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Doctors' strikes and mortality: A review
Abstract
A paradoxical pattern has been suggested in the literature on doctors' strikes: when health workers go on strike, mortality stays level or decreases. We performed a review of the literature during the past forty years to assess this paradox. We used PubMed, EconLit and Jstor to locate all peer-reviewed English-language articles presenting data analysis on mortality associated with doctors' strikes. We identified 156 articles, seven of which met our search criteria. The articles analyzed five strikes around the world, all between 1976 and 2003. The strikes lasted between nine days and seventeen weeks. All reported that mortality either stayed the same or decreased during, and in some cases, after the strike. None found that mortality increased during the weeks of the strikes compared to other time periods. The paradoxical finding that physician strikes are associated with reduced mortality may be explained by several factors. Most importantly, elective surgeries are curtailed during strikes. Further, hospitals often re-assign scarce staff and emergency care was available during all of the strikes. Finally, none of the strikes may have lasted long enough to assess the effects of long-term reduced access to a physician. Nonetheless, the literature suggests that reductions in mortality may result from these strikes.
... The general expectation is that HCWs' strikes would lead to a decline in care and increase in mortality. However, several studies have suggested that when doctors go on strike, mortality rates paradoxically may fall [14]. ...
... Cunningham et al. [14] drew attention to the limitations of the use of mortality as outcome, because death can be considered in some way a rare event, and therefore is not a good indicator for changes that do not culminate in death, but that can increase suffering and delays in the use of health services. Smith et al. [54] argue that despite the argument of risks of strikes to patients, there is no clear evidence on an increase in patient morbidity or mortality during periods of strike action. ...
... According to several studies [12,14,19,63,64], the main results of HCWs' strikes are disruption of healthcare service delivery, leading to cancelation of outpatients' appointments, hospital admissions, and elective procedures and surgeries. Existing evidence suggests that strikes have little impact on in-patient morbidity. ...
Background
Public health emergencies of international concern (PHEICs) as the COVID-19 pandemic and others that have occurred since the early 2000s put enormous pressure on health and care systems. This is being a context for protests by health and care workers (HCWs) because of additional workload, working conditions and effects on mental and physical health. In this paper, we intended to analyze the demands of HCWs associated with industrial actions, protests, strikes and lockouts (IAPSLs) which occurred during COVID-19 pandemic and other PHEICs; to identify the impact of these grievances; and describe the relevant interventions to address these IAPSLs.
Methods
We included studies published between January 2000 and March 2022 in PubMed, Embase, Scopus, BVS/LILACS, WHO’s COVID-19 Research Database, ILO, OECD, HSRM, and Google Scholar for grey literature. Eligibility criteria were HCWs as participants, IAPSLs as phenomenon of interest occurring in the context of COVID-19 and other PHEICs. GRADE CERQual was used to assess risk of bias and confidence of evidence.
Results
1656 records were retrieved, and 91 were selected for full-text screening. We included 18 publications. A system-wide approach, rather than a limited approach to institutions on strike, makes it possible to understand the full impact of the strike on health and care services. PHEICs tend to aggravate already adverse working conditions of HCWs, acting as drivers for HCWs strikes, leading to staff shortages, and financial issues, both in the North and in the Global South, particularly evident in Asia and Africa. In addition, issues related to deficiencies in leadership and governance in heath sector and lack of medical products and technologies (e.g., lack of personal protective equipment) were the main drivers of strikes, each contributing 25% of the total drivers identified.
Conclusions
It is necessary to focus on the preparedness of health and care systems to respond adequately to PHEICs, and this includes being prepared for HCWs’ IAPSLs, talked much in the context of COVID-19 pandemic. Evidence to assist policymakers in defining strategies to respond adequately to the health and care needs of the population during IAPSLs is crucial. The main impact of strikes is on the disruption of health care services’ provision. Gender inequality being a major issue among HCWs, a proper understanding of the full impact of the strike on health and care services will only be possible if gender lens is combined with a systemic approach, rather than gender-undifferentiated approaches limited to the institutions on strike.
... Strikes by physicians or non-physician healthcare workers (HCWs) have been a global occurrence for several decades, and it has been debated whether they are ethical or morally justifiable due to the potential increase of mortality in patients [1]. Even though HCW strikes obviously often have an impact on the healthcare services, most studies have not found any increase in mortality associated with HCW strikes, especially when emergency services have been maintained [2][3][4][5]. A paradoxical pattern of decreased mortality during strikes by physicians, followed by increased mortality thereafter, has in some cases been attributed to resumption of elective surgeries [3,6]. ...
... Even though HCW strikes obviously often have an impact on the healthcare services, most studies have not found any increase in mortality associated with HCW strikes, especially when emergency services have been maintained [2][3][4][5]. A paradoxical pattern of decreased mortality during strikes by physicians, followed by increased mortality thereafter, has in some cases been attributed to resumption of elective surgeries [3,6]. ...
... Other potential reasons for the associated increased mortality observed in patients diagnosed with bacteremia during the strike period could, in addition to the minimum number of HCWs during the strike period, potentially also be associated with the likely resumption of elective procedures or resumption to duty of less experienced HCWs after the strike, as reported by other studies [3,6]. ...
This study explored all-cause mortality of bacteraemia diagnosed during a 60-day non-physician healthcare worker strike in 2008. A significant change, with 5.0% (95% CI 1.2-8.7%, p<0.01) absolute risk increase, was seen in 90-day mortality during the strike (n=598) compared with the rest of the study period 2000-2015 (n=75 647).
... The formal assessment of the impact of health workers' strikes on mortality has demonstrated counterintuitive outcomes [1] contrary to mass media reports and reported health worker concerns [2,3]. The nurses' and doctors' strikes in Kenya generated perceptions of unmet health needs [3]. ...
... The nurses' and doctors' strikes in Kenya generated perceptions of unmet health needs [3]. Paradoxically, studies in industrialized nations show mortality to remain the same or decline [1] under strike conditions. Data from a different, low resourced context has been limited [4]. ...
... They may not be able to afford care in private health facilities if government facilities were not fully operational. It has also been observed in developed nations, that a continuity in provision of emergency services [1,16], could avert deaths and reduce the mortality impact of health worker strikes. However, the partial or complete disruption of such services in developing countries or a combination of all these factors could possibly aggravate effects of a health worker strike in developing versus developed nations [17]. ...
Background
Health worker strikes are a significant threat to universal access to care globally and especially in sub Saharan Africa. Kenya’s health sector has seen an increase in such industrial action. Globally there is limited data that has examined mortality related to such strikes in countries where emergency services were preserved. We sought to assess the mortality impact of an 100 day physician strike which was followed by 151 day nurses’ strike and 20 day clinical officer strike in Kenya.
Methods
Monthly mortality data was abstracted from four public hospitals, Kenyatta National Referral Hospital, AIC Kijabe Hospital, Mbagathi Hospital and Siaya Hospital between December 2016 and March 2018. Differences in mortality were assessed using t-tests and multiple linear regression adjusting for facility, numbers of patients utilizing the hospital and department.
Results
There was a significant decline in the numbers of patients seen, comparing the non-strike and strike periods; beta (ß) coefficient − 649 (95% CI -950, − 347) p < 0.0001. The physicians’ strike saw a significant decline in mortality (ß) coefficient − 19.0 (95%CI -29.2, − 8.87) p < 0.0001. Nurses and Clinical Officer strikes’ did not significantly impact mortality. There was no mortality increase in the post-strike period beta (ß) coefficient 7.42 (95%CI -16.7, 1.85) p = 0.12.
Conclusion
Declines in facility-based mortality during strike months was noted when compared to a non-striking facility, where mortality increased. The decline is possibly associated with the reduced patient volumes, and a possible change in quality of care. Public health facilities are congested and over-utilized by the local population majority of whom cannot afford even low cost private care. Health worker strikes in Kenya where the public health system is the only financially accessible option for 80% of the population pose a significant threat to universal access to care. Judicious investment in the health infrastructure and staffing may decrease congestion and improve quality of care with attendant mortality decline.
... Introduction on (seemingly) exogenous variation caused by fluctuations in patient loads (Evans and Kim 2006), minimum staffing regulations (Cook et al. 2012;Tong 2011) or on strikes in the health system (Gruber and Kleiner 2012;Cunningham et al. 2008). The disadvantage of these variations, caused within or as a reaction to the situation in the health system, is that they can be foreseen and accounted for, potentially causing endogeneity problems that downward bias the point estimates. ...
... The disadvantage of these variations, caused within or as a reaction to the situation in the health system, is that they can be foreseen and accounted for, potentially causing endogeneity problems that downward bias the point estimates. During physician strikes in Israel, for instance, doctors refused to treat patients in hospitals but established separate aid stations for treatment outside (compare Cunningham et al. 2008). One other notable exception to this literature is provided by Friedrich and Hackmann (2017) who study the effects of a parental leave program offered to Danish parents on health care delivery. ...
... This paper is among the first to use exogenous variation affecting hospital staffing but not originating in the health system. Earlier empirical evidence is mostly based on (seemingly) exogenous variation caused by fluctuations in patient loads (Evans and Kim 2006), minimum staffing regulations (Cook et al. 2012;Tong 2011) or on strikes in the health system (Gruber and Kleiner 2012;Cunningham et al. 2008). The disadvantage of these variations, caused within or as a reaction to the situation in the health system, is that they can be foreseen and accounted for, potentially causing endogeneity problems that downward bias the point estimates. ...
This dissertation empirically investigates forces that shape the human capital base in the German labor market. Its three essays provide evidence on governmental interventions that promote or change the supply of human capital and impact health, education and migration, respectively.
... In any setting, strikes do not automatically impact on health outcomes such as mortality [19][20][21] or cause a total shut down of health service delivery [1,22]. Rather, the effects depend on the length of the strike, the specific strike actions adopted, responses by the management and the ability of affected populations to access alternative care [1,3,19,23]. ...
... In any setting, strikes do not automatically impact on health outcomes such as mortality [19][20][21] or cause a total shut down of health service delivery [1,22]. Rather, the effects depend on the length of the strike, the specific strike actions adopted, responses by the management and the ability of affected populations to access alternative care [1,3,19,23]. In addition, in settings where healthcare provision under normal circumstances is particularly compromised, service provision or health outcomes may be minimally affected by health workers strikes; the norm cannot really get much worse [24]. ...
... The authors noted that the lack of change in overall mortality could have been because the strikes between 2010 and 2016 were relatively short, with only one lasting for more than a month (42 days). Evidence from other settings suggests that the effects of strikes on health outcomes are increased where emergency services are not available or the affected populations are not able to access viable (available and affordable) alternate healthcare services [1,3,19,67,68]. In Kenya, the Irimu et al (2018) study reviewing admissions in 13 public hospitals during the 2017 doctors' and nurses strikes noted that 'preventable deaths likely occurred on a massive scale', particularly for the poor [27]. We identified similar perceptions in our study, but this may be in contrast with the more modest effects reported for prior strikes [24] . ...
Background:
While health worker strikes are experienced globally, the effects can be worst in countries with infrastructural and resource challenges, weak institutional arrangements, underdeveloped organizational ethics codes, and unaffordable alternative options for the poor. In Kenya, there have been a series of public health worker strikes in the post devolution period. We explored the perceptions and experiences of frontline health managers and community members of the 2017 prolonged health workers' strikes.
Methods:
We employed an embedded research approach in one county in the Kenyan Coast. We collected in-depth qualitative data through informal observations, reflective meetings, individual and group interviews and document reviews (n = 5), and analysed the data using a thematic approach. Individual interviews were held with frontline health managers (n = 26), and group interviews with community representatives (4 health facility committee member groups, and 4 broader community representative groups). Interviews were held during and immediately after the nurses' strike.
Findings:
In the face of major health facility and service closures and disruptions, frontline health managers enacted a range of strategies to keep key services open, but many strategies were piecemeal, inconsistent and difficult to sustain. Interviewees reported huge negative health and financial strike impacts on local communities, and especially the poor. There is limited evidence of improved health system preparedness to cope with any future strikes.
Conclusion:
Strikes cannot be seen in isolation of the prevailing policy and health systems context. The 2017 prolonged strikes highlight the underlying and longer-term frustration amongst public sector health workers in Kenya. The health system exhibited properties of complex adaptive systems that are interdependent and interactive. Reactive responses within the public system and the use of private healthcare led to limited continued activity through the strike, but were not sufficient to confer resilience to the shock of the prolonged strikes. To minimise the negative effects of strikes when they occur, careful monitoring and advanced planning is needed. Planning should aim to ensure that emergency and other essential services are maintained, threats between staff are minimized, health worker demands are reasonable, and that governments respect and honor agreements.
... Sometimes, HCWs were unable to carry out their duties effectively due to disruption of work environments by other striking public service employees as reported from South Africa [9,12,58]. In other instances, doctors and nurses have been attacked or raped at work because of poor safety and security as reported from some South African hospitals [59,60] [40][41][42][43][44][45][46][52][53][54][55][56][57]64,65]. It is this public opprobrium consequent to lack of access to a basic human right, that brings pressure to bear on the primary stakeholders, including doctors, employers, and governments, to try and resolve the impasse created by failure of collective bargaining negotiations leading to the strikes [1 && ,2,9,10 & , 12,[20][21][22][23]26,[33][34][35][36][37][38]44,[50][51][52][53]57]. ...
... Despite huge public outcries and anecdotal reports which accompany most doctor/HCWs strikes, previous studies globally, have not revealed any significant increase in patient mortality during such [2,3,58,64]. The only reported incidents of increased mortality during this review period, was from Kenya, where a faith-based hospital for pediatrics and obstetric care was overwhelmed during a 100-day HCWs strike in Kenya, which also included withdrawal of emergency services [11 && ]. ...
... Please provide complete bibliographic details such as author name, volume, year of publication, and page range for Refs. [3,4,5,7,8,16,17,18,19,20,23,24,28,44,49,50,51,52,53,55,56,57,58,59,60,64]. ...
Purpose of review:
This review analyzed legal and ethical issues surrounding recent doctor and healthcare worker (HCW) strikes and considered whether HCW strikes are legally and morally justifiable, underlying causes, and impact of such strikes on healthcare service delivery.
Recent findings:
Recent reports show that doctor and HCW strikes are an ongoing phenomenon globally, occurring in both developed and developing countries. The main reasons for HCW strikes are failed employer-employee negotiations regarding fair wages and working conditions, policy issues, infrastructural deficiencies in poorer countries, and concerns by HCWs regarding personal security in the workplace. The main impact of HCW strikes is disruption of healthcare service delivery, such as canceled outpatients' appointments, hospital admissions, and elective surgeries. There was no clear evidence of increased patients' mortality during strikes, except in isolated cases, where emergency services were also withdrawn during strikes.
Summary:
Doctors and HCWs strikes are lawful deadlock-breaking mechanisms when collective bargaining negotiations have reached an impasse. Doctors' strikes appear to create an ethical conflict with the Hippocratic tradition and obligation to place patients' best interests as the primary moral consideration in medical practice. However, the rise of consumerism in healthcare, and loss of power by doctors, many of whom now work as employees, subject to regulations imposed by different stakeholders, including governments, health-maintenance organizations, and healthcare insurers, has impacted on modern medical practice. Therefore, doctors, like other employees may occasionally resort to strikes to extract concessions from employers. Mortality is rarely increased during HCW strikes, especially where emergency healthcare services are provided.
... Some studies have reported no change in mortality, [15][16][17] others an increase in deaths, 6,11,18 yet other studies have shown an unexpected decrease in mortality. 4,19 Findings of no change in mortality have been attributed largely to continued access to emergency services, 1,20 partial involvement of striking staff, and continued service provision by other cadres of medical staff. 14,15,17 Reduced mortality has been ascribed to with drawal of elective surgical procedures and continued provision of emergency care, 1,19,21 whereas increased mortality has been attributed to poorer quality of care 6,18 and reduced access to emergency services. ...
... 5,6,11,12 Reasons for no change in mortality in settings other than ours include continued provision of emergency services during strikes, 1,16,19,20 partial involvement of doctors or nurses in strikes, 2,4,14 standin staff replacements during strikes, 2,17,27 and strikes lasting for too short a duration to have a substantial effect. 20 Strikes have also been associated with a reduction in exposure to potentially harmful interventions, such as elective surgical procedures, 10,20,21 and sometimes an overall decrease in mortality was recorded during strikes. 1,19,20 During the nationwide strikes in Kenya, although service delivery (including emergency services such as caesarean sections) was affected in public hospitals including KCH, healthcare provision was continued in private facilities and at hospitals run by faithbased organisations. ...
... 5,6,11,12 Reasons for no change in mortality in settings other than ours include continued provision of emergency services during strikes, 1,16,19,20 partial involvement of doctors or nurses in strikes, 2,4,14 standin staff replacements during strikes, 2,17,27 and strikes lasting for too short a duration to have a substantial effect. 20 Strikes have also been associated with a reduction in exposure to potentially harmful interventions, such as elective surgical procedures, 10,20,21 and sometimes an overall decrease in mortality was recorded during strikes. 1,19,20 During the nationwide strikes in Kenya, although service delivery (including emergency services such as caesarean sections) was affected in public hospitals including KCH, healthcare provision was continued in private facilities and at hospitals run by faithbased organisations. ...
Background: Health workers' strikes are a global occurrence. Kenya has had several strikes by health workers in recent years but their effect on mortality is unknown. We assessed the effect on mortality of six strikes by health workers that occurred from 2010 to 2016 in Kilifi, Kenya. Methods: Using daily mortality data obtained from the Kilifi Health and Demographic Surveillance System, we fitted a negative binomial regression model to estimate the change in mortality during strike periods and in the 2 weeks immediately after strikes. We did subgroup analyses by age, cause of death, and strike week. Findings: Between Jan 1, 2010, and Nov 30, 2016, we recorded 1 829 929 person-years of observation, 6396 deaths, and 128 strike days (median duration of strikes, 18·5 days [range 9–42]). In the primary analysis, no change in all-cause mortality was noted during strike periods (adjusted rate ratio [RR] 0·93, 95% CI 0·81–1·08; p=0·34). Weak evidence was recorded of variation in mortality rates by age group, with an apparent decrease among infants aged 1–11 months (adjusted RR 0·58, 95% CI 0·33–1·03; p=0·064) and an increase among children aged 12–59 months (1·75, 1·11–2·76; p=0·016). No change was noted in mortality rates in post-strike periods and for any category of cause of death. Interpretation: The brief strikes by health workers during the period 2010–16 were not associated with obvious changes in overall mortality in Kilifi. The combined effects of private (and some public) health care during strike periods, a high proportion of out-of-hospital deaths, and a low number of events might have led us to underestimate the effect. Funding: Wellcome Trust and MRC Tropical Epidemiology Group.
... Some studies have reported no change in mortality, [15][16][17] others an increase in deaths, 6,11,18 yet other studies have shown an unexpected decrease in mortality. 4,19 Findings of no change in mortality have been attributed largely to continued access to emergency services, 1,20 partial involvement of striking staff, and continued service provision by other cadres of medical staff. 14,15,17 Reduced mortality has been ascribed to with drawal of elective surgical procedures and continued provision of emergency care, 1,19,21 whereas increased mortality has been attributed to poorer quality of care 6,18 and reduced access to emergency services. ...
... 5,6,11,12 Reasons for no change in mortality in settings other than ours include continued provision of emergency services during strikes, 1,16,19,20 partial involvement of doctors or nurses in strikes, 2,4,14 standin staff replacements during strikes, 2,17,27 and strikes lasting for too short a duration to have a substantial effect. 20 Strikes have also been associated with a reduction in exposure to potentially harmful interventions, such as elective surgical procedures, 10,20,21 and sometimes an overall decrease in mortality was recorded during strikes. 1,19,20 During the nationwide strikes in Kenya, although service delivery (including emergency services such as caesarean sections) was affected in public hospitals including KCH, healthcare provision was continued in private facilities and at hospitals run by faithbased organisations. ...
... 5,6,11,12 Reasons for no change in mortality in settings other than ours include continued provision of emergency services during strikes, 1,16,19,20 partial involvement of doctors or nurses in strikes, 2,4,14 standin staff replacements during strikes, 2,17,27 and strikes lasting for too short a duration to have a substantial effect. 20 Strikes have also been associated with a reduction in exposure to potentially harmful interventions, such as elective surgical procedures, 10,20,21 and sometimes an overall decrease in mortality was recorded during strikes. 1,19,20 During the nationwide strikes in Kenya, although service delivery (including emergency services such as caesarean sections) was affected in public hospitals including KCH, healthcare provision was continued in private facilities and at hospitals run by faithbased organisations. ...
Background:
Health workers' strikes are a global occurrence. Kenya has had several strikes by health workers in recent years but their effect on mortality is unknown. We assessed the effect on mortality of six strikes by health workers that occurred from 2010 to 2016 in Kilifi, Kenya.
Methods:
Using daily mortality data obtained from the Kilifi Health and Demographic Surveillance System, we fitted a negative binomial regression model to estimate the change in mortality during strike periods and in the 2 weeks immediately after strikes. We did subgroup analyses by age, cause of death, and strike week.
Findings:
Between Jan 1, 2010, and Nov 30, 2016, we recorded 1 829 929 person-years of observation, 6396 deaths, and 128 strike days (median duration of strikes, 18·5 days [range 9-42]). In the primary analysis, no change in all-cause mortality was noted during strike periods (adjusted rate ratio [RR] 0·93, 95% CI 0·81-1·08; p=0·34). Weak evidence was recorded of variation in mortality rates by age group, with an apparent decrease among infants aged 1-11 months (adjusted RR 0·58, 95% CI 0·33-1·03; p=0·064) and an increase among children aged 12-59 months (1·75, 1·11-2·76; p=0·016). No change was noted in mortality rates in post-strike periods and for any category of cause of death.
Interpretation:
The brief strikes by health workers during the period 2010-16 were not associated with obvious changes in overall mortality in Kilifi. The combined effects of private (and some public) health care during strike periods, a high proportion of out-of-hospital deaths, and a low number of events might have led us to underestimate the effect.
Funding:
Wellcome Trust and MRC Tropical Epidemiology Group.
... Strike action is experienced globally but the effects are particularly severe in LMICs due to pre-existing health system fragilities (Russo et al., 2019;Waithaka et al., 2020). Though there is conflicting evidence on the direct effects of HWS on population mortality (Cunningham et al., 2008;Metcalfe et al., 2015), strikes in LMICs are thought to have significant health systems effects, for example leading to a decrease in in/out-patient flow, a breakdown in trust between community and health workers, decreasing health worker motivation or entrenching inequalities as strike effects are felt disproportionately by the poor Scanlon et al., 2021a;2021b;Adam et al., 2018). HWS are concerning as human resources for health (HRH) are arguably the most fundamental building block of a health system (World Health Organization, 2016). ...
... In the global literature, the continuation of emergency services was cited as one of the primary resilience mechanisms that led to constant or decreased mortality rates (Cunningham et al., 2008;Metcalfe et al., 2015). The withdrawal of emergency services is thus a concerning finding, making continuing services in private hospitals all the more crucial. ...
In low and middle-income countries like Ghana, private providers, particularly the grouping of faith-based non-profit health providers networked by the Christian Health Association of Ghana (CHAG), play a crucial role in maintaining service continuity during health worker strikes. Poor engagement with the private sector during such strikes could compromise care quality and impose financial hardships on populations, especially the impoverished. This study delves into the engagement between CHAG and the Government of Ghana (GoG) during health worker strikes from 2010-2016, employing a qualitative descriptive and exploratory case study approach. By analysing evidence from peer-reviewed literature, media archives, grey literature, and interview transcripts from a related study using a qualitative thematic analysis approach, this study identifies health worker strikes as a persistent chronic stressor in Ghana. Findings highlight some system-level interactions between CHAG and GoG, fostering adaptive and absorptive resilience strategies, influenced by CHAG’s non-striking ethos, unique secondment policy between the two actors, and the presence of a National Health Insurance System. However, limited support from the government to CHAG member facilities during strikes and systemic challenges with the National Health Insurance System pose threats to CHAG’s ability to provide quality, affordable care. This study underscores private providers’ pivotal role in enhancing health system resilience during strikes in Ghana, advocating for proactive governmental partnerships with private providers and joint efforts to address human resource-related challenges ahead of strikes. It also recommends further research to devise and evaluate effective strategies for nations to respond to strikes, ensuring preparedness and sustained quality healthcare delivery during such crises.
... However, previous studies have reported that mortality is not markedly altered during a healthcare worker strike. In a review by Cunningham et al. [1], four studies reported reduced mortality, and three studies reported no difference in mortality during a physicians' strike. A study conducted in Kilifi, Kenya, using data registered in the Kilifi Health and Demographic Surveillance system, revealed no considerable change in mortality during the six physician and nurse strikes that took place between 2010 and 2016. ...
... Contrary to popular belief, however, a previous review did not observe a clear correlation between physician Control period 2 vs. strike period "others" 47 (0.5%) vs. 14 (0.2%); control period 2 vs. strike period "unknown" 2 (0.0%) vs. 4 (0.1%), respectively. strikes and mortality [1]. ...
Background:
To prepare for future work stoppages in the medical industry, this study aimed to identify the effects of healthcare worker strikes on the mortality rate of patients visiting the emergency department (ED) at six training hospitals in Daegu, Korea.
Methods:
We used a retrospective, cross-sectional, multicenter design to analyze the medical records of patients who visited six training hospitals in Daegu (August 21-September 8, 2020). For comparison, control period 1 was set as the same period in the previous year (August 21-September 8, 2019) and control period 2 was set as July 1-19, 2020. Patient characteristics including age, sex, and time of ED visit were investigated along with mode of arrival, length of ED stay, and in-hospital mortality. The experimental and control groups were compared using t-tests, and Mann-Whitney U-test, chi-square test, and Fisher exact tests, as appropriate. Univariate logistic regression was performed to identify significant factors, followed by multivariate logistic regression analysis.
Results:
During the study period, 31,357 patients visited the ED, of which 7,749 belonged to the experimental group. Control periods 1 and 2 included 13,100 and 10,243 patients, respectively. No significant in-hospital mortality differences were found between study periods; however, the results showed statistically significant differences in the length of ED stay.
Conclusion:
The ED resident strike did not influence the mortality rate of patients who visited the EDs of six training hospitals in Daegu. Furthermore, the number of patients admitted and the length of ED stay decreased during the strike period.
... Intangible and immaterial consciousness exists because he experiences it. Descartes' dualistic separation of fundamental substances, dividing res extensa (material substance that occupies space) from res cogitans (immaterial substance of the mind), ceded authority over immaterial spirit and mind to the Catholic Church and Inquisition, effectively excluding subjective consciousness and mind from the domain of scientific inquiry [80]. ...
... It is key that there was no increase in mortality (which is more significant than a statement of decrease). See Cunningham et al. [80]. See also Siegel-Itzkovich [81]. ...
Unifying Themes in Complex Systems is a well-established series of carefully edited conference proceedings that serve to document and archive the progress made regarding cross-fertilization in this field.
The International Conference on Complex Systems (ICCS) creates a unique atmosphere for scientists from all fields, engineers, physicians, executives, and a host of other professionals, allowing them to explore common themes and applications of complex systems science. With this new volume, Unifying Themes in Complex Systems continues to establish common ground between the wide-ranging domains of complex systems science.
... It is key that there was no increase in mortality (which is more significant than a statement of decrease). See Cunningham et al. (2008) [80] . See also Siegel-Itzkovich (2000) [81]. ...
... It is key that there was no increase in mortality (which is more significant than a statement of decrease). See Cunningham et al. (2008) [80] . See also Siegel-Itzkovich (2000) [81]. ...
This paper applies risk analysis to medical problems, through the properties of nonlinear responses (convex or concave). It shows 1) necessary relations between the nonlinearity of dose-response and the statistical properties of the outcomes, particularly the effect of the variance (i.e., the expected frequency of the various results and other properties such as their average and variations); 2) The description of "antifragility" as a mathematical property for local convex response and its generalization and the designation "fragility" as its opposite, locally concave; 3) necessary relations between dosage, severity of conditions, and iatrogenics. Iatrogenics seen as the tail risk from a given intervention can be analyzed in a probabilistic decision-theoretic way, linking probability to nonlinearity of response. There is a necessary two-way mathematical relation between nonlinear response and the tail risk of a given intervention. In short we propose a framework to integrate the necessary consequences of nonlinearities in evidence-based medicine and medical risk management. Keywords: evidence based medicine, risk management, nonlinear responses
... They concluded that physician strikes are associated with a reduced mortality rate. 12 In all the cases reviewed, the strike modality implemented reduced care but continued to offer emergency and life-saving care. 12 In the Los Angeles, California, USA, strike experience, surveys of the population indicated people either had access to their usual care sources or access to open emergency rooms. ...
... 12 In all the cases reviewed, the strike modality implemented reduced care but continued to offer emergency and life-saving care. 12 In the Los Angeles, California, USA, strike experience, surveys of the population indicated people either had access to their usual care sources or access to open emergency rooms. 13 In the Israeli experience, striking doctors staffed emergency rooms as on holidays and weekends and in major population centres impromptu aid stations were staffed by physicians. ...
Published reviews of national physician strikes have shown a reduction in patient mortality. From 5 December 2016 until 14 March 2017, Kenyan physicians in the public sector went on strike leaving only private (not-for-profit and for-profit) hospitals able to offer physician care. We report on our experience at AIC-Kijabe Hospital, a not-for-profit, faith-based Kenyan hospital, before, during and after the 100-day strike was completed by examining patient admissions and deaths in the time periods before, during and after the strike. The volume of patients increased and exceeded the hospital’s ability to respond to needs. There were substantial increases in sick newborn admissions during this time frame and an additional ward was opened to respond to this need. Increased need occurred across all services but staffing and space limited ability to respond to increased demand. There were increases in deaths during the strike period across the paediatric medical, newborn, paediatric surgical and obstetric units with an OR (95% CI) of death of 3.9 (95% CI 2.3 to 6.4), 4.1 (95% CI 2.4 to 7.1), 7.9 (95% CI 3.2 to 20) and 3.2 (95% CI 0.39 to 27), respectively. Increased mortality across paediatric and obstetrical services at AIC-Kijabe Hospital correlated with the crippling of healthcare delivery in the public sector during the national physicians’ strike in Kenya.
... смертей ежегодно, а согласно последним оценкам, число предотвращённых смертей, связанных с нанесением вреда пациенту медицинским вмешательством в госпиталях США, достигает 200− 400 тыс. Косвенно на существование аналогичных взаимосвязей указывают результаты обзора семи исследований, проводившихся в США, Испании, Израиле и посвящённых влиянию забастовок врачей на уровень смертности [36]. Во всех исследованиях отмечалось, что смертность за период забастовок либо не изменялась, либо снижалась, ни в одном случае не было выявлено роста смертности. ...
... Во всех исследованиях отмечалось, что смертность за период забастовок либо не изменялась, либо снижалась, ни в одном случае не было выявлено роста смертности. Парадоксальные данные в статье [36] объясняются тем, что, вопервых, во время забастовок больницы зачастую концентрируют и усиливают службы неотложной помощи, а во-вторых, ни одна из попавших в фо-ВЕСТНИК РОССИЙСКОЙ АКАДЕМИИ НАУК том 86 № 11 2016 БОЙЦОВ, САМОРОДСКАЯ кус рассмотрения забастовок не продолжалась настолько долго, чтобы можно было оценить последствия долгосрочного ограничения доступа к медицинской помощи. В качестве третьей причины называют фактор невыполнения во время забастовок плановых операций, в том числе тех, которые назначаются без достаточных оснований. ...
Domestic and international studies on the effect of socioeconomic and environmental factors, genetic and behavioral features, and the health care system on mortality are analyzed. The necessity to distinguish between the notions factors affecting mortality rates and factors affecting mortality (longevity) is specified. Mortality rates are significantly affected by demographic processes (birth rate, mortality, migration), while mortality depends on a complex of factors, the significance of each of which is still undetermined and, in the opinion of the authors, varies substantially in various populations depending on combinations of these factors.
... This demonstrates that the impact of residents' resignation on patient PED visits was as significant as that of the COVID-19 pandemic. Previous studies reported a small impact of doctor strikes on patient mortality [17]. However, in these studies, the impact may have been limited because the doctors' strikes lasted only a few days to less than 3 months. ...
Background
In February 2024, the South Korean government announced a 67% increase in medical school admissions (2,000 more students), leading to the resignation of approximately 10,000 residents from major university hospitals. This study investigated the impact of these resignations on pediatric emergency department (PED) visits at a major tertiary hospital in Korea.
Methods
We conducted a retrospective observational study analyzing PED visits under 15 years old at a tertiary hospital from January 2019 to May 12, 2024. After excluding cases with missing diagnostic codes or disposition records, we analyzed visits during the 12-week period from February 19 to May 12 across different years (2019–2024). We used segmented regression of Interrupted Time Series (ITS) analysis to evaluate the impact of three key events: the COVID-19 onset, lifting of mask-wearing mandates, and residents’ resignation, adjusting for seasonal variations and autocorrelation.
Results
Among 11,574 analyzed cases, weekly PED visits decreased significantly after residents’ resignation (133.6 ± 22.4) compared to pre-COVID-19 (246.3 ± 45.2) and post-COVID-19 (263.7 ± 61.2) periods. The proportion of KTAS 3 cases increased to 67.2% during the resignation period compared to pre-COVID-19 (48.9%). ITS analysis revealed significant immediate changes in weekly visits: COVID-19 (-157.81 visits, 95% CI: -202.04 to -113.58), mask mandate removal (48.26 visits, 95% CI: 3.21 to 93.32), and residents’ resignation (-77.82 visits, 95% CI: -134.85 to -20.80). Notably, the proportion of infectious diseases increased (36.9% vs. 18.6% pre-COVID-19), while respiratory diseases decreased (20.1% vs. 33.6% pre-COVID-19).
Conclusion
A substantial reduction in both absolute and relative weekly patient visits was observed following the start of the nationwide resident strike at our pediatric emergency department. Additional studies are needed to better understand how this affected pediatric emergency care delivery and access.
... Similar trends were reported when the emergency services were staffed by the senior workforce in the absence of junior doctors because of industrial actions [10,11]. In 2001, resident doctors at a teaching hospital in Barcelona went on industrial action for nine days, leaving patients in the emergency department to be managed by more senior staff members. ...
Purpose
To assess the impact of the junior doctors’ industrial action on one of the largest emergency eye departments (EED) in the United Kingdom.
Methods
We compared staff allocation, patient presentation, time in streaming, time in the department, the Manchester Triage System (MTS) score, number of eye emergencies and follow-up care of patients who attended the EED in the Manchester Royal Eye Hospital (MREH) during the 3-day industrial action (13–15 March 2023) compared with control periods 2 weeks before and 2 weeks after the industrial action.
Results
During the industrial action, there were almost 1.5 times more staff allocated to EED with a near doubling of the senior workforce. There was no difference in patient presentation, MTS score, number of eye emergencies or patient follow-up during the industrial action. However, patients had significantly less time in streaming (p < 0.001) and in the department (p < 0.001) during the industrial action compared to control periods.
Conclusion
Emergency ophthalmic patient care was not compromised during the industrial action due to the reallocation of the workforce to EED. The results of this study may help in the planning of ophthalmic eye-care services in the event of future industrial actions.
... It is important to know the effects of healthcare worker (HCW) strikes especially on vulnerable populations such as pregnant women and children so that they can be averted or mitigated [1]. The impacts of strikes on health in general have been found to be on the direct provision of services [2], the healthcare system itself [3], detection of disease or complications [4] and on health promotion investments for future health [5]. The disputing parties and in particular policy-makers should be as cognisant of these impacts as possible, yet studies thus far tend to look at hospital facility level and so may not fully capture impacts at population level let alone subgroups within Open Access *Correspondence: Abdu.mohiddin@aku.edu ...
Background
Studies of the impact of health care workers’ strikes tend to look at facility-level activity rather than populations, with evidence from low and middle-income countries relatively sparse. This study explored the effect of national strikes on maternal and child health. It looked at the impact on health system activity in both public and non-public sectors (e.g. private, faith-based), on health promotion investments like immunisation, and on disease detection like post-partum haemorrhage (PPH). A 100 day doctors’ strike started in December 2016, a 150 day nurses strike from June 2017 and then the clinical officers for 21 days that September.
Methods
Time series descriptive analysis of attendance data from the Kenyan Health Management Information System (public, non-public sector facilities). The setting was Kilifi, a coastal county in Kenya with a population of about 1.5 million.
Results
Along the care pathway from antenatal, postnatal and out-patient child health clinics, activity levels dropped markedly in the public sector with only partial compensatory increases in non-public sector activity. The number of fully immunised children fell during the nurses strike as did women seen with PPH during all strikes. These health care strikes caused significant adverse health impacts at the time and potentially inter-generationally as exemplified by the fall in antenatal haematinics supplementation and syphilis testing. Some post-strike ‘’catch-up” activity occurred, however this may have been too late in some instances.
Conclusions
Policy-makers at national and county level need to ensure population health is protected at times of strikes and ideally resolve disputes without such action. Not to do so risks major negative effects on maternal and child health. Increased use of the non-public health sector could be done by the authorities in mitigation should strikes occur again.
... outcomes and on health professionals' well-being (Aiken, 2002;Aiken et al., 2003). There is also some literature looking at the direct impact of strikes on health outcomes (Cunningham et al., 2008). ...
Hospital strikes in the Portuguese National Health Service (NHS) are becoming increasingly frequent. This paper analyses the effect of different health professionals' strikes (physicians, nurses, and diagnostic and therapeutic technicians (DTT) ‐ DTT) on patient outcomes and hospital activity. Patient‐level data, comprising all NHS hospital admissions in mainland Portugal from 2012 to 2018, is used together with a comprehensive strike dataset with almost 130 protests. Data suggests that hospital operations are partially disrupted during strikes, with sharp reductions in surgical admissions (up to 54%) and a decline on both inpatient and outpatient care admissions. The model controls for hospital characteristics, time and regional fixed effects, and case‐mix changes. Results suggest a modest increase in hospital mortality limited for patients admitted during physicians' strikes, and a slight reduction in mortality for patients already at the hospital when a strike takes place. Increases in readmission rates and length of stay are also found. Results suggest that hospitals and legal minimum staffing levels defined during strikes are not flexible enough to accommodate sudden disruptions in staffing, regardless of hospital quality in periods without strikes.
... The empirical literature suggests that strikes do not lead to an increase in patient mortality. 36 While perhaps the airline pilot analogy could hold for staff caring for those critically unwell, like we discussed above, we are unaware of any healthcare strike that has simply resulted in all staff walking off the job and leaving those who are most in need of care. In saying this, the risks with strike action go far beyond that to individual patients; this was overlooked by a number of articles included in this review. ...
Strike action in healthcare has been a common global phenomenon. As such action is designed to be disruptive, it creates substantial ethical tension, the most cited of which relates to patient harm, that is, a strike may not only disrupt an employer, but it could also have serious implications for the delivery of care. This article systematically reviewed the literature on strike action in healthcare with the aim of providing an overview of the major justifications for strike action, identifying relative strengths and shortcomings of this literature and providing direction for future discussions, and theoretical and empirical research. Three major themes emerged related to (1) the relationship between healthcare workers, patients and society; (2) the consequences of strike action; and (3) the conduct of strike action. Those who argue against strike action generally cite the harms of such action, particularly as it relates to patients. Many also argue that healthcare workers, because of their skills and position in society, have a special obligation to their patients and society more generally. Those who see this action as not only permissible but also, in some cases, necessary have advanced several points in response, arguing that healthcare workers do not necessarily have any special obligation to their patients or society, and even if so, this obligation is not absolute. Overwhelmingly, when talking about the potential risks of strike action, authors have focused on patient welfare and the impact that a strike could have. Several directions for future work are identified, including greater explorations into how structural and systemic issues impact strike action, the need for greater consideration about the contextual factors that influence the risks and characteristics of strike action and finally the need to tie this literature to existing empirical evidence.
... The overarching aim of this review is to synthesise and analyse the empirical literature that examines the impact of strike action on patient morbidity, that is, all patient outcomes except mortality. This reviews seeks to (1) understand if strike action has an impact on morbidity and if so (2) what factors related to the strike, or the health of patients in particular impact these outcomes. ...
Strike action in healthcare has been common over the last several decades. The overarching aim of this systematic review was to synthesise and analyse the empirical literature that examines the impact of strike action on patient morbidity, that is, all patient outcomes except mortality. After conducting a search and apply eligibility criteria, 15 studies were included in this review. These articles included a variety of outcomes from hypertension control to rates of chlamydia. Strikes ranged from 13 to 118 days, with a mean strike length of 56 days. A textual narrative synthesis was employed to arrange studies by whether they had a positive, mixed or neutral or negative impact on patient morbidity. Results suggest that strike action has little impact on patient morbidity. The majority of studies reported that strike action had a neutral or mixed impact of strike action on patient morbidity. One study reported positive outcomes and three studies reported negative outcomes, however in both cases, the impact that the strike had was marginal.
... However, a systematic review examining several strikes involving physicians reported that patient mortality remained the same or fell during the industrial action. 24 A study after the 2012 British Medical Association strike has even shown that there were fewer in-hospital deaths on the day, both among elective and emergency populations, although neither difference was significant. 25 Similarly, a recent study in Kenya showed declines in facility-based mortality during strike months. ...
Photo by Ishan @seefromthesky on Unsplash
ABSTRACT
A strike to highlight the plight facing contract doctors which has been proposed has received mixed reactions from those within the profession and the public. This unprecedented nationwide proposal has the potential to cause real-world effects, posing an ethical dilemma. Although strikes are common, especially in high-income countries, these industrial actions by doctors in Malaysia are almost unheard of. Reviewing available evidence from various perspectives is therefore imperative to update the profession and the complexity of invoking this important human right.
INTRODUCTION
Contract doctors in Malaysia held a strike on July 26, 2021. COVID-19 cases are increasing in Malaysia. In June, daily cases ranged between 4,000 to 8,000 despite various public health measures. The R naught, which indicates the infectiousness of COVID-19, remains unchanged. During the pandemic, health care workers (HCWs) have been widely celebrated, resulting in a renewed appreciation of the risks that they face.[1] The pandemic has exposed flawed governance in the public healthcare system, particularly surrounding the employment of contract doctors.
Contract doctors in Malaysia are doctors who have completed their medical training, as well as two years of internship, and have subsequently been appointed as medical officers for another two years. Contract doctors are not permanently appointed, and the system did not allow extensions after the two years nor does it offer any opportunity to specialize.[2] Last week, Parliament did decide to offer a two-year extension but that did not hold off the impending strike.[3] In 2016, the Ministry of Health introduced a contract system to place medical graduates in internship positions at government healthcare facilities across the country rather than placing them in permanent posts in the Public Service Department. Social media chronicles the issues that doctors in Malaysia faced. However, tensions culminated when and contract doctors called for a strike which ended up taking place in late July 2021.
BACKGROUND
Over the past decade, HCW strikes have arisen mostly over wages, work hours, and administrative and financial factors.[4] In 2012, the British Medical Association organized a single “day of action” by boycotting non-urgent care as a response to government pension reforms.[5] In Ireland, doctors went on strike for a day in 2013 to protest the austerity measures implemented by the EU in response to the global economic crisis. It involved a dispute over long working hours (100 hours per week) which violated EU employment laws and more importantly put patients’ lives at risk.[6] The strike resulted in the cancellation of 15,000 hospital appointments, but emergencies services were continued.
Other major strikes have been organized in the UK to negotiate better pay for HCWs in general and junior doctors’ contracts specifically.[7] During the COVID-19 pandemic, various strikes have also been organized in Hong Kong, the US, and Bolivia due to various pitfalls in managing the pandemic.[8] A recent strike in August 2020 by South Korean junior doctors and medical students was organized to protest a proposed medical reform plan which did not address wage stagnation and unfair labor practices.[9] These demands are somewhat similar to the proposed strike by contract doctors in Malaysia. As each national health system operates within a different setting, these strikes should be examined in detail to understand the degree of self-interest involved versus concerns for patient’s welfare.
l. The Malaysia Strike
An anonymous group planned the current strike in Malaysia. The group used social media, garnering the attention of various key stakeholders including doctors, patients, government, and medical councils.[10] The organizers of the strike referred to their planned actions as a hartal. (Although historically a hartal involved a total shutdown of workplaces, offices, shops, and other establishments as a form of civil disobedience, the Malaysian contract doctors pledged no disturbance to healthcare working hours or services and intend a walk-out that is symbolic and reflective of a strike.)[11] The call to action mainly involved showing support for the contract doctors with pictures and placards. The doctors also planned the walk-out.[12]
Despite earlier employment, contract medical doctors face many inequalities as opposed to their permanent colleagues. These include differences in basic salary, provisions of leave, and government loans despite doing the same job. The system disadvantages contract doctors offering little to no job security and limited career progression. Furthermore, reports in 2020 showed that close to 4,000 doctors’ contracts were expected to expire by May 2022, leaving their futures uncertain.[13] Some will likely be offered an additional two years as the government faces pressure from the workers. Between December 2016 and May 2021, a total of 23,077 contract doctors were reportedly appointed as medical officers, with only 789 receiving permanent positions.[14] It has been suggested that they are appointed into permanent positions based on merit but the criteria for the appointments remain unclear. Those who fail to acquire a permanent position inevitably seek employment elsewhere.
During the COVID-19 pandemic, there have been numerous calls for the government to absorb contract doctors into the public service as permanent staff with normal benefits. This is important considering a Malaysian study that revealed that during the pandemic over 50 percent of medical personnel feel burned out while on duty.[15] This effort might be side-lined as the government prioritizes curbing the pandemic. As these issues remain neglected, the call for a strike should be viewed as a cry for help to reignite the discussions about these issues.
ll. Right to strike
The right to strike is recognized as a fundamental human right by the UN and the EU.[16] Most European countries also protect the right to strike in their national constitutions.[17] In the US, the Taft-Hartley Act in 1947 prohibited healthcare workers of non-profit hospitals to form unions and engage in collective bargaining. But this exclusion was repealed in 1947 and replaced with the requirement of a 10-day advanced written notice prior to any strike action.[18] Similarly, Malaysia also recognizes the right to dispute over labor matters, either on an individual or collective basis. The Industrial Relations Act (IRA) of 1967[19] describes a strike as:
“the cessation of work by a body of workers acting in combination, or a concerted refusal or a refusal under a common understanding of a number of workers to continue to work or to accept employment, and includes any act or omission by a body of workers acting in combination or under a common understanding, which is intended to or does result in any limitation, restriction, reduction or cessation of or dilatoriness in the performance or execution of the whole or any part of the duties connected with their employment”
According to the same act, only members of a registered trade union may legally participate in a strike with prior registration from the Director-General of Trade Unions.[20]
Under Section 43 of the IRA, any strike by essential services (including healthcare) requires prior notice of 42 days to their employer.[21] Upon receiving the notice, the employer is responsible for reporting the particulars to the Director-General of Industrial Relations to allow a “cooling-off” period and appropriate action. Employees are also protected from termination if permitted by the Director-General and strike is legalized. The Malaysian contract healthcare workers’ strike was announced and transparent.
Unfortunately, even after legalization, there is fear that the government may charge those participating in the legalized strike.[22] The police have announced they will pursue participants in the strike.[23] Even the Ministry of Health has issued a warning stating that those participating in the strike may face disciplinary actions from the ministry. However, applying these laws while ignoring the underlying issues may not bode well for the COVID-19 healthcare crisis.
lll. Effects of a Strike on Health Care
There is often an assumption that doctors’ strikes would unavoidably cause significant harm to patients. However, a systematic review examining several strikes involving physicians reported that patient mortality remained the same or fell during the industrial action.[24] A study after the 2012 British Medical Association strike has even shown that there were fewer in-hospital deaths on the day, both among elective and emergency populations, although neither difference was significant.[25] Similarly, a recent study in Kenya showed declines in facility-based mortality during strike months.[26] Other studies have shown no obvious changes in overall mortality during strikes by HCWs.[27] There is only one report of increased mortality associated with a strike in South Africa[28] in which all the doctors in the Limpopo province stopped providing any treatment to their patients for 20 consecutive days. During this time, only one hospital continued providing services to a population of 5.5 million people. Even though their data is incomplete, authors from this study found that the number of emergency room visits decreased during the strike, but the risks of mortality in the hospital for these patients increased by 67 percent.[29] However, the study compared the strike period to a randomly selected 20-day period in May rather than comparing an average of data taken from similar dates over previous years. This could greatly influence variations between expected annual hospital mortality possibly due to extremes in weather that may exacerbate pre-existing conditions such as heart failure during warmer months or selecting months with a higher incidence of viral illness such as influenza.
Importantly, all strikes ensured that emergency services were continued, at least to the degree that is generally offered on weekends. Furthermore, many doctors still provide usual services to patients despite a proclaimed strike. For example, during the 2012 BMA strike, less than one-tenth of doctors were estimated to be participating in the strike.[30] Emergency care may even improve during strikes, especially those involving junior doctors who are replaced by more senior doctors.[31] The cancellation of elective surgeries may also increase the number of doctors available to treat emergency patients. Furthermore, the cancellation of elective surgery is likely to be responsible for transient decreases in mortality. Doctors also may get more rest during strike periods.
Although doctor strikes do not seem to increase patient mortality, they can disrupt delivery of healthcare.[32] Disruptions in delivery of service from prolonged strikes can result in decline of in-patient admissions and outpatient service utilization, as suggested during strikes in the UK in 2016.[33] When emergency services were affected during the last strike in April, regular service was also significantly affected.
Additionally, people might need to seek alternative sources of care from the private sector and face increased costs of care. HCWs themselves may feel guilty and demotivated because of the strikes. The public health system may also lose trust as a result of service disruption caused by high recurrence of strikes. During the COVID-19 pandemic, as the healthcare system remains stretched, the potential adverse effects resulting from doctor strikes remain uncertain and potentially disruptive.
In the UK, it is an offence to “willfully and maliciously…endanger human life or cause serious bodily injury.”[34] Likewise, the General Medical Council (GMC) also requires doctors to ensure that patients are not harmed or put at risk by industrial action. In the US, the American Medical Association code of ethics prohibits strikes by physicians as a bargaining tactic, while allowing some other forms of collective bargaining.[35] However, the American College of Physicians prohibits all forms of work stoppages, even when undertaken for necessary changes to the healthcare system. Similarly, the Delhi Medical Council in India issued a statement that “under no circumstances doctors should resort to strike as the same puts patient care in serious jeopardy.”[36]
On the other hand, the positions taken by the Malaysian Medical Council (MMC) and Malaysian Medical Association (MMA) on doctors’ strikes are less clear when compared to their Western counterparts. The MMC, in their recently updated Code of Professional Conduct 2019, states that “the public reputation of the medical profession requires that every member should observe proper standards of personal behavior, not only in his professional activities but at all times.” Strikes may lead to imprisonment and disciplinary actions by MMC for those involved. Similarly, the MMA Code of Medical Ethics published in 2002 states that doctors must “make sure that your personal beliefs do not prejudice your patients' care.”[37] The MMA which is traditionally meant to represent the voices of doctors in Malaysia, may hold a more moderate position on strikes. Although HCW strikes are not explicitly mentioned in either professional body’s code of conduct and ethics, the consensus is that doctors should not do anything that will harm patients and they must maintain the proper standard of behaviors. These statements seem too general and do not represent the complexity of why and how a strike could take place. Therefore, it has been suggested that doctors and medical organizations should develop a new consensus on issues pertaining to medical professional’s social contract with society while considering the need to uphold the integrity of the profession.
Experts in law, ethics, and medicine have long debated whether and when HCW strikes can be justified. If a strike is not expected to result in patient harm it is perhaps acceptable.[38] Although these debates have centered on the potential risks that strikes carry for patients, these actions also pose risks for HCWs as they may damage morale and reputation.[39]
Most fundamentally, strikes raise questions about what healthcare workers owe society and what society owes them. For strikes to be morally permissible and ethical, it is suggested that they must fulfil these three criteria:[40]
a. Strikes should be proportionate, e., they ‘should not inflict disproportionate harm on patients’, and hospitals should as a minimum ‘continue to provide at least such critical services as emergency care.’
b. Strikes should have a reasonable hope of success, at least not totally futile however tough the political rhetoric is.
c. Strikes should be treated as a last resort: ‘all less disruptive alternatives to a strike action must have been tried and failed’, including where appropriate ‘advocacy, dissent and even disobedience’.
The current strike does not fulfil the criteria mentioned. As Malaysia is still burdened with a high number of COVID-19 cases, a considerable absence of doctors from work will disrupt health services across the country. Second, since the strike organizer is not unionized, it would be difficult to negotiate better terms of contract and career paths. Third, there are ongoing talks with MMA representing the fraternity and the current government, but the time is running out for the government to establish a proper long-term solution for these contract doctors.
One may argue that since the doctors’ contracts will end in a few months with no proper pathways for specialization, now is the time to strike. However, the HCW right to strike should be invoked only legally and appropriately after all other options have failed.
CONCLUSION
The strike in Malaysia has begun since the drafting of this paper. Doctors involved assure that there will not be any risk to patients, arguing that the strike is “symbolic”.[41] Although an organized strike remains a legal form of industrial action, a strike by HCWs in Malaysia poses various unprecedented challenges and ethical dilemmas, especially during the pandemic. The anonymous and uncoordinated strike without support from the appropriate labor unions may only spark futile discussions without affirmative actions. It should not have taken a pandemic or a strike to force the government to confront the issues at hand. It is imperative that active measures be taken to urgently address the underlying issues relating to contract physicians. As COVID-19 continues to affect thousands of people, a prompt reassessment is warranted regarding the treatment of HCWs, and the value placed on health care.
[1] Ministry of Health (MOH) Malaysia, “Current situation of COVID-19 in Malaysia.” http://covid-19.moh.gov.my/terkini (accessed Jul. 01, 2021).
[2] “Future of 4,000 young doctors who are contract medical officers uncertain,” New Straits Times - November 26, 2020. https://www.nst.com.my/news/nation/2020/11/644563/future-4000-young-doctors-who-are-contract-medical-officers-uncertain
[3] “Malaysia doctors strike, parliament meets as COVID strain shows,” Al Jazeera, July 26, 2021. https://www.aljazeera.com/news/2021/7/26/malaysia-doctors-strike-parliament-meets-as-covid-strains-grow
[4] R. Essex and S. M. Weldon, “Health Care Worker Strikes and the Covid Pandemic,” N. Engl. J. Med., vol. 384, no. 24, p. e93, Jun. 2021, doi: 10.1056/NEJMp2103327; G. Russo et al., “Health workers’ strikes in low-income countries: the available evidence,” Bull. World Health Organ., vol. 97, no. 7, pp. 460-467H, Jul. 2019, doi: 10.2471/BLT.18.225755.
[5] M. Ruiz, A. Bottle, and P. Aylin, “A retrospective study of the impact of the doctors’ strike in England on 21 June 2012,” J. R. Soc. Med., vol. 106, no. 9, pp. 362–369, 2013, doi: 10.1177/0141076813490685.
[6] E. Quinn, “Irish Doctors Strike to Protest Work Hours Amid Austerity,” The Wall Street Journal, 2013. https://www.wsj.com/articles/no-headline-available-1381217911?tesla=y (accessed Jun. 29, 2021).
[7] “NHS workers back strike action in pay row by 2-to-1 margin,” The Guardian, 2014. https://www.theguardian.com/society/2014/sep/18/nhs-workers-strike-pay-unison-england (accessed Jun. 29, 2021); M. Limb, “Thousands of junior doctors march against new contract,” BMJ, p. h5572, Oct. 2015, doi: 10.1136/bmj.h5572.
[8] J. Parry, “China coronavirus: Hong Kong health staff strike to demand border closure as city records first death,” BMJ, vol. 368, no. February, p. m454, Feb. 2020, doi: 10.1136/bmj.m454; “MultiCare healthcare workers strike, urging need for more PPEs, staff support,” Q13 FOX, 2020. https://www.q13fox.com/news/health-care-workers-strike-urging-need-for-ppes-risks-on-patient-safety (accessed Jun. 29, 2021); “Bolivia healthcare workers launch strike in COVID-hit region,” Al Jazeera, 2021. https://www.aljazeera.com/news/2021/2/9/bolivia-healthcare-workers-strike-covid-hit-region (accessed Jun. 29, 2021).
[9] K. Arin, “Why are Korean doctors striking?” The Korea Herald, 2020. http://www.koreaherald.com/view.php?ud=20200811000941 (accessed Jun. 29, 2021).
[10] “Hartal Doktor Kontrak,” Facebook. https://www.facebook.com/hartaldoktorkontrak.
[11] “Hartal,” Oxford Advanced Learner’s Dictionary. https://www.oxfordlearnersdictionaries.com/definition/english/hartal (accessed Jun. 29, 2021).
[12] “Hartal Doktor Kontrak,” Facebook. https://www.facebook.com/hartaldoktorkontrak.
[13] R. Anand, “Underpaid and overworked, Malaysia’s contract doctors’ revolt amid Covid-19 surge,” The Straits Times, 2021.
[14] Anand.
[15] N. S. Roslan, M. S. B. Yusoff, A. R. Asrenee, and K. Morgan, “Burnout prevalence and its associated factors among Malaysian healthcare workers during covid-19 pandemic: An embedded mixed-method study,” Healthc., vol. 9, no. 1, 2021, doi: 10.3390/healthcare9010090.
[16] Maina Kiai, “Report by the Special Rapporteur on the Right to Freedom of Peaceful Assembly and Association,” 2016. [Online]. Available: http://freeassembly.net/wp-content/uploads/2016/10/A.71.385_E.pdf.
[17] ETUI contributors, Strike rules in the EU27 and beyond. The European Trade Union Institute. ETUI, 2007.
[18] National Labor Relations Board, National Labor Relations Act. 1935, pp. 151–169.
[19] Ministry of Human Resources, Industrial Relations Act 1967 (Act 177), no. October. 2015, pp. 1–76.
[20] Article 10 of the Federal Constitution states that all citizens have the right to form associations including registered trade or labor unions. A secret ballot with two-third majority will suffice to call for a strike required for submission to the DGTU within 7 days as stated in Section 25(A) of the Trade Union Act 1959.
[21] Ministry of Human Resources Malaysia, Guidelines on Strikes, Pickets and Lockouts in Malaysia. Putrajaya, 2011.
[22] Ordinance Emergency which was declared in Malaysia since 12 January 2021. Under the Ordinance Emergency, the king or authorized personnel may, as deemed necessary, demand any resources.
[23] “Malaysia doctors strike, parliament meets as COVID strain shows,” Al Jazeera, July 26, 2021. https://www.aljazeera.com/news/2021/7/26/malaysia-doctors-strike-parliament-meets-as-covid-strains-grow
[24] S. A. Cunningham, K. Mitchell, K. M. Venkat Narayan, and S. Yusuf, “Doctors’ strikes and mortality: A review,” Soc. Sci. Med., vol. 67, no. 11, pp. 1784–1788, Dec. 2008, doi: 10.1016/j.socscimed.2008.09.044.
[25] M. Ruiz, A. Bottle, and P. Aylin, “A retrospective study of the impact of the doctors’ strike in England on 21 June 2012,” J. R. Soc. Med., vol. 106, no. 9, pp. 362–369, 2013, doi: 10.1177/0141076813490685.
[26] G. K. Kaguthi, V. Nduba, and M. B. Adam, “The impact of the nurses’, doctors’ and clinical officer strikes on mortality in four health facilities in Kenya,” BMC Health Serv. Res., vol. 20, no. 1, p. 469, Dec. 2020, doi: 10.1186/s12913-020-05337-9.
[27] G. Ong’ayo et al., “Effect of strikes by health workers on mortality between 2010 and 2016 in Kilifi, Kenya: a population-based cohort analysis,” Lancet Glob. Heal., vol. 7, no. 7, pp. e961–e967, Jul. 2019, doi: 10.1016/S2214-109X (19)30188-3.
[28] M. M. Z. U. Bhuiyan and A. Machowski, “Impact of 20-day strike in Polokwane Hospital (18 August - 6 September 2010),” South African Med. J., vol. 102, no. 9, p. 755, Aug. 2012, doi: 10.7196/SAMJ.6045.
[29] M. M. Z. U. Bhuiyan and A. Machowski, “Impact of 20-day strike in Polokwane Hospital (18 August - 6 September 2010),” South African Med. J., vol. 102, no. 9, p. 755, Aug. 2012, doi: 10.7196/SAMJ.6045.
[30] M. Ruiz, A. Bottle, and P. Aylin, “A retrospective study of the impact of the doctors’ strike in England on 21 June 2012,” J. R. Soc. Med., vol. 106, no. 9, pp. 362–369, 2013, doi: 10.1177/0141076813490685.
[31] D. Metcalfe, R. Chowdhury, and A. Salim, “What are the consequences when doctors strike?” BMJ, vol. 351, no. November, pp. 1–4, 2015, doi: 10.1136/bmj.h6231.
[32] D. Waithaka et al., “Prolonged health worker strikes in Kenya- perspectives and experiences of frontline health managers and local communities in Kilifi County,” Int. J. Equity Health, vol. 19, no. 1, pp. 1–15, 2020, doi: 10.1186/s12939-020-1131-y.
[33] The study has shown that there were 9.1% reduction in admissions and around 6% fewer emergency cases and outpatient appointments than expected. An additional 52% increase in expected outpatient appointments cancelations were made by hospitals during that period. D. Furnivall, A. Bottle, and P. Aylin, “Retrospective analysis of the national impact of industrial action by English junior doctors in 2016,” BMJ Open, vol. 8, no. 1, p. e019319, Jan. 2018, doi: 10.1136/bmjopen-2017-019319.
[34] D. Metcalfe, R. Chowdhury, and A. Salim, “What are the consequences when doctors strike?” BMJ, vol. 351, no. November, pp. 1–4, 2015, doi: 10.1136/bmj.h6231.
[35] R. Essex and S. M. Weldon, “Health Care Worker Strikes and the Covid Pandemic,” N. Engl. J. Med., vol. 384, no. 24, p. e93, Jun. 2021, doi: 10.1056/NEJMp2103327.
[36] M. Selemogo, “Criteria for a just strike action by medical doctors,” Indian J. Med. Ethics, vol. 346, no. 21, pp. 1609–1615, Jan. 2014, doi: 10.20529/IJME.2014.010.
[37] Malaysian Medical Association, “Malaysian Medical Association Official Website.” https://mma.org.my (accessed Jun. 29, 2021).
[38] M. Toynbee, A. A. J. Al-Diwani, J. Clacey, and M. R. Broome, “Should junior doctors strike?” J. Med. Ethics, vol. 42, no. 3, pp. 167–170, Mar. 2016, doi: 10.1136/medethics-2015-103310.
[39] R. Essex and S. M. Weldon, “Health Care Worker Strikes and the Covid Pandemic,” N. Engl. J. Med., vol. 384, no. 24, p. e93, Jun. 2021, doi: 10.1056/NEJMp2103327.
[40] M. Selemogo, “Criteria for a just strike action by medical doctors,” Indian J. Med. Ethics, vol. 346, no. 21, pp. 1609–1615, Jan. 2014, doi: 10.20529/IJME.2014.010; A. J. Roberts, “A framework for assessing the ethics of doctors’ strikes,” J. Med. Ethics, vol. 42, no. 11, pp. 698–700, Nov. 2016, doi: 10.1136/medethics-2016-103395.
[41] “Malaysia doctors strike, parliament meets as COVID strain shows,” Al Jazeera, July 26, 2021. https://www.aljazeera.com/news/2021/7/26/malaysia-doctors-strike-parliament-meets-as-covid-strains-grow
... One study from Kenya found that absenteeism is associated with lower rates of prenatal HIV testing and treatment and with lower rates of facility delivery [15]. While public health workforce disruptions from strikes are of a different nature than disruptions from absenteeism, evidence suggests that strikes in LMICs have been associated with lower utilization of health care including facility-based deliveries, contraceptive use, and immunizations [16][17][18][19][20], with mixed effects on health outcomes [21][22][23][24]. While health worker strikes are an important form of health service interruption, strikes represent a form of acute, large-scale disruption in service delivery that may have a substantively different impact on patients than chronic health worker absenteeism. ...
Introduction
Absenteeism of frontline health workers in public sector facilities is widespread in low-income countries. There is little quantitative evidence on how health worker absenteeism influences patient treatment seeking behavior, though low public sector utilization and heavy reliance on the informal sector are well documented in low-income settings.
Methods
Using a unique panel dataset covering health facilities and households over a 10-month period in Uganda, we investigate the extent to which health worker absenteeism (defined as zero health workers present at a health facility) impacts patient care seeking behavior, testing, and treatment.
Results
We find high rates of health worker absenteeism at public sector health facilities, with most of the absenteeism occurring at lower level public health clinics. On average, no health worker was present in 42% of all days monitored in lowest level public health clinics, whereas this number was less than 5% in high level public hospitals and private facilities. In our preferred empirical model with household fixed effects, we find that health worker absenteeism reduces the odds that a patient seeks care in the public sector (OR = 0.65, 95% CI = 0.44–0.95) and receives malaria testing (OR = 0.73, 95% CI = 0.53–0.99) and increases the odds of paying out-of-pocket for treatment (OR = 1.41, 95% CI = 1.10–1.80). The estimated differences in care-seeking are larger for children under-five than for the overall study population.
Conclusions
The impact of health worker absenteeism on the quality of care received as well as the financial burden faced by households in sub-Saharan Africa is substantial.
... The impact of strikes on health systems and services is under-explored. To date, much of the literature uses facility data on inpatient utilization trends and mortality [4][5][6], and we know little about the impacts on primary and community-based services. While it is di cult to generalize the impact of strikes across cases and settings [7], studies in Kenya show that recent strikes are associated with signi cant decreases in inpatient admissions and outpatient visits in public health facilities [1,8], but the relationship between strikes and mortality is less clear [9][10][11]. ...
Background:
Health care workers in Kenya have launched major strikes in the public health sector in recent years but how strikes by health care workers affect health systems and services is under-explored. We conducted a qualitative study to explore maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers (CHVS), and health facility managers.
Methods:
We conducted interviews and focus group discussions (FGDs) with three populations: women who were pregnant in 2017, CHVs, and health facility managers. Participants were part of a previous study and recruited using convenience sampling from a single County in western Kenya. Interviews and FGDs were conducted in English or Kiswahili using semi-structured guides that probed women’s pregnancy experiences and maternal and child health services in 2017. Interviews and FGDs were audio-recorded, translated, and transcribed. Content analysis followed a thematic framework approach using deductive and inductive approaches. Data were collected March to July 2019. All participants provided written informed consent.
Results:
Forty-three women (mean age 28) and 22 CHVs (mean age 47) participated in 4 FGDs and 3 FGDs, respectively, and 8 health facility managers (mean age 38) participated in interviews. CHVs and health facility managers were majority female (80%). Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and led to indirect economic effects due to households paying for services in the private sector. Participants overwhelmingly felt it was the poor, particularly poor women, who were most affected since they were more likely to rely on public services, while CHVs highlighted their own poor working conditions in response to strikes by other health care workers. Strikes strained relationships and trust between communities and the health system that were identified as particularly important to maternal and child health care.
Conclusion:
The impacts of strikes by health care workers extend beyond negative health and economic effects and exacerbate fundamental inequities in the health system with important implications for health systems strengthening and universal health coverage in Kenya and other countries.
... Governments have implemented social distancing interventions to reduce the speed of SARS-CoV-2 spread and avoid hospital overload, and home confinement measures have been ordered in most countries [3,4]. Patients were advised by the authorities to stay home unless they had a severe condition. ...
Background
Governments have implemented social distancing interventions to curb the speed of SARS-CoV-2 spread and avoid hospital overload. SARS-CoV-2 social distancing interventions have modified several aspects of society, leading to a change in the emergency medical visit profile.
Objective
To analyze the impact of COVID-19 and the resulting changes on the non-SARS-CoV-2 emergency medical care system profile.
Methods
This is a retrospective multicenter cross-sectional study evaluating medical consultations, urgent hospitalizations, and deaths in São Paulo, the largest city of the Americas. Changes in the medical visit profile according to demographic data and diagnoses were assessed. The change in mortality was also assessed.
Results
A total of 462,412 emergency medical visits were registered from January 2019 to July 2020. Of these emergency medical visits, only 4.7% (21,653) required hospitalization. Of all visits, 592 resulted in deaths, equivalent to 0.1% of the sample. There was a clear decreasing trend in the number of weekly emergency medical visits as social distancing was mandated by decree (Coef. -3733.13; 95% CI −4579.85 to −2886.42; p < 0.001). The number of medical visits for conditions such as trauma, abdominal pain, chest pain, and the common cold decreased (p<0.05). However, the number of medical visits for the following conditions did not change after the onset of the pandemic (p≥0.05): ureterolithiasis, acute appendicitis, acute cholecystitis, acute myocardial infarction, and stroke.
Conclusion
The COVID-19 pandemic has changed the non-SARS-CoV-2 emergency profile. The overall number of emergency medical visits has reduced. The mortality of non-SARS-CoV-2 emergencies has not increased in São Paulo.
... The same way a doctor's strike when just and with the right intention of greater good of most doctors is considered fine. The strike must not be political or aimed at political ambitions, it should not be because of one man's ire against the government or an act meant for the aggrandizement of one's ego or a means to show one's power [3]. The criterion of just cause often demands a utilitarian philosophy determinant which demonstrates that ultimately, the beneficial repercussions of the strike on the health system that must outweigh the temporary disruption and suffering caused by it. ...
... The current decline in mortality in some affected countries may foretell higher-than-expected morbidity and mortality, once non-COVID-19-related care resumes, given delays in chronic care treatments, a large backlog of postponed surgeries [24] (estimated to be 28 million worldwide), and a surge of mental health issues for both healthcare providers and the public [25]. This response may be similar to what occurs after physician strikes are over and elective services are resumed, when overall mortality rates are higher than pre-strike rates [26]. ...
... Withdrawal-based effect estimates may also be confounded by transitional effects, introduction or withdrawal of other interventions at the same time, or by compensating behaviors. The paradoxical finding that mortality remains stable or falls during doctors' strikes reflects the fact that emergency care is maintained, while elective procedures that carry a short term risk are postponed, rather than evidence that healthcare is pointless or harmful (Cunningham et al., 2008). In circumstances of fiscal austerity, a wholesale reduction in public spending may make it difficult to identify the effect of a specific withdrawal. ...
Many interventions that may have large impacts on health and health inequalities, such as social and public health policies and health system reforms, are not amenable to evaluation using randomised controlled trials. The United Kingdom Medical Research Council's guidance on the evaluation of natural experiments draws attention to the need for ingenuity to identify interventions which can be robustly studied as they occur, and without experimental manipulation. Studies of intervention withdrawal may usefully widen the range of interventions that can be evaluated, allowing some interventions and policies, such as those that have developed piecemeal over a long period, to be evaluated for the first time. In particular, sudden removal may allow a more robust assessment of an intervention's long-term impact by minimising ‘learning effects’. Interpreting changes that follow withdrawal as evidence of the impact of an intervention assumes that the effect is reversible and this assumption must be carefully justified. Otherwise, withdrawal-based studies suffer similar threats to validity as intervention studies. These threats should be addressed using recognised approaches, including appropriate choice of comparators, detailed understanding of the change processes at work, careful specification of research questions, and the use of falsification tests and other methods for strengthening causal attribution.
Evaluating intervention withdrawal provides opportunities to answer important questions about effectiveness of population health interventions, and to study the social determinants of health. Researchers, policymakers and practitioners should be alert to the opportunities provided by the withdrawal of interventions, but also aware of the pitfalls.
Algo no muy usual ha sucedido. Ver a cientos de médicos, muchos especialistas, y otros profesionales de la salud marchar por las calles en protesta contra las políticas del gobierno nacional. La “marcha de batas blancas” fue convocada por la Asociación Colombiana de Sociedades Científicas, intentando unificar las posturas de las sociedades médicas de las distintas especialidades. Esto, que parece exótico en el contexto colombiano, no lo es en el nivel global pues en varios países se están presentando problemas que han llevado a que los médicos y otros profesionales de la salud se manifiesten mediante protestas y paros. Tampoco Colombia ha sido ajena a este tipo de situaciones. Por ejemplo, son bien conocidas las protestas en Chile, Francia, Brasil, Canadá, India, el Reino Unido, entre muchas más. Los temas más recurrentes de estas protestas son los laborales, salariales y de carencias de los servicios de salud.
The safety of surgery and anesthesia has seen many advances over the last several decades; however, the frequency of complications experienced by patients undergoing surgical operations remains high. Most of these complications are avoidable, with a considerable portion of surgical patient injuries originating from human factors. Telling stories and assessing what went wrong and why for lessons to be learned are proven methods used to improve patient safety in anesthesia. In this narrative, we revisited a case of an anesthesia mishap that occurred in 1982, leaving the victim in a coma for nearly four decades until his death in September 2021. The patient reported for his operation, but a number of the hospital's staff were on strike. His operation, however, went ahead and the reduction in anesthesia care team members and its consequential increase in workload resulted in a series of avoidable errors. Decades after this event, many of the issues identified still remain a challenge in anesthesia care; there are still lessons to learn. We identified and discussed three major issues of concern: the non-cancellation of his procedure amid a strike action, giving a delicate anesthetic duty to a trainee without active supervision, and poor coordination and teamwork among team members in the operating room.
The complex answer to why the United States does so poorly in health measures has at its base one pervasive issue: The United States has by far the highest levels of inequality of all the rich countries. Inequality Kills Us All details how living in a society with entrenched hierarchies increases the negative effects of illnesses for everyone. The antidote must start, Stephen Bezruchka recognizes, with a broader awareness of the nature of the problem, and out of that understanding policies that eliminate these inequalities: A fair system of taxation, so that the rich are paying their share; support for child well-being, including paid parental leave, continued monthly child support payments, and equitable educational opportunities; universal access to healthcare; and a guaranteed income for all Americans. The aim is to have a society that treats everyone well-and health will follow.
We extend techniques and learnings about the stochastic properties of nonlinear responses from finance to medicine, particularly oncology where it can inform dosing and intervention. We define antifragility. We propose uses of risk analysis to medical problems, through the properties of nonlinear responses (convex or concave). We 1) link the convexity/concavity of the dose-response function to the statistical properties of the results; 2) define "antifragility" as a mathematical property for local beneficial convex responses and the generalization of "fragility" as its opposite, locally concave in the tails of the statistical distribution; 3) propose mathematically tractable relations between dosage, severity of conditions, and iatrogenics. In short we propose a framework to integrate the necessary consequences of nonlinearities in evidence-based oncology and more general clinical risk management.
Objective:
This study sough to evaluate the impact of healthcare strike action on patient mortality.
Data sources:
EMBASE, PubMed CINAHL, BIOETHICSLINE, EconLit, WEB OF SCIENCE and Grey literature were searched up to December 2021.
Study design:
A systematic review and meta-analysis was utilised.
Data collection/extraction:
Random-effects meta-analysis was used to compare mortality rate during-strike versus pre or post strike, with meta-regression employed to identify factors that might influence the potential impact of strike action. Studies were included if they were observational studies that examined in-hospital/clinic or population mortality during a strike period compared to a control period where there was no strike action.
Principal findings:
Seventeen studies examined mortality; 14 examined in-hospital mortality, three examined population mortality. In-hospital studies represented 768,918 admissions and 7,191 deaths during strike action and 1,034,437 admissions and 12,676 deaths during control periods. The pooled relative risk (RR) of in-hospital mortality did not significantly differ during strike action vs. non-strike periods (RR = 0.91, 95% CI [0.63, 1.31], p = .598). Meta-regression also showed that mortality RR was not significantly impacted by country (p = 0.98), profession on strike (p = .32 for multiple professions, p = 0.80 for nurses),the duration of the strike (p = 0.26) or whether multiple facilities were on strike (p = 0.55). Only three studies that examined population mortality met the inclusion criteria, therefore further analysis was not conducted. However it is noteworthy that none of these studies reported a significant increase in population mortality attributable to strike action.
Conclusions:
Based on the data available, this review did not find any evidence that strike action has any significant impact on in-hospital patient mortality.
Background:
Previous studies demonstrated a 'weekend effect' and a 'night effect' of increased mortality among patients admitted during weekends or night shifts, presumably due to understaffing. In this study, we rather examined whether death during hospitalization follows a similar effect regardless of admission time.
Methods:
A retrospective cohort study among deceased patients hospitalized in the internal medicine wing of a tertiary medical center in Israel, between 2019-2020. Demographic and medical data were retrieved from electronic medical charts. Causes of death were specifically catogrized. We applied statistical models to test for differences in mortality using incidence rate ratio (IRR) according to the day, time and cause of death.
Results:
1,278 deceased patients were included. All-cause mortality was similar among weekends and weekdays. When sepsis was the cause of death, higher IRR were demonstrated on Fridays in comparison to weekdays (IRR 1.4 95% CI 1.1-1.9, p<0.05). Other causes of death were not consistent with a 'weekend effect'. Mortality during nightshifts was higher in comparison to the afternoon (IRR 1.5 95% CI 1.3-4.7) and similar to the morning (IRR 1 95% CI 0.9-1.2).
Conclusion:
Our study did not find a pattern of 'weekend effect' or 'night effect' on all-cause mortality among hospitalized patients in internal medicine wards. Our findings suggests that perhaps specifically death from sepsis, and not all-cause mortality, can be used as a surrogate for the measurement of understaffing or quality of care in the internal ward. This article is protected by copyright. All rights reserved.
Background:
The impact of a pandemic on unplanned hospital attendance has not been extensively examined. The aim of this study is to report the nationwide consequences of the COVID-19 pandemic on unplanned hospital attendances in Denmark for 7 weeks after a 'shelter at home' order was issued.
Methods:
We merged data from national registries (Civil Registration System and Patient Registry) to conduct a study of unplanned (excluding outpatient visits and elective surgery) hospital-based healthcare and mortality of all Danes. Using data for 7 weeks after the 'shelter at home' order, the incidence rate of unplanned hospital attendances per week in 2020 was compared with corresponding weeks in 2017-2019. The main outcome was hospital attendances per week as incidence rate ratios. Secondary outcomes were general population mortality and risk of death in-hospital, reported as weekly mortality rate ratios (MRRs).
Results:
From 2 438 286 attendances in the study period, overall unplanned attendances decreased by up to 21%; attendances excluding COVID-19 were reduced by 31%; non-psychiatric by 31% and psychiatric by 30%. Out of the five most common diagnoses expected to remain stable, only schizophrenia and myocardial infarction remained stable, while chronic obstructive pulmonary disease exacerbation, hip fracture and urinary tract infection fell significantly. The nationwide general population MRR rose in six of the recorded weeks, while MRR excluding patients who were COVID-19 positive only increased in two.
Conclusion:
The COVID-19 pandemic and a governmental national 'shelter at home' order was associated with a marked reduction in unplanned hospital attendances with an increase in MRR for the general population in two of 7 weeks, despite exclusion of patients with COVID-19. The findings should be taken into consideration when planning for public information campaigns.
Since the last 100 years, physicians from many countries have been taking collective action. However, the media, civic groups, and the government have denounced them as inhuman and unethical. This study comprehensively analyzed the background and results of physicians’ collective actions that occurred in countries around the world, and reviewed the issues surrounding them. Among 314 cases in 70 countries discussed in the literature, 180 cases in 65 countries were analyzed. Of these 180 cases, 111 (61.7%) were successful, indicating that collective action has brought favorable results to physicians. Furthermore, 177 out of 301 requirements brought favorable results (58.8%). The main reason for collective actions was ‘improvement of working conditions’, which includes improving the medical and the reimbursement systems, adjusting working hours and wages, increasing manpower, supporting medical research, and improving other working environment and conditions. This study is significant because it provides statistical data on the causes and results of collective actions taken by physicians in countries around the world.
Throughout medical history, physicians have rarely formed unions and/or carried out strikes. Today, the medical profession worldwide seems in a heightened state of discontent, but their chosen directions to fight back over their conditions of labor appear blurry and ineffective. With the continual increase in corporatization schemes, physicians continue to be drawn into the role of employee of ever-larger organizations which leave the independent physician-run practice behind; it has become financially more and more difficult to maintain a practice while procuring sufficient reimbursement from insurance companies and patients. As a result, they are not able to maintain their professional independence, which would allow them to act as their patient’s agent in determining what would be done and where it would be done. Because they now have to obey the corporate mandate of revenue enhancement and cost cutting, they no longer have free rein to do as they wish in their professional practice. This condition may impair patient well-being and may surely affect the larger public health.
Medical malpractice has been one of the most misunderstood American policy debates over the past 40 years. This chapter explores the concept of medical malpractice, what is currently discussed as policy alternatives, and some possible ways to address the real crisis, which is not too many physicians getting sued, but rather that too many patients are being harmed in healthcare settings. It is our belief that such altering the focus from liability avoidance and defensive medicine to patient safety, harm reduction, and transparency is necessary. Therefore, documenting, discussing, and fixing systemic issues that cause medical errors to occur can result in better and safer patient care, as well as improved quality at lower cost.
While American physicians have traditionally practised as non-unionised professionals, there has been increasing debate in recent years over whether physicians in training (known also as interns, residents or house staff) are justified in unionising and using collective action. This paper examines specific ethical criteria that would permit union action, including a desire to ameliorate patient care as well as the goal of improving the conditions of working physicians. We posit that traditional rebuttals to physician unionisation often lean on an infinite conception of a doctor’s energies and obligations, one that promotes burnout and serves to advance the financial motives of hospital management and administration. Furthermore, this paper explores the empirical justifications for collective action, which include substantial reductions in medical error. Finally, we address the free-rider problem posed by non-union physicians who might benefit from working improvements garnered through union action. We conclude that in order to maintain a notion of justice as fairness, resident physicians who benefit from union deliberations are impelled to acquire union membership or make a commensurate donation and that the healthcare organisations for which they work ought to share in the responsibility to improve patient care.
Objective: To analyse the characteristics, frequency, drivers, outcomes and stakeholders of health workers’ strikes in low-income countries.
Methods: We reviewed the published and grey literature from online sources for the years 2009 to 2018. We used four search strategies:
(i) exploration of main health and social sciences databases; (ii) use of specialized websites on human resources for health and development;
(iii) customized Google search; and (iv) consultation with experts to validate findings. To analyse individual strike episodes, pre-existing
conditions and influencing actors, we developed a conceptual framework from the literature.
Results: We identified 116 records reporting on 70 unique health workers’ strikes in 23 low-income countries during the period, accounting
for 875 days of strike. Year 2018 had the highest number of events (17), corresponding to 170 work days lost. Strikes involving more than one
professional category was the frequent strike modality (32 events), followed by strikes by physicians only (22 events). The most commonly
reported cause was complaints about remuneration (63 events), followed by protest against the sector’s governance or policies (25 events)
and safety of working conditions (10 events). Positive resolution was achieved more often when collective bargaining institutions and higher
levels of government were involved in the negotiations.
Conclusion: In low-income countries, some common features appear to exist in health sector strikes’ occurrence and actors involved in
such events. Future research should focus on both individual events and regional patterns, to form an evidence base for mechanisms to
prevent and resolve strikes.
Herbert was a 34-year-old man suffered from multiple sclerosis (MS) for 8 years. His initial symptom was trouble walking, and he was found to have multiple demyelinating lesions in his spine and brain. He was placed on glatiramer acetate, a safe, but only partially effective treatment. He continued to have multiple relapses with resultant progression in his disability. Five years into his disease course, he was using a cane and had developed cognitive and visual impairment. The decision was made to place him on natalizumab, a monoclonal antibody given intravenously every month. It is highly effective in preventing relapses in MS, however carries a significant risk for a potentially fatal viral infection known as progressive multiple focal leukoencephalopathy (PML). The causative virus is the JC virus, and Herbert had serum antibodies against the JC virus detected in his serum. In patients with significantly elevated antibody levels, the risk of PML is about one in 100. Based on Herbert’s blood tests, he had an approximately 1:1000 risk of contracting PML if continued on natalizumab.
This paper applies risk analysis to medical problems, through the properties of nonlinear responses (convex or concave). It shows (1) necessary relations between the nonlinearity of dose-response and the statistical properties of the outcomes, particularly the effect of the variance (i.e., the expected frequency of the various results and other properties such as their average and variations); (2) The description of “antifragility” as a mathematical property for local convex response and its generalization and the designation “fragility” as its opposite, locally concave; (3) necessary relations between dosage, severity of conditions, and iatrogenics.
Although the payment systems of public health insurance vary greatly across countries, we still have limited knowledge of their effects. To quantify the changes from a benefits in kind system to a refund system, we exploit the largest physician strike in Japan since the Second World War. During the strike in 1971 led by the Japan Medical Association (JMA), JMA physicians resigned as health insurance doctors, but continued to provide medical care and even health insurance treatment in some areas. This study uses the regional differences in resignation rates as a natural experiment to examine the effect of the payment method of health insurance on medical service utilization and health outcomes. In the main analysis, aggregated monthly prefectural data are used (N = 46). Our estimation results indicate that if the participation rate of the strike had increased by 1 percentage point and proxy claims were refused completely, the number of cases of insurance benefits and the total amount of insurance benefits would have decreased by 0.78% and 0.58%, respectively compared with the same month in the previous year. Moreover, the average amount of insurance benefits per claim increased since patients with relatively less serious diseases might have sought health care less often. Finally, our results suggest that the mass of resignations did not affect death rates.
To assess whether and how the rankings of the world's health systems based on disability adjusted life expectancy as done in the 2000 World Health Report change when using the narrower concept of mortality amenable to health care, an outcome more closely linked to health system performance.
Analysis of mortality amenable to health care (including and excluding ischaemic heart disease).
Age standardised mortality from causes amenable to health care
19 countries belonging to the Organisation for Economic Cooperation and Development.
Rankings based on mortality amenable to health care (excluding ischaemic heart disease) differed substantially from rankings of health attainment given in the 2000 World Health Report. No country retained the same position. Rankings for southern European countries and Japan, which had performed well in the report, fell sharply, whereas those of the Nordic countries improved. Some middle ranking countries (United Kingdom, Netherlands) also fell considerably; New Zealand improved its position. Rankings changed when ischaemic heart disease was included as amenable to health care.
The 2000 World Health Report has been cited widely to support claims for the merits of otherwise different health systems. High levels of health attainment in well performing countries may be a consequence of good fortune in geography, and thus dietary habits, and success in the health effects of policies in other sectors. When assessed in terms of achievements that are more explicitly linked to health care, their performance may not be as good.
Current conditions surrounding the house of medicine-including corporate and government cost-containment strategies, increasing market-penetration schemes in health care, along with clinical scrutiny and the administrative control imposed under privatization by managed care firms, insurance companies, and governments-have spurred an upsurge in physician unionization, which requires a revisiting of the issue of physician strikes. Strikes by physicians have been relatively rare events in medical history. When they have occurred, they have aroused intense debate over their ethical justification among professionals and the public alike, notwithstanding what caused the strikes. As physicians and other health care providers increasingly find employment within organizations as wage-contract employees and their work becomes more highly rationalized, more physicians will join labor organizations to protect both their economic and their professional interests. As a result, these physicians will have to come to terms with the use of the strike weapon. On the surface, many health care strikes may not ever seem justifiable, but in certain defined situations a strike would be not only permissible but an ethical imperative. With an exacerbation of labor strife in the health sector in many nations, it is crucial to explore the question of what constitutes an ethical physician strike.
The aim of the study was to establish whether the physicians' strike, which took place in Croatia in 2003, had an impact on the mortality of the population. Mortality data from the National Bureau of Statistics relating to the strike period (15 January - 14 February 2003) were selected and compared with the previous and subsequent periods of the same duration in 2001, 2002 and 2004. Of the 52,575 deaths in 2003, Croatia recorded 4,682 (8.9%, 95% Confidence interval 8.4-9.4) in the strike period from the 15th of January to the 14th of February 2003 or 1.1 deaths per 1000. No deviations of the 15th of January to the 14th of February period's share of the death total in relation to other observation periods were noted. It is impossible to associate the strike based on the figures shown in this paper with either an increase or decrease in population mortality.
To the Editor: The 1983 Israel doctors' strike was a sham. The Alternative Medical Service operated by striking doctors, including very senior physicians and department heads, gave patients quicker, cheaper, and more direct access to experts than they had had previously. Hospital admissions were arranged expeditiously when called for. Hospitals were full of working junior and senior doctors, many wearing prominent badges stating, “Physician on Active Military Service.” Hundreds of skullcapped Orthodox physicians, prohibited from participating in the strike by religious leaders, worked as usual. The hunger strike was also phony. For the few doctors I know who took part.
Objective:
To evaluate the indicators of activity and quality within the emergency department (ED) during a resident physicians' strike.
Methods:
This was an observational study comparing a strike period (SP) and a non-strike period (NSP) in the ED of a 1,000-bed tertiary care teaching hospital in Barcelona, Spain, with an annual census of 100,000 emergency visits. During a period of nine nonconsecutive days, the resident physicians were on strike. Emergency visits were handled by staff members. Data were compared between all patients treated in the ED during the SP and those treated during the NSP, matched by the weekday. The authors compared lengths of stay (LOSs), rates of use of laboratory tests and radiology procedures, numbers of patient walkouts, patient/physician ratios, emergency hospital admission rates, home discharge rates, unscheduled return rates, and mortality rates.
Results:
The two groups (SP 2,610 patients and NSP 3,634 patients) were comparable in terms of average daily attendance rate (SP: 290 +/- 12 vs NSP: 302 +/- 21; p = 0.13), elective hospital admission rate, and severity of illness. Statistically significant differences were found in terms of mean total patients' LOS (SP: 206.75 +/- 12.27 vs NSP: 235.10 +/- 27.08 minutes; p < 0.001), number of laboratory tests per patient (SP: 0.30 +/- 0.05 vs NSP: 0.38 +/- 0.04; p < 0.001), and radiographs per patient (SP: 0.78 +/- 0.06 vs NSP: 0.88 +/- 0.09; p = 0.021).
Conclusions:
This study demonstrated that replacing residents with staff physicians resulted in fewer laboratory tests ordered, fewer radiographs ordered, and shorter lengths of stays in the ED.
During the first 35 days of 1976, doctors in Los Angeles County withheld their services, principally for non-emergency surgery, in reaction to escalating premiums for malpractice insurance. To assess the impacts of this action, studies were made along 3 lines (1) a survey of 1000 households to determine the effects on access of people to medical care, (2) collection of data on utilization and finances of a sample of 17 general hospitals, and (3) determination of the county total death rates during and after the slowdown compared with equivalent weeks in the previous 5 years.It was found that only a small percentage of people were inconvenienced by the withdrawal of elective surgical services (since other types of care were evidently continuedl. In the hospitals, there was a decline in occupancy, loss of revenue, and many workers laid off. County mortality rates declined steadily during the slowdown, rising abruptly to a peak in the first week that elective surgery was resumed, and then levelling off to usual rates.
The Los Angeles County (California) physician strike of January 1976 resulted in a partial withdrawal of physician services. Among recorded impacts were a 8.5 million pay loss for hospital employees. Several surveys revealed no evidence of a significant impact on the general public in finding medical care. Analysis of emergency room visits and paramedical ambulance calls showed no significant increases during the strike. County mortality statistics for the strike were not affected. Eighty-eight fatalities among 2,171 patients transferred during the strike were analyzed; a Case Attributable Mortality Probability generated on 21 cases selected for final review by a five-physician multispecialist panel indicated that 29 per cent of the Attributable Mortality could be ascribed to the strike itself and 71 per cent to ongoing "patient dumping" from private sector to County hospitals. Even if sample attributable mortality rates were generalized to overall county deaths, the resultant figures are below the estimated range of 55 to 153 deaths that did not occur because of the number of elective operations not performed secondary to the strike.
To study the influence of the 1988 French nurses' strikes on mortality in a geriatric hospital.
Two nurses' strikes affected the Charles Foix Hospital near Paris from June 29 to July 31 and from September 17 to October 22, 1988. Mortality was studied in nine geriatric wards of this hospital, including two rehabilitation units comprising 187 beds, and seven long-term care units comprising 1,132 beds. Monthly mortality rates were calculated from the hospital's administrative registers and expressed as deaths per 1,000 patient-days. These rates were calculated in each of the aforementioned nine units for the 36 months preceding the first strike (control period) and for the 12 months following it (study period).
Over the control period, monthly mortality was significantly higher in rehabilitation units than in long-term care units (2.46 +/- 1.21 versus 0.83 +/- 0.47, p less than 0.001), but mortality rates among rehabilitation units, as well as among long-term care units, were comparable. Also, during the control period, large seasonal fluctuations in monthly mortality rates were observed in both rehabilitation units and long-term care units (peak in winter and nadir in summer). These rates tended to decrease from year to year in rehabilitation units but not in long-term care units. A statistical model based on time-series analysis of the control period data was used to calculate the expected monthly mortality rates for the study period in rehabilitation units and in long-term care units, respectively. Three of the 12 actual monthly mortality rates exceeded the upper limit of the 95% confidence interval of the 12 expected monthly mortality rates, in the units where the more severe care disruption occurred. A detailed analysis of discharge summaries of these units failed to identify a possible link between some of these deaths and a possible absence of care.
The nurses' strikes did not induce a clear-cut increase in mortality in this population of elderly patients. However, we cannot exclude the possibility that these strikes had some negative effects on health. Our results fail to provide answers to the difficult ethical problems created by such stoppages.
For 2 weeks in spring 1980 Sweden was affected by a general labour conflict involving large sections of industry, commerce and public services. Certain parts of the health sector were affected and at some of the Stockholm hospitals all elective surgery was being withheld. The purpose of this study was to find out wether the labour conflict had any effects on the mortality in Stockholm County. The analysis was focused on possible effects of the reduced activity at some major hospitals.From the Stockholm County Medical Information System information on all deaths.as well as deaths occurring in hospitals, was obtained for the years 1979 an 1980. The death rate for eacht week in 1980 was compared with the corresponding week in 1979.During the second week of the conflict and week immediately following, the overall county mortality was remarkably low, and significantly lower than in 1979. The results of the analysis suggest a decrease in overall mortality by the time of the conflict. The decrease in mortality could, however, be explained neither by the withholding of elective surgery nor by the general reduction of hospital activity.
A 4-week, province-wide nurses' strike in Alberta in 1982 caused the closure of 57% of the acute care beds, including 47% of the intensive care beds, in Calgary. The effects of the strike on patient care at Foothills Provincial General Hospital, where nurses did not strike, were assessed. The number of emergency admissions, severity of illness and rate of death in the intensive care unit increased. On the other hand, the rate of death, length of stay and number of unexpected deaths on the medical wards were similar to those in the control periods before and after the strike. A subjective perception by hospital personnel of deteriorating patient care caused much anxiety; however, the results of analysis of measurable aspects of care suggested that the patients admitted to hospital received care during the strike that was comparable to care given before or after the strike. The inconvenience and potential harm to the patients not admitted because they had less severe illness were not measured.
A previous report showed steady decline in the death rate during a ‘doctor slowdown’ (involving essentially the withholding of elective surgery) in Los Angeles County, California—followed by a sharp rise in the death rate as soon as ‘surgery as usual’ was resumed. To determine if this sequence was, in fact, related to post-operative deaths, the actual death certificates for the fortnight after the 1976 slowdown (N = 2574) and those for the corresponding period of 1975 (N = 2663) were examined. Most death certificates, of course, had no indication of surgery done, but comparing deaths associated with surgery in the two periods showed 90 more such deaths in 1976 than in 1975. Separate study of a sample of local hospitals showed withholding of nearly 11,000 elective operations during the slowdown. A widely used average post-operative case-fatality rate for elective surgery of 0.50% would imply avoidance of 55 deaths. The finding of 90 excess deaths associated with surgery in 1976, compared with 1975, therefore, suggests strongly that the sudden rise in the overall Los Angeles County death rate, following the 1976 doctor slowdown, was indeed due, at least in part, to the performance of postponed surgical procedures.
Industrial action by doctors in Israel seems to be good for their patients'health. Death rateshave dropped considerably in most of the country since physicians in public hospitals implementeda programme of sanctions three months ago, according to a survey of burial societies.
The Israel Medical Association began the action on 9 March to protest against the treasury's proposed imposition of a new four year wage contract for doctors. Since then, hundreds of thousands of visits to outpatient clinics have been cancelled or postponed along with tens of thousands of elective operations. Public hospitals, which provide the vast majority of secondary and tertiary medical care, have kept their emergency rooms, dialysis units, oncology departments, obstetric and …
We compared trends in deaths considered amenable to health care before age seventy-five between 1997-98 and 2002-03 in the United States and in eighteen other industrialized countries. Such deaths account, on average, for 23 percent of total mortality under age seventy-five among males and 32 percent among females. The decline in amenable mortality in all countries averaged 16 percent [corrected] over this period. The United States was an outlier, with a decline of only 4 percent. If the United States could reduce amenable mortality to the average rate achieved in the three top-performing countries, there would have been 101,000 fewer deaths per year by the end of the study period.