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A real agent of change
Dr Zulaika Ali remembers when two women had to share a bed at the maternity ward of the Port-of-Spain General Hospital.
In her more than 30 years as a paediatrician, neonatologist and UWI professor in child health/neonatology at the university’s St Augustine campus, she has seen a great many other things. But Ali was never content to be simply a spectator. Her memories of the changing face of healthcare in T&T, especially as it relates to child health and HIV care, tend to include her as a major agent of change.
By the time she was awarded the Chaconia Medal (silver) in 2010 for “long and meritorious service to the Republic of T&T in the sphere of medicine,” she had been one of the forces behind a number of improvements at the Eric Williams Medical Complex and had spearheaded a series of initiatives designed to improve healthcare across the country.
When she was presented with the Medal by then President Max Richards, his wife Jean, also a medical professional, said of Ali, “She has done so much for child healthcare. She is always travelling and working. She is always interested in child healthcare and its advancement. She is a hard worker.”
In 1981, a year after her first medical appointment as registrar in the paediatric ward at the Port-of-Spain General Hospital, Ali was appointed as a consultant to what was then the new Mt Hope Women’s Hospital (MHWH). One of her first challenges was to set up a neonatal ward with very few resources.
“There were no deliveries taking place originally,” says Ali, “patients were being decanted out of Port-of-Spain after delivering their babies so it was sort of healthy mothers and their babies. As time went by the hospital started having women deliver and as a result of that they needed a neonatal service.”
Ali explains that with a staff of only two house officers, two nurses and one registrar, it was almost impossible to provide an adequate service. “The nurses were working three shifts in 24 hours,” says Ali, “as a consultant I was there 24 hours a day, the two house officers were alternating.”
Despite the time and dedication required to provide just a “minimal service,” Ali says that in less than three years, “we gradually increased the amount of service we were able to provide so that by 1984 at the maternity hospital we were delivering the same number of patients as Port-of-Spain General Hospital.”
“It has always been about pushing for change,” says Ali reflectively, “pushing for equipment, pushing for nurses, pushing for junior doctors.” Asked about the process she says, “write letters, make noise, make noise, make noise.” She laughs heartily and adds, “I think if you don’t have a passion for something, you wouldn’t get it.”
Ali’s noise-making helped with improvements in the number, quality and training of nurses at Dr Eric Williams Medical Complex, a regular supply of medical consumables, better monitoring equipment, cleaning equipment, robust infection control, and better management of intravenous nutrition. And that was just in the first few years of just one part of her career.
At UWI she worked to improve how medical students are taught and assessed at undergraduate and postgraduate level—she is interested in ensuring that local practices are in line with international standards—and among other things, helped to introduce the Objective Structured Clinical Examination (OSCE) and worked to change the format of written papers for the final Medical Board BSc examinations.
In 2004, her dedicated efforts at UWI were rewarded with the title of Professor of Child Health (Neonatology). Her other accomplishments had included writing for a number of medical books, medical journals, and the presentation of over 80 papers in a mix of local and international medical forums.
And then there is UWI Telehealth. A service launched in 2004 that helps families with children whose illnesses prove difficult to diagnose and therefore treat, to access medical care from a panel of international experts.
The service which relies on the use of telecommunications and videoconferencing technology is also the route through which children can and have benefitted from free surgeries at the Hospital for Sick Children (SickKids), Canada’s “most research-intensive hospital and the largest centre dedicated to improving children’s health.” According to the service’s brochure, “the survival rate for those who have benefitted from the programme is 100 per cent.” Ali is the service’s founder and director.
The T&T Health Training Centre (TTHTC) opened its doors in 2007. Ali says the centre, which shares the same building as UWI Telehealth service, “was developed to cater for the upskilling of healthcare providers in treatment, care and support for people living with and affected by HIV.”
Working in the area of HIV was not a deviation from working with children because says Ali, “when HIV came to the fore in the 1980s … mother to child transmission … was the main way in which children were acquiring HIV.” Confronted then with the problem of mother to child transmission and the gaps in HIV care in T&T, Ali initially answered the call from the Ministry of Health, to assist in training health care professionals “on how HIV affected women and children.” She also gave lectures to healthcare providers and says Ali, she was a regular feature on local radio programmes in an effort to confront the fear, stigma, and discrimination HIV was met with.
“And then in 2004,” says Ali, “the government developed the National Aids Co-ordinating Committee (NACC) and I was invited to be a member of that committee, a UWI member, together with Professor Carl Theodore.
And because I was in the Faculty of Medical Sciences involved in training and also in treating patients, and sat on the sub-committee for treatment, care and support and research and surveillance, it meant that we were able—the members of the NACC—to get national information, treatment care and support not only from the institutions but also from the NGOs and as a result of that we needed to devise ways in which we could alleviate and mitigate the effect of the HIV and one of the ways that I thought we could use is by training.”
Never shy of the work involved or what can appear to her to be the obvious progression of an earlier idea, Ali says that she worked with Dr Violet Duke and Dr Oscar Osho to put together the proposal to the ministry for the training centre, which was accepted.
“If you don’t have the knowledge you will continue to be afraid, you will continue to stigmatise, you will continue to discriminate,” says Ali, “training is for healthcare professionals in the main, but we also train NGOs, we train members of the protective services, but in the main - public servants in public health institutions and the NGOs because the NGOs interact with the public.”
Ali explains that the centre which is funded by the T&T government and a grant from the US government, focuses on research and curriculum development, as well as training. “We train in all aspects of HIV management,” she says, “that is clinical, psycho-social, prevention. We train on the national guidelines on treating HIV, we train in conflict management, [and] nutrition as a support to treatment of HIV.”
Ali was able to see that in her capacity as a professor at UWI, how she could assist in strengthening HIV training to ensure more robust care. “Working in the training centre, we realised people get trained but the doctors and other professionals want more than just the three days, two days of training — they want a certificate at the end of the day — so that was where I decided that the next step is to create this diploma geared towards professionals working in the field.” The idea for the University of the West Indies postgraduate diploma in the Management of HIV infection was born. “I sold it to UWI and to I-TECH,” says Ali, explaining that she was able to collaborate with the international training and education centre at University of Washington, Seattle (I-TECH) from the beginning. They were able to assist her in securing funding for what was an initially a face-to-face course and were excited by her further idea to make the diploma available online.
The part-time diploma which started in 2012, and is geared towards “doctors, nurses, dieticians, social workers, pharmacists, middle management staff” is now even more accessible as a result of being virtual. Its initial cohorts of 12 and eight students in years one and two respectively, were almost all from Trinidad but now the course is available to medical staff across the Caribbean, including those smaller islands that have limited HIV services. As part of the course, students from a medical background are expected to complete 48 hours clinical practice, and students from these smaller islands will be able to benefit from clinical exposure in facilities in Trinidad, Barbados, Jamaica and Nassau, where “the variety of clinical problems that come through the clinic” will enhance their learning experience.
Ali says that the hopes for the diploma build on those she nursed for the TTHC, - that it will help with “capacity building, improve clinical care of patients and also show or teach the participants ways in which they can improve the quality and service [of HIV care].” Ali who recently retired says that the diploma is her last big project before taking up gardening. “I want to get it out,” she says, “make sure it’s a success so I am there to work through any challenges, teething problems so that my successor will be able to carry it forward.”
Acknowledging that she had not mentioned all of the successful endeavours she had been a part of throughout her career – after all, there had also been the introduction at UWI of the postgraduate Doctor of Medicine degree in Paediatrics, Ali says, “I would say I have had a very rewarding career. I think I have succeeded in helping or contributing to the development of the healthcare of the nation, from the public service point of view and also in the development of the faculty of the medical sciences from the point of view of programmes.”
She admits disappointment that it would appear that those infected by HIV have become complacent because of the success of new HIV treatments and that the end of the five-year funded NACC means that national HIV advocacy must virtually start from scratch, but says Ali, “We are improved. We now have national guidelines,” she explains, “we have people trained, doctors trained in managing the patients.” “But we still have a lot to improve,” she concedes. “We still have a problem with stigma and discrimination, we still have a problem with testing. We need more people to come forward and test, we still need a lot of work in prevention and in those patients who are on treatment, a lot of support work in the area of assisting them to disclose, to assist them in their management and in drug adherence because if you don’t take your drugs as prescribed, then you will get the virus mutating and you will get resistance.”
With so many problems yet to solve, Ali admits that true retirement may not be that easy.
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