A Pakistani Dream (including some Goats being sacrificed)

It all started from a tweet. I don’t remember who tweeted it. All I know is that it mentioned a fantastic opportunity. I was facing a rough time in those days. Due to a quirky mixture of fate, my own failings and administrative errors, I was among the three people from my class of medical graduates that didn’t get a job. I spent days marching up and down the corridors of my college and the hospital attached to it, in pursuit of the job. There was little light at the end of that tunnel, and at times, it felt as if there was no tunnel either. I was surrounded by despair. I seriously thought about leaving the profession at one stage. It was only because of my parents and their supportive phone calls from hometown that kept me going. Amidst all that, I saw that tweet.

It was about a fellowship in the United States(by a Think Tank)  being offered to fifteen young Pakistanis with leadership skills. I should confess that I have never been comfortable with the title ‘leader’ ( too much resposibility on my frail shoulders eh). Anyhow, I thought I had the relevant experience to be considered for this fellowship.It was already the last ten days of April and the deadline for submitting the application was on the first of May.  I filled up the form, answered the lengthy essay questions, contacted two people to provide references(one was my Professor of Pathology, the other was one of my editors and mentors). I managed to send it before the deadline. 

I managed to get the job at the hospital after countless pleadings and arm-twisting. Within a fortnight, I had received a call from the Think Tank. There was a Skype interview, which went reasonably well(at least according to my standards). Then there was an in-person interview in Lahore for which the interviewer flew all the way from the US to Pakistan. That went alright as well(I still think I gave some stupid answers ). After a few hiccups in the selection process created by certain people with whom I had been associated in the past, the final call came.

I was sleeping in the living area of my house on a mattress, and woke up at the usual time to get ready for hospital(6:50 am, Pakistan Standard Time). A week before that, there had been a major strike in our state’s hospitals and most of the doctors(including myself) had abstained from working at the hospitals due to attack on one of our hostels and arrest of many of our colleagues. I had spent that whole week glued to twitter and had written three emotional blogs on that topic for Pakistani newspapers(Self-Promotion Alert:My work was even mentioned in Foreign Policy Magazine during that time). While the strike had ended after a week, we were facing a high patient load in our wards. I was supposed to fly to Karachi that evening(for the first time in my life) to attend the inaugural Indo-Pak Social Media Summit.

As has been my routine over the last few years, my first chore after waking up is to stop the alarm and then check my mails and facebook. There was a mail from the Think Tank’s director. My eyes were still hazy when I opened the mail. After going through the first line which mentioned that I had been selected, I couldn’t believe my eyes. I felt as if I was still watching a dream. I read it again. And again. And again. And then I jumped. I jumped up and down the living room. It was a moment of pure joy, something I had waited too long for. I don’t remember what happened during the rest of the day, partly because I was delirious. Until I reached the airport for the Karachi Flight. It was Thursday, 12^th July, 2012.

Three months after that day, I was waiting for my Visa. I had submitted the Visa application and had undergone the interview process. Six people out of fifteen from our group had received their visas within a month. I was among the people who hadn’t gotten it yet. We had a pre-departure briefing a day before the flight. Despite the uncertainty that I might not make it, as my visa was yet to materialize, I decided to drive to Islamabad anyway.At that point in time, six people out of fifteen had yet to receive the Visas. I packed my bags and left Lahore. I was almost a 100 Kilometers away from Lahore that I stopped at a gas station. There was a long queue there so I checked my email during that time. There was an email from our contact at the U.S Embassy. He wrote in the first line: I have good news and bad news. Three out of six have gotten their visas, the other three are still on the waiting list.

My heart sank. I didn’t want it to go all downhill at that point. I had invested too many hopes in this venture. At first, I didn’t want to read those three names. What If my name was not there? What would I do? Go back? No, I thought, I am NOT going back, come what may. After making that mental decision, I glanced at my mobile screen again. The first name wasn’t mine. Nor was the second. Then I read the third name. I HAD MADE IT. I had almost the same feeling that Archimedes had, while discovering the principle now used in fluid dynamics. While Archimedes was in a bath at that time and ran out naked, shouting Eureka! Eureka! I was not in a bath, and not naked. So I just decided to share the happiness around. Called my dad and texted all the friends who had cared enough to keep tabs on my progress.

The drive(of more than 300 Kms) from Lahore went smoothly until I was almost 90 Kilometers from Islamabad. My car engine got very very hot and the thermostat needle was going through the roof. I had fortunately brought a spare bottle of car coolant with me. I tried pouring it at the requsisite place. It didn’t work. I had no chance but to drive somehow to the nearest service station. It was about 20 Kilometers away and I couldn’t drive at a speed more than 20 Km/hour on the best built motorway in Pakistan. Somehow, I managed to reach the place. It took the mechanic almost four hours to fix the problem. Thankfully, I was in Islamabad by mid-night.

Our flight was scheduled to leave at 4 a.m. on 27^th October, 2012. It was Eid-ul-Azha in Pakistan on that day. It was the first time in my life that I was not going to be home for an Eid. During the 17 hour journey, I kept remembering everything we usually did on Eid Days.

A typical eid day at my house starts very early, by the call for Morning Prayers. I usually sleep late on the nights before eid, so it is always hard waking up so early. The grumpy, sleepy me then take a bath and get ready for Eid Prayers. Eid Prayers have different timings, with our sect(the Wahabbis, similar to the Saudi version of Islam) leading this race. I have had to participate in prayers as early as 6.15 am.!! Other sects have prayers a little later(many people just wake up and drive around to find which time suits them the best and join that congregation). Traditionally, eid prayers are supposed to be held in big grounds, so that more people can participate.  During the drive to the place, the roads are clean(probably the only time in the year, courtesy the municipal corporation) and slaked lime is scattered along the roads, giving the whole occasion a festive look. People dressed in traditional shalwar kamees dresses move towards the Prayer place.

After the prayers, there is a small sermon(although it depends on the Mullah, who tries his best to prolong it) followed by a prayer for proseprity in the coming year. Afterwards, evevryone hugs their relatives/friends(this goes on throughout the day).Due to some quirky reason that I have yet to find, people hug each other three times, in a robot-like sequence(I refuse to do this and almost wrestled a few cousins in the last two years by putting a kibosh after one hug). On Eid-ul-azha, people are in a hurry as soon as the prayer finishes. This is because they want to find butchers to sacrifice the goats/cows. Because of a disparity between the number of customers and service-providers, a lot of makeshift butchers also throw their hats in the rings. People who can’t find a butcher in time resort to trusting the temporary butchers(a diverse category actually, some are clerks, some are policemen, some from other professions).

After the sacrifice, the meat has to be divided into three equal parts. One part is supposed to go to people who can’t afford to buy meat, one part for relatives and the last part is for the consumption of the family that made the sacrifice. I personally do not witness the act of slaughter(despite watching enough blood and gore in the hospital) but many parents ask their kids to watch, a practice that I find disgusting. Following the sacrifice, people make packets of meat in shopping bags, for the purpose of distribution. People who sacrifice every year find a horde of beggars outside their homes, begging for the meat packets.

While men are busy in all this fuss, the real enjoyment on Eid is reserved for the ladies. They get to wear new and sometimes fancy dresses, apply henna on their hands, wear bangles, and visit relatives.
Following eid, most streets of Pakistan resemble sets of Zombie apocalypse movies, with intestines and offal of slaughtered animals littering the streets. Happens every year. Is not a pretty sight to watch.

Being the Grinch that I am, I do not always enjoy Eid. I feel that its terribly boring. I spend a good part of the day sleeping or on the Laptop. During med school years, I was usually worried on Eids because of approaching exams. But even after graduation, my enthusiasm didn’t increase. In fact, I was on duty last year on the third day of Eid-ul-Fitr(which follows the month of Ramazan).

My cousins who live abroad, tell me that they can’t feel the ‘spirit of Eid’ when they are in other countries. I wonder if I would miss this as much If I leave?    

Doctors on Strike

(My first Article published in The News on 31st January, 2013)

A cat and mouse game is raging on between Young Doctors and Government of Punjab. There is a set pattern being followed by both sides, based on earlier skirmishes in the last two years. The primer is usually an untoward incident involving young doctors. As a consequence,there is outrage from young doctors while the government announces some form of committee to sort out the problem. Nothing discernible happens for next few weeks/months. Doctors come out on the streets and OPD(Out Patient Departments) are closed. A few individuals are dismissed from service by the Government and a few people are arrested. As a last resort, doctors announce withdrawal of emergency services, crippling the already overloaded public health system. Within a few days, some makeshift solution is cobbled up and things go back to normal. This routine is being followed for last 2 years and if things remain as they are, can be repeated this time as well.

Young Doctors have been branded assassins and mercenaries, devoid of all humanity,  sacrificing all moral values to bargain for their demands. Hundreds of doctors have been terminated  over the last two years, and dozens have been jailed. A vicious propaganda campaign was designed last year, costing the public exchequer more than 400 Million Rupees  to malign doctors. There is little understanding of the issue plaguing doctors in this country and they are seen with derision and contempt because they have the temerity to demand their rights. The most prevalent misunderstanding about the doctors’ protests is the belief that they are demanding a pay raise. While this was true two years ago, the issue of pays was resolved. Let me clarify that it is not mentioned anywhere in the Hippocratic or any other medical oath that doctors ‘have’ to provide medical care regardless of the conditions. Regarding the morality of strikes, Awais Aftab, a fellow doctor, explained,

“A doctor enters into a contract with the society only by virtue of his contract with the Government, therefore, if the Government refuses to honor its obligation of providing adequate facilities and working conditions for the doctors, then the doctors’ obligation to work for the Government becomes questionable. This includes the issue of pay and service structure. If the amount of work and the circumstances in which they are expected to perform deviate significantly from the pay and facilities they are receiving, Government is violating its obligations. This can be augmented by a utilitarian justification. If the short-term harm brought about by the strike is balanced by a long-term benefit to the society in the form of an improvement in health-care, virtue of the fact that doctors can work more efficiently in better working conditions, then a strike is justified. But this utilitarian argument can only be an augmentation, not the crux, because we all know that human lives cannot be added and subtracted.”


The Prime demand of doctors is provision of a better service structure. The current structure is dependent totally on the whims of Baabus at Civil Secretariat who consider doctors as inferior and despicable species. There is no uniform system of promotion. I have documented cases of different doctors who graduated in the same year, from the same college, and having similar qualifications, where one of the two was promoted as a Professor and the other is still in grade 18. Hundreds of “relics of the past” are occupying positions in Major cities while young doctors are transferred to far flung areas. Professors of respective wards are kept busy in administrative affairs, affecting teaching schedules and regimes. Induction of doctors on Medical Officer posts is done via Federal Public Service Commission(FPSC). There were no inductions on regular seats for more than 15 years in the last two decades, contract employment was favored instead. Young Doctors in most major hospitals live in dilapidated hostels, single rooms shared by upto three people. More people do house jobs without any pay than those who get pay. These issue are important when you are doing more than 60 hours work per week without any reward.   

In November 2012, an agreement was reached between Young Doctors and Government of Punjab that the new service structure would be implemented. Two months after that understanding  there was no sign of implementation. The dispute over non-renewal of contracts and housing allowance was simmering in District Head Quarters(DHQ) Hosiptal Gujrawnala as a direct consequence of the non-implementation of doctors’ demands. A team of interlocutors from Lahore was there on 2^nd January 2013 when the whole scene got ugly, resulting in physical violence by doctors and by hospital administration. It was broadcast on live television across the nation with some spiced up subtitles. As a result, more than a dozen doctors were arrested and are still in Jail. OPDs(Out Patient Departments) are closed throughout the province in protest and a major ‘Dharna’ has been planned for 7^th February 2013.

Personally, I do not endorse the physical violence unleashed by young doctors in Gujranwala and want an impartial inquiry into the matter. Apart from that, I stand by the doctors’ community in the struggle for the proposed(and agreed-upon) service structure. Government of Punjab has tried all sorts of delaying tactics including court delays, invitation to 200 Army doctors, induction of substandard doctors during the strikes and police torture. As a doctor and as a human being, I hope the issue is resolved completely this time, or both sides are going to lose.
 

Public Health Care in Pakistan: A basket case

(Originally Published in two parts in The News as "Our Sickly Health Care" on February 7 and February 8 2013)






"The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being" according to the constitution of World Health Organization.
The constitution of Pakistan guarantees basic rights and liberties to all citizens of the state. These rights derive from fundamental principles of justice in accordance with which the State of Pakistan assumes the sole monopoly of power over its citizens. To provide health facilities to the citizenzs, there is a Universal Health Care system in Pakistan. This means that any citizen of Pakistan can get treatment at public sector health care facilities in the country. Pakistan has a wide network of healthcare infrastructure, including 919 hospitals, 5334 Basic Health Units (BHUs) and Sub-Health Centres, 560 Rural Health Centres (RHCs), 4712 Dispensaries, 905 Maternal and Child Health (MCH) Centres and 288 Tuberculosis Centres. This system is supposed to cater to a population of around 190 million people.

Thus, one doctor at a public hospital is supposed to cater to about 1724 people, while 1504 people have to vie for a single bed at a public hospital. In a physician per 1000 people statistic, Pakistan ranks 120^th among 200 countries, with only India, Iran and Egypt among developing nations below us.

Pakistan is among the only three countries left in the world with Polio Virus infection, the other two being Afghanistan and Nigeria. Recent reports indicate that Karachi, Peshawar and Hyderabad,Lahore and Rawalpindi have turned ‘polio-endemic’ due to continuous detection of the wild poliovirus virus type-1 in the sewage samples collected from there. There are more than a million people in Pakistan have Chronic Liver Disease while 10% of the population has had exposure to Hepatitis B and C viruses. As many as 1.2 million people die of waterborne diseases in Pakistan every year, of them 250,000 are children under the age of five years. In a recent meeting organized by a public health research and consultancy firm, 54% of the most serious crises and shocks Pakistan has suffered in the last three years have been health-related as compared to only 3% that have been law and order related.


We have had brushes with Widespread Dengue Virus Infection, the PIC(Punjab Institute of Cardiology)-Syndrome outbreak, Naegleria Infection in Karachi and the very recent Cough Syrup-controversy. To quote a report by Pakistan Institute of Development Economics,
“Pakistan’s health care system is inadequate, inefficient, and expensive; and comprises an under-funded and inefficient public sector along with a mixed, expensive and unregulated private sector. These poor conditions in the health sector may be attributed to a number of factors like poverty, malnutrition, unequal access to health facilities, inadequate allocation for health, and high population growth and infant mortality.”

There is acute shortage of data for health indicators in Pakistan. Health, is not a priroity of either the Government, or the people, until an emergency strikes. Every new government has brought in new health policies but implementation of these policies has not been undertaken over time. Take the case of Punjab. It is the most populated province of Punjab. There has been no Health Minister for the last 5 years and the Chief Minister has kept the portfolio with himself. The current government has opened medical colleges in almost all major cities of Punjab over the last 4 years. The lack of planning is apparent in this case as no new teaching hospital has been established and retaliatory shelving of plans by the previous government has affected the system. Without proper teaching hospitals, medical students graduating from newer colleges will have to move to other cities for getting better exposure to clinical training. The last teaching hospital established in Punjab was Jinnah Hospital, in Lahore, in the mid-90s.  Regarding retaliatory politics, the half-complete building of Wazirabad Institute of Cardiology is a living testament.


Started on the orders of the previous Chief Minister, this project aimed at catering to cardiac patients between Lahore and Rawalpindi and adjoining areas. At present, if a person needs cardiac care in Gujranwala/Gujrat/Jhelum area, he/she needs to visit either Lahore or Rawalpidni due to lack of any facilities nearby. Time, though is a crucial matters in cases of Heart disease and an early detection can significantly improve chances of Improvement. Patients are brought from all over northern part of Punjab to Lahore because of Lahore-centric health spending. There are 17 medical colleges in Lahore, compared to 17 in the rest of the province. For about 600 burn patients annually, there are a grand total of THREE specialized burn centers in Punjab. Similarly, only 155 mechanical ventilators are available in Lahore’s public hospitals for a patient load of more than 5 hundred thousand patients every month. 

Tubeculosis, Hepatitis, Cholera, Malnutrition,Polio and recently, Measles, are some of the major problems being faced by the Public health providers. With the advent of Breaking News culture, any issue deemed imprtant by the media becomes important, public health almost never makes the cut, unless there is significant panic, as in cases of Dengue, PIC-syndrome and Cough Syrup-controversy. High mortality rates don’t bring high ratings, thus no need to focus on the isssue, let the children die. Newborns only matter when bitten by mice etc, that sells. The dismal condition of public health infrastructure has given rise to a popular phenomenon in Pakistan; People taking up things in their own hands. We required a public ambulance service, Cue Edhi and Cheepa. We needed good schools and Universities; Enter Private Schools and Universities. Similarly, to fill the huge void of public health, private entities and charity based organization stepped in. Currently, almost 80% of health sector in Pakistan is based in Private sector.

For a self-respecting middle class Pakistani, visiting a public sector hospital is nothing less than a nightmare. Due to over-burden of patient load, resources dry up fast. Data collected by the author for one particular ward at a teaching hospital in Lahore revealed that in a duration of 24 hours, around 700 patients visited the medical emergency of the hospital. There were only 45 beds available in that particular ward. At the end of 24 hours, 60 patients had been admitted, resulting in patients having to share beds in majority of cases. There is acute shortage of beds in teaching hospitals and there are no plans on the horizon till now that anything is going to be done in this regard. According to figures from last budget, Punjab Government has allocated a spending of Rs 120 for every citizen of Punjab. That is not sufficient even if you want 2 surgical sutures.!!



There is an overall sense of pessimism in the Public Hospitals, which ultimately leads to the exodus of doctors to greener pastures. This is just the tip of the iceburg. All doctors are not god-fearing, messianic figures either. A lot of senior doctors practice twice a day; spending morning in government hospitals and evenings at private clinics. Then there is the issue of equipments and their effective running. Two months ago, the X-ray machine at the largest hospital of the Province was out of order, and remained like that for at least two weeks. No heads rolled. No reporting in the media. Situation is even worse in other provinces. There are hardly any specialized centers in Balochistan or even Khyber Pakhtunkhwa(excluding Peshawar) or Gilgit Baltistan. 

It is the first law of Health Economics that 
“ Increased Spending on health leads to increase in per capita GDP”. Currently less than 2% budget is allocated for Health Sector and even with this pittance, the behemoth of public health care system is functioning admist crises. The first and foremost solution to the numerous problems is presence of political will to spend more money on healthcare. Until that will is mustered, there is scant chance of improvement in the system.

Furthermore, there are significant Problems concerning public health both at the policy and implementation level, especially after the devolution of Health Ministry to Provinces. Spending has to be increased, population explosion has to be halted, Long term policies have to adopted to increase the outreach of public sector healthcare, private sector needs to be regulated, more Teaching hospitals and specialized centres need to be established in areas like FATA, Balochistan, Southern Punjab and Gilgit Baltistan.Our State has failed in providing the citizens good health care and it  is affecting the whole economy. Media and civil society have an increased role to play in this regard, because of negligent behaviour of the state. One of the tenets of the doctors’ movement has been increased spending on public hospitals and decrease in VIP protocol patients. Very recently, category for “poor” patients was shelved by the administration at Punjab Institute of Cardiology and no one has taken any notice of that.

It should not be forgotten that a state that absolves itself of its responsibilities, is paving way for its own downfall. Spending public money on flyovers, foreign visits and security guards is not going to solve the problems of health and education in this country.

Of Protocols and Parchi System

Published on 04 January, 2012 in The Friday Times

"Kindly admit our patient, Doctor Sahab. We have talked to the Medical Superintendant and your Head of Department. They have sent us here."


I was sitting in the ward, making discharge slips for patients when someone got my attention by uttering these words. I checked the papers and found that the man was right. He had been sent to our hospital by a top office-bearer of the ruling political party in the province. I was reluctant to oblige such commands as I don't personally think political workers are any more deserving of a doctor's attention than the downtrodden people who fill government hospitals. By sheer luck, there was no vacant bed available in the ward. I explained the situation politely to the man and the hospital employee sent by the "Protocol Office" (designated to oblige influential people, their relatives and lackeys). They tried to reason with me by pointing out that the M.S. had talked to our professor twice and he had written on a slip that these people should be accommodated. I asked my immediate superior about this, and he was also of the view that we have no spare beds and can't accommodate someone just because they have better connections. He talked to my interlocutor himself and in the end the party left without the bed. This was one of those rare times when we resisted the protocol patients, as we have come to call them. Most of the time, however, anyone designated as a protocol case gets preference over ordinary patients.
At the public hospital where I work, there are special VIP and VVIP wards specified for senior bureaucrats, political figures, judges and their families. In spite of that, countless patients are referred by political figures to the hospital with small slips on their letter pads. This is true for almost every public hospital in Pakistan. As we are based in Lahore, we get most of our "slips" from party affiliates or government officials employed by the ruling party of Punjab. In other provinces, only the names change and the "slip system" remains the same. Underlying this whole culture is the belief that unless you are influential enough, you won't get good treatment from public service providers, be they doctors or engineers or policemen. This understanding breeds a more-than-bearable nepotism for any society.

The worst abusers of public service systems are public servants themselves. Senior bureaucrats consider government property as their personal fiefdom. To ensure that every whim of the politicians and bureaucrats is fulfilled, most appointments on the post of Medical Superintendents are politically motivated. Subservience and acquiescence are the requisite qualities desired by the higher-ups for the highest posts in public hospital administration. 

Doctors themselves are no less culpable. It is usually said that doctors make the worse patients. I would like to add to this axiom that they not only are the worst patients, they usually are the worst attendants as well. I distinctly remember one time when a classmate of mine at medical school brought her grandmother over to our ward for admission. We provided her with the best care that we could. After two days, she passed away. Since then my classmate has not talked to me, as if it was my fault. She herself is a doctor. 



I have worked in the Intensive Care Unit (ICU) and a lot of times we've had undeserving patients brought in by other doctors. The ICU is supposed to be for patients whose lives can be saved by intensive care and who are on the brink of death. This is true unless you happen to know a doctor; then rules and regulations can be thrown out of the window. The tragedy of public hospitals in Pakistan is that unless you know someone working there, you are not awarded any extra care. As a doctor, I always try to provide equal care to my patients, irrespective of their status. I am not alone in behaving like this. We feel ashamed when resources are diverted for the sake of "sifarshis". We are sick of tending to the favored ones. We believe that our healthcare system is already neglected and needs no further roadblocks than the ones it already confronts. My request and plea to the people at the top: kindly stop pulling your rank to make us care for your cronies. Thank You.

Brain Drain(Part 2)

(Published in The Friday Times on 12th October, 2012)

Dr. Adnan was the best graduate of his MBBS session three years ago. He had achieved the highest marks in almost all the annual exams during his five years of medical school. He completed his house job of one year and spent almost 6 months in preparing for the entrance exam to a Residency program in the United States (the USMLE or United States Medical Licensing Exam). He cleared the first two stages (it's a three-stage exam) with ease and applied for a visa, so that he could visit the United States and take the third and final exam of USMLE. But he was denied a visa for the United States. He has spent almost 300,000 rupees in fees for the tests, and it has taken him a year for him to reach this stage. But his efforts have been in vain.

126,931. That is the number of Registered Medical Practitioners (people who have obtained MBBS degrees and have completed a house job of one year) in Pakistan, according to the Pakistan Medical and Dental Council. Every year, some 8,000 fresh medical graduates join this list. A vast majority of Pakistan's medical graduates want to move to either the United States, the United Kingdom, Australia, the Middle East or other green pastures in the world beyond Pakistan. According to a report aired on Geo News on 8th August 2012, Pakistan has become the largest exporter of young doctors to Britain's state-funded National Health Service (NHS). The number of Pakistanis registered on the GMC (General Medical Council) data stood at 8,552 on 7th of August, 2012. Similarly, according to a research paper titled 'Pakistani Physicians and the Repatriation Equation', published in the New England Journal of Medicine, Pakistan has contributed approximately 10,000 international medical graduates (IMGs) to the United States. In a research conducted in 2007 titled 'Reasons for migration among medical students from Karachi', it was revealed that Over 95% of Aga Khan University (AKU) and over 65% of Baqai University (BU) final-year medical students intend to go abroad for their postgraduate training.

And all this while Pakistan is facing an acute shortage of trained doctors, according to reports by the World Health Organization (WHO).Pakistan cannot meet its needs for healthcare, given the current levels of production and dependency on physicians in the organization of the system. Although out-migration contributes to the problem, it is the growing demand for healthcare from increases in population and adverse conditions that generates ill-health. The most important question to ask about this mass migration is: Why are all these people leaving their country?

The answer is manifold and, speaking as a health professional myself, painful to state.

The survey done on medical students of Karachi's elite Aga Khan University and Baqai Medical University revealed that the two most important factors behind this intent as pointed out by the students are poor salary structure and poor quality of training in Pakistan. I can vouch from my personal experience that as soon as a medical student enters the medical school, the next big question regarding his/her life is the "plan" or path he/she intends to take after graduation. Even during the one-year training of the house job - something I am currently pursuing - the queries about the "future" are among the most frequently asked questions by one's seniors and family members.

It is an absolute travesty that in Pakistan the practice of "Career Counseling" for medical professionals is practically nonexistent. Most middle-class parents only have three or four career options for their kids: Doctor, Engineer, Banker/Accountant and if all else fails, Army. In a similar fashion, when a medical student enters medical school, it is from his/her seniors that guidance about any future plans is acquired. Traditionally, there are four ways to pursue post-graduation for Pakistani students. The first one is the FCPS (Fellow of College of Physicians and Surgeons, Pakistan) route, which involves four years of clinical training at a tertiary care hospital in Pakistan. After completing four years of training and passing the FCPS exams, you are considered a specialist in whichever field you chose to pursue. The second and most attractive option is that of obtaining a residency in the United States, where the training standards are the highest in the world. For that route, a candidate has to go through the three stages of the USMLE exam (the examination fee for each step is more than 1.5 lakh rupees), the third of which can only be done in the United States.

After the residency and an exam, the candidate becomes "Diplomat American Board" for the chosen specialty. It should be noted that the ratio of people who get their desired residency after passing the exams is around 50-60%, which means that despite getting excellent marks, you are not guaranteed to get your favored specialty (for example Anesthesia or Neurosurgery) in 50 to 60% cases. The time required to complete this whole process ranges between 3 to 5 years.

The third option is that of pursuing post-graduation in the UK. To follow that route, one first has to pass the PLAB (Professional and Linguistic Assessments Board) exam, which is a two-stage test. The examination fee for each stage is also more than one lakh rupees. After completion of PLAB, post-graduation courses are taken, based on available spots in the preferred specialty. The whole process of completing this route takes around 5-7 years. An alternate route to acquiring British certification is the MRCP/MRCS (Member of Royal College of Medicine/Surgery) route, which is a two-stage route, but the training can be obtained in Pakistan while exams have to be taken in the UK.

The fourth and latest addition to the options is that of post-graduation in Australia. For that, a candidate has to pass the entrance exam of the AMC (Australian Medical Council), which also has two separate tests. The examination fee for each step is in the range of the fee for USMLE. There is no guarantee of getting a post-graduate education in Australia even after getting excellent marks in the first entrance exam.

Most medical students in Pakistan don't know which path they will take, even whether they will be able to work in their desired field or if they will get a job where the salary is adequate after about ten years of medical training. And this, I am sorry to say, is the primary dilemma of the medical community, the so-called "cream" of the Pakistani nation.

Doctors Strike: The Aftermath

Doctors’ Strike: The Aftermath



It has been two months since one of the largest strike by doctors shook the province of Punjab. It all started with the closure of Outdoor Patient Departments (OPDs) in all major hospitals across the province as a gesture to protest against the attitude of the Government of Punjab in provision of a better service structure for Doctors. It was a move designed to be of minimal impact because only ‘stable’ patients visit OPDs and there was no threat to patients’ lives. Last year similar protests by doctors led to a commitment by the Chief Minister to provide a new service structure and committees were formed to pave the way for formulating an acceptable formula. The closure of OPDs happened after one year of useless meetings with the representatives of Punjab government.

Last year, government was unable to control doctors and the chaos led to loss of many precious lives and ended with a truce. This time around, Khwaja Salman Rafiq (brother of Saad Rafiq and Special Assistant to Chief Minister on matters of Health) was designated the responsibility to ‘deal’ with the situation. Punjab Government started giving half-page advertisements in all major newspapers stating it had already done too much for the doctors and that doctors were essentially getting too big for their own boots. An estimated Rs. 1.6 million per day was given to newspapers and Rs. 450 million of public money was spent on advertising by ‘Khadim e Aala’s government. In addition, Essential Services Act was enforced by the govt, making it mandatory for doctors to do their OPD duties or else receive legal proceedings.

On 1^st July, 2012(after 21 days of OPD closure), a police raid was conducted at Doctors’ Hostel, Services hospital Lahore, resulting in arrest of numerous doctors. The same night, hundreds of other doctors were arrested from their homes. There was another raid at Doctors’ Hostel, King Edward Medical College on the night of 2^nd July. A total of 360 doctors were kept in Jails including Kot Lakhpat, Attock and Mianwali for four days. As a result of all this, emergency services were withdrawn from all major hospitals and any negotiations were made subject to release of all the doctors.

I want to recount some of the ‘stunts’ pulled out by the government during all this, apart from ‘Advertisement’ money from the public exchequer.  

1. ‘Medical Martial Law’:

As a ‘contingency’ plan during the closure of OPDs, Punjab government requested help of Army Medical Corps (AMC) to decrease patient overload. This was an unprecedented act of desperateness and expediency shown by the big-wigs of Punjab Government. This ‘experiment’ did not work out though. It failed miserably. Senior Doctors said it on record that the Army doctors were not trained to deal with such situations. Additionally, those doctors were paid Rs 2000 per hour of duty and special police contingents were employed outside hospitals where the Army doctors worked. For comparison, government of Punjab was paying Rs 800 per day to junior doctors and Rs 1400 per day to seniors whose places the Army doctors took for few days.
There were reports of those Army doctors misbehaving with the senior doctors and the ‘flexible’ duty hours practiced by our 'Jarri Jawans'. At the start of the Strike, Zaid Hamid's Baloongra's alleged that YDA punjab is actually “NGO funded Young Animal Association” and they work for money, not for saving lives. The 'Brave' Army Doctors that came 'to the rescue' didn't work for free though. This is the characteristic selective Amnesia practiced by Qibla Zaid Hamid and his followers.  For the Record, only 200 Army Doctors were deployed.!!!

2. The PCO Doctors

During the strike by Junior Doctors, Government hired around 500 new doctors (in place of around 5000 doctors) on ad-hoc basis. Those individuals are known these days as ‘PCO doctors’. They mostly include foreign graduates (who can’t normally get jobs at Government Hospitals as per orders of Chief Minister) and people who could not get job in ordinary circumstances. Some people, who had not practiced medicine for more than 10 years, joined the service just to get a paid Job. Chief Minister Punjab is fond of parroting the mantra of ‘Merit’ but these blatantly out-of-merit inductions did not gain his attention. All these people were hired against the rules and on ‘paid seats’ while more than 50% doctors work in government sector without getting any pay.

3. The legal Front

Apart from hundreds of doctors arrested without any justification, four doctors from Mayo Hospital were charged with Murder of a child that died in the Pediatrics Ward on the night of 1^st July, 2012. The Strike was also challenged in court and it resulted in involvement of Lahore High Court in the matter. The court ordered to release all doctors who were arrested without any legal reason and granted bail to the four doctors alleged to be involved in the Murder. It was further ordered that matters pertaining to Service Structure should be solved amicably by the Punjab Government.

4. Lies and Damn Lies
Throughout the strikes, there was a continuous propaganda mongering done against the ‘Cream of Nation’. Government Officials lied on Television programs and press-conferences about doctors being greedy, selfish, hooligans etc. The entire Advertisements campaign consisted of Jacked up figures that were used to fool people.

The Aftermath

On 2^nd August, one month after the strike, a follow-up meeting was called up by Young Doctors Association in Services Hospital Lahore. Dr. Amir Bandesha, member of the committee delibrating the future service structure, explained at length about the proposed changes to the existing structure and the points on which a consensus had been reached between Punjab Govt and YDAP. ‘PCO Doctors’ are still working in the hospitals despite resumption of services by young doctors and it is the demand of YDAP to transfer them to DHQs and RHCs.  After the meeting of general council of Young Doctors Association on 29^th August, 2012, province-wide protests were held on 5^th of September to exert further pressure on the Govt to solve our problems. Committees have failed to provide us any relief and even the Lahore High Court has been unable to enforce the writ of law. Another Protest/Dharna is planned for 19^th September and a March to the CM Punjab House after that. Is another showdown between doctors and State on the way?

Brain Drain-1

(Published in The Friday Times on 14-09-2012)

33,703 candidates appeared in the entry test for medical colleges in Punjab last year, competing for 5,271 seats in 40 public and private medical and dental colleges. Nearly 3,500 seats are available in 15 medical and 3 dental colleges in the public sector, while 1,850 seats are available in private medical and dental colleges. This suggests that the top 3,000 candidates would be able to secure admission in the public sector and around 2,000 more will get admission in Private Medical Institutes.

These figures raise the question: What about the rest of the 28,000 students who passed FSc (Pre-Medical) with more than 60% marks but were deemed not good enough to get admission into a medical college, either due to merit or financial issues, as Private Medical Colleges charge almost half a million rupees every year only in tuition fee? 

As the saying goes: where there is a will, there is a way. And that's another way of saying that students who want to become doctors should make use of opportunities to study medicine abroad.

Medical education in developed countries such as USA,UK, Australia and Canada is much more expensive than in Pakistan, so the options for most Pakistani students are either China or the ex-Soviet states such as Kazakhstan or Kyrgyzstan. Medical Education in these countries is imparted in English, so there's no worry about language barriers. Browse through any English or Urdu daily in Pakistan and you'll see advertisements for institutes in these countries. 

This trend of going abroad to get a degree in medicine started in the 1990s when Central Asian colleges became a destination for students who lacked good marks. It should be pointed out that the minimum eligibility criteria for the Medical Colleges Admission Test (MCAT) is 60% marks in FSc. Initially, students with marks as low as 35-40% were able to secure admissions in Central Asian colleges. It was a dream come true, a shortcut bypassing the system in Pakistan. Chinese medical institutes offering medical courses in English started in the last decade.

At present, around 2,000 Pakistanis are studying medicine in various medical schools across Kyrgyzstan. According to the United Nations, a July 2006 survey of medical students at nine institutions in Kyrgyzstan rated their level of knowledge between 2 and 2.6 on a five-point scale. In China, there are 6  medical colleges and 1 dental college recognized by the Pakistan Medical and Dental Council (PMDC). Each of these medical schools has around 150-200 Pakistani students per session. Nine hundred Pakistani medical students are presently studying medicine in Cuba on scholarships awarded by the Cuban government after the 2005 earthquake. But PMDC does not recognize Cuba's medical colleges and the living conditions of our students there are pathetic. Around 100 Pakistani students are studying medicine in Bangladesh. Vulnerable students are duped into some of these places with fancy titles like 'WHO Recognized Medical Institute'. The fact remains that WHO (World Health Organization) "has no authority to grant any form of recognition or accreditation to schools of medicine or other training institutions. Such a procedure remains the exclusive prerogative of the national government concerned." (This is WHO's own clarification.) The Pakistani state has done little to stall this "business". Pakistan's embassies in the respective countries do not own the students if they face any difficulties regarding the whole process. In Cuba, students live 15 Kilometres away from the city in which their college is located. In China, many universities which are not officially recognized enroll students using paid agents in Pakistan. Every admission gets the agent a fixed amount of money and the unsuspecting student can't get out of this maze easily. The big problem facing Pakistan's health system is the influx of these Foreign Educated Doctors and their integration into the system. These medical graduates are not at par with their counterparts from Pakistan-based institutes and that creates a chasm in their ability levels. In almost all the foreign universities, clinical training, the backbone of undergraduate programs, is seriously lacking because of obvious language constraints. You can teach students in English but you can't teach them all the required nuances of the local language in such a short period of time. Without the necessary knowledge of the local language, how can anyone get a good medical history from a patient? (Around 70% of clinical diagnoses are based on a patient's medical history.)  PMDC has made it compulsory for all international medical graduates to pass a specially designed test to practice medicine in Pakistan. This is the only intervention done on a governmental level for these doctors. A lot of those who can't pass the test end up working for private hospitals, as they can't get jobs in the public sector. This alternate pathway for medical education is going to flood Pakistan with a lot of substandard doctors very soon.

Diary of a young doctor(part 6)

(Published in The Friday Times on 17th August, 2012)

Medical Science, like other disciplines of science, is a constantly evolving subject. New discoveries are being made, new ways to treat and look at diseases are being researched and newer drugs are being introduced on a daily basis. But the medical profession in Pakistan is lagging far behind the rest of the word in innovation and research. Very little, if any, research is being done by public sector hospitals and medical colleges. Apart from the Aga Khan University and Shaukat Khanam Hospital, there are no recognizable research centers in the country. Due to this issue, most of the books we consult during MBBS are written by Western or Indian authors.
It may come as a surprise to the reader that doctors in Pakistan are required to do research as part of their curriculum, both at the undergraduate and post-graduate levels. The ground realities, though, are very different. Very few of the "researches" done by Pakistani authors are published in international publications. On the undergraduate level, the research is mostly very basic and does not require much critical thinking, nor is it up to an international standard. The Community Medicine departments (responsible for overseeing research) ask students to choose from a particular list of topics on which research can be done. No funding is provided for the purposes of research. Students usually take shortcuts just to fulfill the academic requirement, and the matter is over after the final exams.
On the post-graduate level, where research is an important tool in the rest of the world, Pakistani doctors do not spend enough time on research topics. Most of the topics are re-hashed versions of the same old 'traditional' things. A grand sum of Rs 2,200 can get you a good synopsis on your chosen topic. Plagiarism is not thoroughly checked, so liberties can be taken in that regard. I questioned some of the senior doctors about this trend and they pointed out a few factors responsible for this problem.

The foremost issue is financial. Most post-graduates do not have job security and often have to work at multiple hospitals. In addition, they do not get any kind of funding for the sake of research. In such conditions, all they do is look for shortcuts to fulfill the academic requirement. In Shaukat Khanam Hospital, doctors are paid handsome salaries and have job security, resulting in some serious research work being done there. The proposed Service Structure that was the demand of doctors during their recent strikes is a much-needed step as it would at least provide job security, if not lavish pays.

The second most important reason for lack of research is the absence of critical thinking from our curricula. Research is borne out of questions about persisting problems and requires finding solutions to problems. We, on the other hand, learn and see throughout our academic life that 'he/she who crams the most, achieves the maximum marks'. From nursery school all the way to the final year of MBBS, we learn how to rote-learn particular texts and then regurgitate them in our exams. Questions are discouraged at almost every level and many teachers think it a disgrace if they do not know the answer to a student's question. In addition, there are almost no research societies working in medical colleges. The only one that I encountered was a small society working out of Punjab Medical College, Faisalabad.

The third factor in this regard is the lack of teachers and instructors who can guide students about research. This problem is present both in medical schools and in the College of Physicians and Surgeons, the premier body that awards specialization degrees in Pakistan. In many cases, the supervisors for research are not well-versed in the art of evaluating a research paper as it is very different from an examination paper.

Despite all these problems and glitches, there are still some success stories. Pakistani doctors, particularly surgeons, have developed many indigenous solutions to the problems they have faced over the years. The need of the hour is to promote critical thinking and research among the medical community so that Pakistani doctors can compete on an even keel with their international colleagues.

Diary of a Young Doctor(part 5)

(published in The Friday Times on 27th July, 2012)


"I am really thankful to you doctor sahiba, you saved my daughters' life today," said the mother of a young woman to one of my female colleagues.

The very next day, another attendant had this to say,

"You doctors are murderers. You don't know how it feels when your loved ones die. You have killed our young brother. We will never forgive you."
Both of the above-mentioned statements reflect a common misconception in our society, that doctors are supposed to be messiahs who save lives. I may have to face the wrath of some of my fellow professionals for saying it out loud, but this can't be farther from the truth. During the five years of medical school, followed by countless years of medical training, all we learn are a set number of protocols to follow. There is no subject or even a chapter dedicated in any of our books on 'How to Save a Life' (excuse me for the reference to a song with the same name by the band The Fray). The main problem with this assumption is the immense responsibility it places on the shoulders of the attending physician/surgeon. Doctors, in general, safeguard the best interests of their patients but having the mantle of 'saviour' placed on their shoulders is more than a little unfair.
As a result of the 'messiah' label, doctors become the automatic fall guys when a tragedy occurs. Doctors are obliged to do their best, regardless of the expected results, and when their efforts fail, the first impulse of the attendants is to blame the doctor for the demise of their loved one. I am not saying that medical science is guesswork; but why is the medical profession considered a "calling from God"? It is high time we learned to differentiate between a profession and a calling from God. Doctors are "working" in hospitals. They aren't on a divine mission to save everyone who comes their way. They provide a service and in return expect to get paid for it. (And we know how that's gone done in our country.)
When doctors announced a strike to demand for a better service structure, the widespread reaction was that doctors should be philanthropists who put others before themselves and don't ask for a compensation package in return for the time they have invested.
To quote the columnist Ayaz Amir: "The young doctors' strike was not about doctors versus ailing and suffering humanity. In the Islamic Republic suffering humanity is a handy cliche, readily invoked to score a political point and as readily consigned to the upper layers of forgotten memory when the need passes. If anything, this strike was doctors versus a hidebound bureaucracy, one of the most ossified bureaucracies in the lands which can claim descent from the British Raj."

During the strike by doctors, one of the major objections was that doctors were supposed to provide health services in any condition, as they have taken an oath to do so. Let me make it absolutely clear that in the original Hippocratic Oath that was formulated around the year 425 BC, there is no provision that makes it mandatory for a doctor to provide health services to anyone who wants them. In the revised Hippocratic Oath, constituted by the British Medical Association, one of the points declares: "I will do my best to help anyone in medical need, in emergencies. I will make every effort to ensure the rights of all patients are respected."
Similarly, according to PM&DC (Pakistan Medical and Dental Council) Ordinance of 16th July 2011, Section 9, Sub-Section 2 (a) : "A medical or dental practitioner shall be free to choose whom to serve, with whom to associate and lay the timings and place of professional services to be provided."

While Sub Section 2(b) reads: "A medical or dental practitioner shall not be bound to treat each and every person asking his/her services."
In my opinion, one of the underlying causes of outrage against doctors during the strikes was the "messiah" proposition. How can someone who is supposed to "save lives" go on strike? As a nation, we are prone to miracles and magical rescues; we are always hoping for some messiah to come and save us from the "mess" we are in. This messiah complex has in the past led to acquiescence to dictators and demagogues. We, as a nation, need to mature and start believing in processes and institutions, not saviours. Bottom Line: Doctors are not messiahs; they are ordinary professionals doing the best that they can.

Diary of a young doctor (Part 4)

(published in The Friday Times on 13th July, 2012)

Pay Up
"Please give me some money, I'm hungry and don't have any money to buy food," said the beggar.

"I wish I could, my friend, but I earn less than you do," was my reply. And I was not bluffing. 

There is a simple basic rule that governs almost all professions in the world: you work and that earns you money. There are strings attached to this simple fact according to diferent fields but the basic notion remains the same. Soldiers claim to fight for the country, police officers risk their lives for maintaing law and order, public servants work (or at least they are supposed to work) to provide services to their countrymen. At the end of the day, however, they all get paid for it. From the highest offices of the country to the lowest, from generals to chowkidars, from CEOs to clerks, the maidservants that work in houses, sewage workers, technicians, sales boys, they all get paid for doing their job. But in present-day Pakistan we are making one big exception to this rule: doctors.

I have chronicled the lives of young doctors and have described the trials and tribulations associated with their job. It is hard to believe that despite all this hard work, most doctors working in public sector hospitals are not paid. Imagine a person with 17 years of education, working 28 days a month, doing 30 hr/48 hr duties, and earning a grand total of zero rupees per month. 

Imagine a life with no pay, no job security and no health insurance (given that we deal routinely with HIV positive and Hepatitis C infected patients). All that keeps us going are the 'thank yous' of patients and a hope that someday, things will be better. 

After the doctors' protests last year, pays were increased. This does not mean that everyone is getting that pay. In the department where I work, there are 28 people working as House Officers and around 30 as Medical Officers/Post Graduate Trainees (PGRs). Out of 28 House Officers, only 8 are on the paid seats while the remaining 20 are working on 'honorary' basis (there is not much honor involved; it is a euphemism). Similarly, out of 30 Medical Officers, only 15 are getting paid. The situation is similar or worse in other departments and hospitals across Punjab. People working on honorary seats perform equal duties, do everything as others do, the only difference is that they are not paid for doing that work. This is a unique and frankly disgusting way of treating a professional, and there is no precedent for it anywhere in the world. Apart from interns at offices, everyone gets paid for their jobs. At times, even the Senior Registrars, after 10 years of medical training, have to work on honorary basis. 

There is an inside story to this practice. Theoratically, the seats in wards of teaching hospitals are preferably given to the graduates of the institute that the hospital is attached to. This results in unequality at times because graduates of other institutes opt for institutes in bigger cities. In the case of Punjab, graduates from all over the province prefer to do their clinical training in either Lahore, Multan or Rawalpindi. There is also the issue of non-residents. If a resident of Lahore got admission in Rawalpindi Medical College or Nishtar Medical College, he/she would prefer to complete his/her post-graduate training in the native town. Due to this shuffling, there are more candidates for less seats and departments employ different people on honorary basis. The merit list for giving a job for post graduate training starts from graduates of the same institute. Second on the list are graduates of other government institutes and lastly, the graduates of private medical colleges, including the ones in China and Russia.

There are ways that people bypass the merit system, because in Pakistan there is a single key for every lock: Sifarish. If you have the requisite Sifarish, you can bypass the merit and get a paid seat in your desired department. 

To cope with the economic pressure due to lack of any pay, doctors from public hospitals look for jobs in the private sector which forms 80% of our health sector. As a result, most of the unpaid (and in some cases, even the paid ones) do jobs at private hospitals in the evenings and in public hospitals in the morning. After living for more than 25 years on the largesse of your parents, if you still do not earn anything on your own, it reflects poorly on you. Also, during post-graduation, a lot of doctors are tied in the knot of marriage and it is difficult to ask your parents for sustenance of another person while you earn nothing. I personally know some people who delayed their marriages because they did not have the means to support a new member of the family. In some other cases, the young doctors were the only source of income for their families and had to wait till completion of their post graduation to marry. 

This system of 'honorary' jobs should end as it is nothing but a kind of slavery.