal mime

and later he worked with world’s greatest mime Marcel Marceau. ‘Marcel was a legend and he inspired me greatly. It’s still hard to believe that a man like him considered me to be like his son and there were so many nights in Paris that he would come by at my hostel and have dinner with me,’ he says, the pangs of nostalgia only too visible in his eyes.

After Partha completed his course, Marcel asked him to stay back and work on a project that incorporated elements of Indian dancing and culture into modern mime and enrich it further. They co-authored the thesis ‘Oriental and Occidental Mime’ which now occupies a prominent place in mime literature. In the process of this research, Partho went on to perform in great stages in England, Belgium, Germany, Italy, Spain and many other countries across the globe.

By 1990, Partha started his own mime school in Bretagne, and taught deaf and dumb children. In the process of his work, he added new dimensions to this art and learnt the beauty of being able to make a difference through silence. ‘When words cannot do justice, it is this art that can hold strong,’ he says proudly.

Partha wrote and choreographed a mimodrama, in a record time of two months, which was staged in Bangladesh in 1994. This was achieved with the collaboration of different group theatres and professional dancers from Dhaka. The mimodrama concerning child abuse was the first of its kind to be shown on South East Asian stages.

Back in Paris, Partho is also a proud father of two children who are involved in art and music greatly. ‘They love Bangladesh and they know, back here, it’s always home.’

When Marcel died in 2007, the mime world was threatened by the risk of not being able to survive, and in that difficult time, Partha was one of the artists who refused to give up. ‘Marcel had instilled within me so much inspiration and determination that I could never let him down,’ he says silently.

As Partha rushes to the workshop, he tells me enthusiastically about the young men and women he has come across here. ‘There are so many talents back home. There is so much potential to bring back mime to life. Children here do not have any form of entertainment and many are introverted. This art is not just for entertainment, but also for being able to open up, ’he explains.

When I ask him about his future plans, he tells me that the journey has not ended yet and as long as he breathes, the art will live through.

Currently Partha is in the process of creating a new episode on the theme of environmental pollution. The mime maestro is currently in town upon an invitation of Bangladesh Lung Foundation to perform at the 1st International Conference on Lung Health (to be held from February 20 to 22 at the Bangladesh China Friendship Conference Centre). Moreover, Partha will conduct several workshops on mime for theatre actors and models through out the weeks.

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Outbreak (with Saad Hammadi)

Ever since the news of an outbreak of avian influenza broke on January 22, the prices of farm chicken and eggs have marked a sharp decline. Although there has so far been no report of transmission of the H5N1 virus to human in any of the districts where avian influenza was found in poultry farms, the customers have stopped buying chicken. As an immediate precautionary measure, the government has asked people not to buy chicken from street vendors or hawkers. The government has also quarantined affected farms, culled chicken and destroyed eggs by the thousand.

Meanwhile, poultry experts, researchers and epidemiologists have sought to calm widespread fear of bird-to-human transmission of the deadly virus. They have prescribed ways and manners in which farm chicken and eggs should be handled to keep off the harm’s way. They say eggs should be washed with soap or detergent and then boiled while the chicken should be handled with gloves on, skinned properly and boiled for a few minutes before dressing. The chicken should be cooked in temperature not less than 70 degrees Celsius, they say quoting the World Health Organisation recommendations.

Such advisories have not calmed the fear, though, and people have largely stopped buying chicken and eggs, sending the poultry market on a downward slope. The prices of broilers have gone down by at least Tk 10 in only three days since January 29. Poultry farmers have been hit hard, as the spread of avian influenza is no longer confined to one single specie.

Sources in the poultry industry claim that the initial outbreak of avian influenza in 2005 was limited to ducks but the government suppressed information of the spread of the H5N2 strand of the virus. ‘Had such secrecy not been maintained and had proper actions been taken by the government, the problem would not have snowballed into a crisis,’ says Dr MM Khan, technical adviser to the Bangladesh Poultry Industries Association. ‘Lack of surveillance has also contributed to the crisis, as bird flu was first reported in February 2007.’

Experts claim that a few thousand ducks and crows have died of avian influenza in the past ten days. Allegations have it that although the industry insiders had voiced concern about a possible outbreak as early as in 2003 the government was not convinced and did not take any precautionary step. Until the last official report on January 30, 97 poultry farms were identified with the deadly disease in 48 upazilas and 30 districts. Over three lakh chickens were culled in the process in 134 farms abiding by the radius calculation for culling.

Apart from culling, every day there have been reports of fowls and crows dying in different parts of the country. Although Bangladesh’s testing laboratories are not equipped to the extent of identifying the pathogens, the death symptoms of the fowls reveal that the H5 avian influenza has taken the form of high pathogenic. In case of high pathogenic influenza the fowls usually die within 48 hours of the outbreak and such has been happening, MM Khan says. ‘The Bangladesh Livestock Research Institute is the lone laboratory capable of detecting H5N1 but cannot specify its pathogen,’ he says. The high pathogenic H5 is vulnerable of getting transmitted to human through air and in close contact between the person and the infected bird.

The reason why the H5 influenza is at an alarming level is that it has transmitted among crows – one of the predominant local birds, fear experts. ‘At this stage the wastes, blood and organs of chicken should be dumped at a safe location so that crows or other animal species do not suck them and become infected,’ says Dr Habibur Rahman of the pathology department at the Bangladesh Agricultural University, Mymensingh.

‘Hygiene for chick feeds should be carefully maintained. It is high time the poultry farms quarantined their chickens as the disease is spreading through the air,’ he says.

‘The virus has not become contagious to humans but has managed to persist in parts of Asia, Africa and probably Europe. It could still trigger a human influenza pandemic,’ says Joseph Domenech, chief veterinary officer of the United Nation’s Food and Agricultural Organisation.

Rampant irregularities in surveillance and misuse of funds by the government’s Department of Livestock Services have allowed the disease to spread within the country, allege poultry industry insiders.

‘The government has prepared a number of projects on bird flu prevention and surveillance. Although funds were received, their implementation has hardly taken place,’ says a source.

Meanwhile, the World Bank has agreed to provide the government with $16 million for a five-year ‘Avian Influenza Preparedness and Response’ project. ‘Half a million dollar has already been sanctioned by the World Bank for 2007-2008,’ says a World Bank source. The government has also received $150,000 on January 18 from the Multi-Donor Trust Fund out of $2 million for a project styled ‘Avian and Human Influenza Facility’.

‘It is high time the government introduced vaccination in the country to protect the poultry market, which is worth more than Tk 4,000 crore,’ says Kazi Zahedul Hasan, managing director of Kazi Farms Limited.

Since 2004, culling has no longer been considered acceptable on economic and ethical reasons for developing countries, MM Khan.

The government has, meanwhile, put a bar on importing vaccines and other logistics in the country on independent initiative, say poultry farmers.

The deadly virus is spreading inside the country but Bangladesh is in a better position than India, says Dr Salehuddin Khan, a director with the livestock department. ‘The surveillance is a continuous process and had we not been on the ball to control the situation it would have turned into havoc,’ he says.

Government officials claim that winter is conducive for the spread of the disease. Salehuddin is hopeful that by February its intensity will decline. He says the government is in the process of beginning door-to-door surveillance for the country 1.50 lakh poultry farms.

‘The steps taken by the government are for one not being explained properly,’ says MM Khan. ‘Secondly, they are not immediate and concrete enough to put an end to this alarming state. There is an absence of technical knowledge and awareness among the government about effective vaccination to control the bird flu,’

The livestock ministry is, however, not convinced about the effectiveness of vaccination. ‘Considering the strain of the virus, vaccination may not be an effective tool,’ says Sunil Chandra Ghosh, director general of the livestock department. ‘It is also a fact that once the vaccination is applied the disease will gain permanence and has the chance to become endemic.’

‘A number of poultry farms have recently started exporting poultry products to some Middle East countries, the north-eastern region of India and Nepal, and the present outbreak will hit hard this effort,’ says MM Khan. ‘Moreover, for the thousands of farms across the country, the livelihood is certainly at stake. While chickens are being culled, there has not been any effort to provide provisions for these farms to recoup the losses.’

‘The government is providing compensation to every farms culled counting on the number of chickens. The compensation is between Tk 70 and Tk 80 varying on the criterions like backyard poultry and commercial layer,’ says Sunil. Compensation is never made at 100 per cent and following the international standard culling compensation is no more than a dollar, he adds.

However, industry insiders point out that there is enough scope for corruption in the compensation process. In the process of disbursing compensation, field officials not only take bribe for disbursement of compensation but also allow farmers to market unchecked poultry chicken.

According to BRAC officials, different micro-credit providers have provided credit to the industry and these people are likely to face recovery crisis in the wake of the recent invasion of bird flu in Bangladesh.

Amidst all the aides and assistance the bird flu outbreak has put Bangladesh’s poultry industry in an unstable situation.

A more alarming situation has been noticed across the border areas. While India has been hit hard by bird flu, Bangladesh has more risk to face. At least 17 out of the 26 affected districts border on the Indian state.

The livestock ministry has informed the border forces to seal entrance for poultry and eggs from India. ‘Smuggling of Indian chickens in this season cannot be eliminated completely,’ said a BDR source.

‘The border between Bangladesh and India stretches to around 4,500 kilometres while this whole distance is covered by 500 border outposts each having only 15 persons,’ said an official of the BDR. He pointed out that around eight to nine kilometres is covered by only 15 persons and that also without any vehicles to aid them.

However, a spokesman for the Bangladesh Rifles claims strict restrictions on cross-border movement of poultry and eggs are in place and vigorously enforced.

India’s West Bengal state is currently struggling to cope with its own bird flu outbreak – described as the third and worst outbreak to strike in India since 2006. Eleven of West Bengal’s 19 districts have now been affected, resulting in over 50,000 birds being culled.

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