LAHORE: The number of renal failure cases in Pakistan is on the rise but with only 80 nephrologists for the entire country, the number of nephrologists is falling. It is not for no reason that the experts are warning against an impending health crisis.

Pakistan has a three-tier healthcare delivery system: primary, secondary and tertiary care. The country spends a lowly 0.5 per cent of its GDP and the paucity of resources is compounded by flawed policies. Consequently, the health sector frequently faces the challenge of dealing with communicable and non-communicable diseases.

This is painfully manifest in the specialised area of nephrology, a branch of medicine that has seen so much progress over the world in recent years. There is human resource in the country and there is infrastructure, but there is no policy.

Globally, nephrology is an integral part of major health facilities. Pakistan chooses to ignore it, at its peril. The patients who should see nephrologists continue to be treated by urologists, who specialise in surgery and not in medicine.

A few months ago, senior nephrologists Dr Mohammad Anees, Dr Mohammad Ibrahim, Dr Saleemuz Zaman Adhmi and Dr Mohammad Nazir came up with a study that highlights the situation. Titled “Comparison of awareness about nephrology and kidney diseases amongst doctors in institutes with and without nephrology departments”, the 2014-research has experts attributing the situation to apathy of the health authorities and medical institutions. They find it alarming that the number of nephrologists at the state-run hospitals is decreasing, mainly because of lack of nephrology departments in affiliated medical colleges.

The study shows that non-availability of nephrologists and nephrology departments in state-run hospitals across the country was a major cause behind renal failure deaths. Timely treatment by nephrologists could have saved many of the lives lost. The situation is worsening with time since “we are undergoing an epidemiological transition with an increase in risk factors of chronic kidney disease (CKD)”. This is dangerous for people and is ultimately a burden on the health system, the study says.

The risks for CKD may be further exaggerated in Pakistan where a substantial proportion of the population is predisposed to chronic diseases, including diabetes and hypertension, because of low birth-weight possibly associated with reduced renal reserve.

Nephrology was introduced as a distinct discipline of medicine in Pakistan in 1970 when the first facility for the care of renal patients was established at the Jinnah Postgraduate Medical Centre in Karachi. The progress in the area has been slow since then and even after the passage of 45 years nephrology is still in its ‘early phase’ in the country.

By the end of 2000 there were 12 nephrology centres for postgraduate academic affiliation in the country. Some 14 years later the number of accredited institutes for training in nephrology in both the public and private sectors is 28 only.

“At present there are only about 80 formally trained and qualified nephrologists in Pakistan for a population of about 160 million as compared to the United States which has more than 5,000 nephrologists for a population of about 300 million,” the study notes.

It says about 8.8m people are suffering from diabetes in Pakistan and this number might be doubled by 2025. According to a survey, prevalence of Type 2 diabetes mellitus (T2DM) among the adult population (25 years) is 15 per cent, almost equal to other countries in South Asia.

Many of these diabetic patients develop complications involving kidneys, eyes and nervous and cardiac systems. Because of missing facilities of dialysis the burden of dialysis patients caused by diabetes and hypertension (60-70pc) has increased enormously on the public sector hospitals making the quality of life of patients very poor. The horrifying fact is that a large number of kidney patients die in the first year of dialysis and the absence of nephrologists is a huge factor in the loss of these precious lives.

Unfortunately, these deaths are going unnoticed since there is no clinical audit system in place to investigate negligence or any other factor behind medical-related mortalities.

The experts also point out that a majority of dialyses units do not have any water treatment facilities despite the fact that the ratio of the new CKD patients in the country each year is 150 to a million. They press the government to take steps without wasting any more time.

Published in Dawn January 31st, 2015

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