The words used to motivate us all to continually strive to improve things for children, in which ever society or community we live in, were those used by Mrs Liew Sau Pheng, founding member of the Malaysian Child Resource Institute, in a truly inspiring speech to close a half-day workshop I ran in Kuala Lumpur this week, supported by the British High Commission. Mrs Liew’s lifetime of work dedicated to children’s advocacy, child protection and the improvement of early education of children demonstrates what a committed, passionate and tenacious person can do to make things better for those people who may not have a voice for themselves.
I’m grateful to the Association of Paediatric Emergency Medicine for the grant that they awarded me which has part-funded the Malaysian component of this project in Kuala Lumpur and Ipoh, Perak.
In a week where a two year old child was abducted from a shopping centre and beheaded beside the river in Kuala Lumpur, and a fifteen year old girl was allegedly repeatedly sexually assaulted by anywhere up to 38 different men in the north of the country, violence against children here in Malaysia is again in the media headlines.
Suspected Child Abuse and Neglect (SCAN) team, the One Stop Crisis Centre (OSCC) and the Emergency Department, Hospital Kuala Lumpur
So prevalent are the crimes against children and vulnerable adults here that the Emergency Department (ED) at Hospital Kuala Lumpur (HKL) has a dedicated OSCC situated in the ED with easy access to the hospital’s SCAN team. I have spent the week trying to find out how child protection cases present to emergency medical services here, with a particular focus on child sexual exploitation (CSE) cases, how these cases are recognised and how they are investigated and managed.
The ED is incredibly busy, seeing in the region of 400-500 children per day out of a total attendance, each day, of 1500 patients. Yup, my jaw dropped as well and I thought I’d misheard but I hadn’t. The vast majority of these patients self-present with very few of them (<10%) coming by ambulance, reflecting the work-in-progress nature of the emergency ambulance service in Kuala Lumpur.
The hospital itself is set on 150 acres and is a tertiary referral hospital with 2300 beds. Out of the 7000 multi-disciplinary staff that the hospital employs there are:
- 200 Consultants and Specialists
- 500 Medical Officers and Registrars
- 32 Matrons
- 221 Ward Managers (Sisters)
- 3101 Registered Nurses
- 253 Community Nurses
- 6 trained Assistant Nurses
- 1 trained Midwife
The remaining staff are pharmacists, tutors, assistant pharmacists, medical assistants, administrative staff and hospital attendants. With around 10000 deliveries per year I wouldn’t like to be that one midwife…
In the Emergency Department the patients are triaged at a counter at the front of the department with a two-stage triage process in operation. A first “quick look” to detect those patients who need to rapidly move to the resuscitation room (or Red Zone as it is referred to) and a second, more comprehensive assessment of those patients who can wait a little longer and be seen in the Green Zone or Yellow Zone.
Although family medicine and primary care services do exist to a greater or lesser extent, it was clear that patients make their own decisions about which health care facility to access and they appear to be voting with their feet in favour of attending the ED rather than other services. The ED staffing levels have to be robust enough, both from a nursing and medical point of view, and the footprint of the ED has to be large enough, to accommodate such a significant number of patients each day but given the robust two-stage triage process in operation and the senior clinical input into the decision making of more junior medical staff, the absolute numbers of patients attending per day is not a barrier to the provision of good quality care.
The charging system for patients attending the Emergency Department is simple – if you are a Malaysian citizen you pay 1 Ringgit per attendance (30 US cents) and if you are not then you pay 50 MYR per attendance (15 USD). Therein lies an issue though – there is an immigration department within the Emergency Department with each patient having to prove their citizenship. At the end of last year our own government made clear its widely reported views about provision of healthcare to overseas visitors. Someone’s immigration status should have no bearing on whether they are able to be provided with emergency healthcare treatment and it remains my view that we must not go down this road in the UK otherwise, as has been seen here on occasions, children (both medical and trauma – including child abuse cases) , sick elderly people, and others who are worried about arrest, as has happened, at the hospital if they try to access healthcare but cannot show that they are in the country legally, with suffer the most and this will drive underground a problem which very much needs to be kept firmly in the open.
The OSCC centre is a fundamental part of the emergency department and works closely with the obstetrics and gynaecology staff as well as the SCAN team to help investigate and manage those patients who present to the ED following alleged crimes against them. It is a sad, but real, state of affairs that one of the first posters seen on entry to the OSCC is the one advising everyone that there is an alternative to ‘baby dumping’ (as it is called here by the staff) which will result in death if the babies are not found quickly enough.
There are an increasing numbers of babies left in waste dumps, bushes, drains and public toilets here in Malaysia. Unmarried mothers or victims of sexual assault who abandon their babies are mostly young and come under pressure arising from social stigma and legal implications, compounded by a sense of hopelessness due to not knowing whom to turn to. The baby hatch hopes to change that by providing an outlet for those women who face such pressure; an outlet designed to save the live of their babies who may otherwise, quite literally, end up on the rubbish dump.
Child Sexual Exploitation
Discussions with hospital and community based professionals as well as staff from charities working in the non-governmental (NGO) sector have shown me that Malaysia faces the same problems at identifying child sexual exploitation cases as we do, but that there are some ways these cases can be more easily identified in patients attending emergency care facilities. Firstly it is important to understand the background risks which may apply to an individual’s situation:
- Living in an institution
- Children going missing
- Parents using their children as prostitutes
- Parents selling children
- Mothers who are in a relationship with someone who is not the father of their child
- Maids from overseas who are often under-age
- Promiscuous teenagers
- Children presenting to the Emergency Department alone or with people who are not their relatives
- False marriage certificates
That list is very female focussed and it is important, along side that, not to forget that boys can be sexually exploited as well as girls.
Secondly it is important to be aware of some of the presenting features which should cause the clinician to think more closely about the presentation and I’ll be coming back to these in my full report.
Finally, there are some questions which, when used appropriately, can be helpful as part of a comprehensive assessment:
- what makes you feel unsafe
- what worries you
- tell me about your family
- who are you worried about in your family
- what makes you sad
- what do you do when you are sad
- who makes you happy
- what makes you happy
- what do you do when you are happy
The purpose of my visit here was to learn from the emergency department and child protection teams and to see how we could apply that learning back in the UK. Turning the (very heavy) resources I’ve been provided with this week as well as my notes and observations into something more structured than this report is something I’ll be doing when I get back to the UK and I aim to have this completed by 31 October 2014.
In exchange for hosting me this week I’ve lectured at HKL, designed and delivered a half day training workshop at HELP University and taken part in a round-table discussion in Ipoh.
It never crossed my mind when I agreed to do this teaching that afterwards I would receive a phone call to say that the Cabinet Minister in charge of the Ministry of Women, Family and Community Development (Kementerian Pembangunan Wanita, Keluarga dan Masyarakat – KPWKM) the Honourable Rohani binti Haji Abd. Karim, Y.B. Dato’ Sri had cleared a 10-15 minute slot in her diary, before giving the closing speech at an event held at a University outside of Kuala Lumpur, to discuss what could be done to improve child protection in Malaysia and I would be going along to meet with her.
The short discussion turned into a 75 minute meeting, and the closing ceremony had to be postponed, as it was clear that everyone present was incredibly keen to find a way to improve the plight of children who are at risk of abuse or who have suffered from abuse, both detected and un-detected. The only down-sides to this meeting were that the ticket I’d bought to go up the Twin Towers, on what was supposed to be my morning off, was not able to be used and I may now need to investigate the excess baggage fees on Malaysia airlines thanks to the extreme generosity of the Honourable Minister in providing me with several gifts, on behalf of the Government Ministry, as a way of welcoming me to Malaysia and saying thank you for the teaching and input I’d given during the week!
I’ve seen some incredibly devoted staff, both in Kuala Lumpur and Ipoh, who are passionate about protecting children and are continually going the extra mile to bypass barriers which appear to be continually obstructing professionals from carrying out a role that is so vitally important – protecting children.
Robust laws covering child abuse already exist in Malaysia but still I have seen and heard, from professionals and families alike, that there continue to be real problems with the child protection system here. Inter-agency communication is not optimal; departments appear to be working within the law but with often completely separate operating procedures; families are sometimes dissuaded from making police reports about crimes, and potential crimes, against children; the processes by which cases are investigated and children are dealt with are inefficient and not coordinated in a number of areas.
It is for these reasons that I propose there needs to be implementation of a two-phase project in a pilot region, with a full evaluation after 12 months of operation, designed to improve inter-agency working and improve the efficiency and standardisation of the investigation of alleged child abuse cases. The first phase should be the creation of an expert panel, with a Malaysian majority and International Input as necessary, to direct the setting up of a Multi-Agency Safeguarding Hub within the region and the second phase should be the design and cascade of a standardised multi-agency training strategy and programme aimed at all professionals working with children and families in health, education, social work, welfare, law enforcement and the judicial system.
But what about the hope that I referred to in the title of this update? The hope I have is that the dedicated staff I’ve come into contact with will not be put off or beaten by the organisation treacle which will have to be waded through until the organisations as well as the individuals are ready for real change, at a grass roots level, which will help protect children better. I’m hopeful, because I have seen the passion in the professionals that I have come into contact with, and I hope that they will continually jump over whatever hurdles are placed in front of them, in a multi-agency way, to improve things for children. And I’m hopeful because I have seen examples of where the system does work and can work again in the future – but these examples are all dependent on individuals so it really is important that if this hope is to become a sustainable reality organisational silos must be joined together so that everyone working to protect children, no matter what their background, their profession or their department, is working to the same procedures, the same rules, the same assessment framework and with the same high levels of empathy, efficiency and enthusiasm that the children and their families deserve.
I leave Malaysia tomorrow feeling that I think I will be back here before too long and when I do return I should be more used to the humidity and propensity for a large amount of water to fall from the sky with a moment’s notice!
With only two destinations left before I treat myself to a final few days holiday, I’m sad to say it won’t be long before my travels come to and end and I have to return to the UK. Next week I’m travelling to Cambodia to see the amazing work being undertaken by Maggie Eno MBE and her team at M’lop Tapang protecting the street children living in and around Sihanoukville. I met Maggie earlier this year when I presented at the Child Exploitation and Online Protection regional workshop so I’m really delighted to be able to meet up again and to spend some time with her and the mobile medical team looking at the work they are doing.
But before that I’m off to devour the Pomelo, currently sitting in my fridge, which was very kindly bought for me by my driver, Siva, today after my own abortive attempt at distinguishing between the sweet and the “I’m sucking on a very bitter lemon” variety!