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.

We Survived Sandy

(A little background on this piece. I am visiting the United States these days as a fellow of "Emerging Youth Leaders of Pakistan" program, initiated by the Atlantic Council, funded by the Carnegie Corporation of New York. This post is a recollection of memories gained in New York, our first destination.)

Times Square

Ad for Newsies

Maine Monument, Central Park

Library of Columbia University

SANDY

Seinfeld Restaurant

Cathedral of St John

NY Skyline from Rockefeller Center

View of NY from Empire state building

We Survived Sandy

“Do you Speak Arabic?” and “Are you wearing a [suicide] vest?” were two of the questions I was asked when I told people that I was from Pakistan. It is usually said that you take some part of your country with you wherever you go and the first thing you do in another country is to confront their stereotype about you. Being in New York, that too during one of the worst storms in the history of the city, was a great experience to have. The first thing I noticed as soon as we reached JFK Airport was the large number of visitors, mostly from Eastern Europe, who were waiting to go through Immigration. I have heard nasty/creepy stories about Immigration at U.S airports but what I got was quite non-descript. No cavity search, no long interrogations, no suspicious looks or change in attitude. It was a bit disconcerting as well to know that they didn’t deem me important/suspicious enough to at least do a full body scan.!! 

As soon as we slipped out of the airport, we faced a gush of strong chilly wind which accompanied us throughout our visit. We reached our hotel after forty minutes of travelling(or sleeping, in my case) and were welcomed there by Mr. Shuja Nawaz and Huma from the Atlantic Council. After depositing our luggage in our respective rooms, we got a chance to wander out in the streets of New York. During that detour, I discovered that Cart food is considered good in New York, which is totally contrary to what we(or at least my family and medical fraternity in general) think about cart food in Pakistan. We got Shawarmas from “The Halal Guys” and later had a walk up the avenue to visit Times Square.

After our first visit of Times Square, we got addicted to it and we visited Times Square at least once daily. We got pictured on the camera feed present there, ventured up the red steps, got loads of pictures and what not.

In the preceding days, we were largely confined to our hotel due to the “Franken-Storm” named Sandy. We had two intellectually engaging sessions with Mr. Shuja Nawaz and I got to meet Prof Manan Ahmad at Columbia University. It was during the meeting with Mr. Manan that I realized where I was sitting at that time. It was the “Seinfeld” restaurant, the exterior of which was showed in almost every episode of my favorite television comedy show. It did not have the same interior design but it was nonetheless a great feeling for a die-hard Seinfeld fan to be at that particular Diner. We also got to visit Columbia University and had lunch at a nearby Japanese Restaurant. I still don’t remember what I ate that day(I was clueless while eating as well).

During the visit to Columbia, we went to witness Cathedral of St. John the divine, which is the 4^th largest Christian church in the world and probably one of the biggest Gothic churches in the world. It had an exquisite exterior and I don’t think I have ever seen a building that grand and beautiful in my entire life. We encounter a shady(albeit Silver-Tongued) character there who, apart from detailing the history of the church and its reconstruction, also pestered us with Conspiracy theories and how different “signs” had already appeared on the walls of the church forecasting the future.

Being in New York City during Sandy was both a nightmare and an opportunity to witness emergency management in a “developed” country by ourselves. Early Warnings were issued and the local government responded to the storm as well as they could. A lot of difficulties had to be faced, including power shutdowns and absence of the Subway system, which practically paralyzed the city. Many of our plans had to be shelved because of these problems but we still managed to walk around the city, as much as we could. It was a unique opportunity for us to have a firsthand experience of how a “Developed Country” responds to national emergencies and disasters. We have seen what happened in our own country in the wake of Earthquake in 2005 and Floods in 2010 and 2011. Due to effective management and early warnings, the impact of the storm was reduced and less than a hundred people lost their lives due to the storm, which does not reflect accurately the gravity of the situation. 

While we were busy confronting our own stereotypes, we also discovered how wrong so many people have been about New Yorkers. It is usually said that New Yorkers are arrogant, detached and apathetic. I confess that one week is too soon to reach any conclusion but at least for this much duration, we(or at least I) found New Yorkers to be none of the above. I had previously thought that taking so many pictures and getting people to take pictures of us or with them would be at least a bit annoying for most people, but No sir, it was not the case. We got pictures with Cops in Times Square at 11 p.m., with paramedics on Broadway at 5 in the morning and asked a florist at 6 a.m. to take a picture of our group. None of those people even displayed a smirk. A taxi driver once refused to charge some of the fellows because he was a Pakistani while a Rickshaw driver gave us good enough discount on the ride. My beard was also supposed to be a problem for me but it never was, not at the immigration, not in the city, not in any of the offices that we went. 

It is also frequently said by travelers that a city can only be truly explored if you walk through it. I have done this experiment previously and have fallen in love with parts of Lahore because of this exercise. In New York, all we did was walking. We were fortunate that our hotel was located near so many memorable places and we got the chance to explore a lot just by walking. On a personal note, I am not a big fan of pets but the amount of cute dogs I saw on the streets of Manhattan reduced some of the strong feelings I had about this issue. Initially there was some problem with food, as after breakfast we had so many options but their “Halal-ness” was not verified so we were reluctant to experiment. I am already a vegetarian so it was not a big gastronomic shock for me but for some of our fellows, it was a very difficult time. I had Japanese food for the first time which I liked, not so much the American staple diets. 

United States is supposed to be the Land of Free so the first thing that I did upon reaching my hotel was to use YouTube, which has been blocked in Pakistan for the last few weeks.
My mind couldn't stop comparisons when I saw different things in the streets of New York. Cart Food, which is shunned by most well-off Pakistanis, is considered good enough in New York. Tap Water can be used for drinking purposes, without a second thought about any water-associated illness. Thank Yous and Sorrys are much more common. No one gives you a second look, whatever your skin color or dress might be. People get out of the way if you want to get pictures of a particular place. Zebra crossings actually work and vehicles would stop for pedestrians even if the pedestrians are violating the rules. No one cuts through the line, how long that might be. No whistling in theaters. People generally follow time for meetings and excuse politely as soon as the time finishes. These few little actions may not be thought of much by people in the U.S because they have grown accustomed to them but for folks from the "developing world" (thats a misnomer), they are fascinating.   

We visited a grassroots organization working for development of under-privileged South Asian children, named SAYA (South Asia Youth Action). It was heartening to witness active community participation in helping the community itself. We also visited an office of the United Nations Organization (UNO), where we met the Chief Knowledge management office of the UN. Later that day, we visited the Rockefeller Centre and Grand Central Station, both of which are among favorite tourist destinations.

One fine morning, we decided to visit Downtown area and ended up in Greenwich Village. To our utter amazement, there was no electricity in the area, reminding us of Pakistan. We even saw a utility store which was being run under the light of a solitary candle. Most of the shops were closed and streets were generally deserted. We saw a statue of Mr. Gandhi in the Greenwich area. It was followed by a spur of the moment decision to visit the Empire State Building which was nearby. I and another fellow were among the first batch of visitors to the Empire State building that day (tours start from 8 a.m. onwards). It was an out of the world experience to be standing on top of Empire State and finding the city of New York under our feet. It was really cold up there as well but the joy and excitement were overwhelming. It was a proper “Empire State of Mind”.

We visited the offices of New York Times, one of the most widely read newspapers in the world, on 2^nd November, 2012. For an aspiring journalist such as myself, it was akin to visiting Heaven. The one thing that caught my eye apart from the exquisite interior design was the amount of books present on each of the staff's workstation. Despite being a bookworm myself (6 half/quarter-read books lying on my own side table), I was amazed. I don't know many journalists or press people in Pakistan who read such a huge amount of books (a few of them do, but they are exceptions not the rule). Douglas Schorzman, Foreign News Editor of NYT talked to us about various issues regarding NY Times. He was joined for sometime by Susan Chira, assistant managing editor for news of The New York Times. Mr. Douglas was eloquent in answering queries of inquisitive youth leaders from Pakistan and provided detailed answers. He also took us on a short tour of the News Offices. We were able to appreciate the “Open Culture” at New York Times which represents transparency on part of the Newspaper. 

To conclude our visit of New York, we got a chance to watch a Broadway Show. Two groups were formed, one of which opted for watching “The Lion King” while the other, including myself, opted for watching “Newsies”. It was one of the most exhilarating experiences of my life. No wonder the play won the prestigious Tony Award for best play. Performance of the actors was so good that one of my companions wondered if it were a 3D movie? I have seen and acted in semi-professional theater in Pakistan and have watched some good theater performances but Broadway was a different galaxy altogether. It was surreal, magical, and inexplicable, beyond the reach of words. It was the perfect ending to our Topsy-turvy tour of New York, a cherry on the top. 

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.