A well-managed health institute does a world of good to many patients
After spending almost 15 years in the US, a potential return to Pakistan created both excitement and anxiety for me. Whether I could adjust to such a drastic change was the imponderable. Nonetheless, the time was ripe because my goals of receiving training and experience in gastroenterology and liver diseases in the US had been fulfilled. The expertise attained could be possibly utilized better in Karachi than a much well-served Phoenix, Arizona where I had shouldered the responsibilities of liver transplant director followed by section chief of gastroenterology (GI) successfully. Besides providing care to the needy, research on basic medical problems is rewarding because it can make a real difference rather than used solely to perk up the bio-data. Finally, one can participate in building up a rudimentary medical system of Pakistan.
After much deliberation, a two-month stint in Karachi at SIUT appeared to be a step in the right direction. The SIUT serves the most underprivileged and is led by individuals with good reputation. My meetings with the SIUT administration had given me a good feeling about their open-minded attitude and support for any genuine agenda. The department of gastroenterology and hepatology (GIH) at the SIUT is relatively new, but has picked up quickly, serving several in and outpatients daily. All set to start, I showed up at the SIUT in mid-August.
A narrow road flanked by pharmacies, fruit vendors and fried food hawkers, bustles with flies fleeting from one food item to another as well as chaotic traffic. This is the quickest path between the new and old buildings of the SIUT separated from one another by a couple of hundred yards. A nearly bare man lying on pavement was rolling in a variety of acrobatic positions probably suffered from schizophrenia. Not-far-from psychiatry ward, he has yet to receive medical attention. Plenty of squalor, dust and emissions of rickshaws freely gain access to respiratory system during blustery weather while commuting between the new and old buildings. Even I felt sick walking down the path to the old building wondering about the plight of sick. The old building is decrepit but the new has an elegant facade. While the new building is entirely the SIUTs, a limited portion of the old building is used to serve patients with kidney diseases. The major responsibilities of the GIH are in the new building where both out and in patient facilities are located, although the GIH staff frequently hobble their way to the old building for assessing any GI problems in patients with kidney disease.
The GI-ward where patients are admitted has a capacity of 22 beds and is occupied by both sexes segregated at opposite ends of the ward. Those requiring intensive care are monitored in a separate room housing six patients. Skinny patients with infectious diseases at the SIUT contrasted sharply with the obese having metabolic problems like diabetes in Phoenix. Many had viral hepatitis related advanced liver disease, tuberculosis associated diarrhoea and fluid overload as well as stones of the biliary tract causing jaundice. Parasites endemic in Pakistan including echinococcus and amebiasis presented as liver abscess. Modern technology including advanced laboratory, radiology, pathology and endoscopy are available to objectively document a medical diagnosis. Antibiotics, intravenous fluids, chemotherapeutic agents and symptom relieving medications are stocked in the hospital or ordered in from outside despite a dwindling budget that can hardly cope with every increasing number of visits.
A young mother of four came all the way from Hyderabad after failing to improve despite seeing many physicians. Between healers and suffering from fever, decreased appetite and weakness had diminished her faith in the medical system. Once diagnosed with an abdominal abscess and appropriately placed on antibiotics, she improved and even agreed to wash her hair in four weeks and felt refreshed. Another girl in her early twenties suffered renal failure from injudicious use of over-the-counter analgesics. She required two hemodialysis sessions of 10,000 rupees per week in Rawalpindi. Her father exhausted his 400,000 rupees retirement savings to sustain her life. Finally, she ended up at the SIUT in the hope of receiving free dialysis.
The unfortunate girl had received either a contaminated blood transfusion or injection and acquired hepatitis C virus. Besides kidney issue, failing liver had caused her belly to be distended with fluid. Her Master’s degree in English literature helped because she could read for solace and kept her mind off her malady. Yet another announcer at Karachi airport was brought to the SIUT with a severe episode of pancreatitis. She had a stormy course and surgery with significant morbidity was considered. Fortunately for her, antibiotics, nutritional support and intense monitoring sufficed. One cantankerous, pencil-thin woman had been vomiting for several months. Endoscopic examination of stomach showed multiple ulcers in small bowel. Treatment with acid suppressing medications improved her condition.
The OPD is run twice a week. Patients are seen on a first-cum-first basis. Up to 150-200 patients are entertained in each session. While some diseases can be treated with oral and relatively inexpensive medications, many therapies particularly used for viral hepatitis are costly and need prolonged injection administration. The treatments for chronic diseases need compliant patients. Ignorance among sick and an ill-prepared health system that has not appropriately utilized the abundantly available man power has failed to ensure compliance. As a result, tuberculosis remains a menace and has perpetuated unabated.
Hepatitis is rampant and not transmitted through sex or drug abuse but by health care providers who have given a contaminated drip or vitamin injection or a blood bank has transfused unscreened blood to an unsuspected recipient. Viral hepatitis results in end-stage-liver-disease and cancer that can be cured by liver transplantation which is not widely available in Pakistan. There is no proper regulation of pharmaceutical industry. Many small companies manufacture medications for profit and several trade names exist for one agent. Interferon for the treatment of hepatitis C is manufactured by 26 companies while countless acid suppressing agents are available. While the efficacy of all these medications is questionable, it creates a big confusion while providing patient care. Many physicians in their blissful ignorance arrive at an incorrect diagnosis quickly and even hastily write several medications for the patient. The faster the doctor, the smarter he/she is. Patients take many opinions and are used to window shopping. Many have received incomplete courses of several prescriptions. While seeing patients at the OPD, I had a challenging task to sort out prior medical history and prescriptions before considering other options. The medical documentation is almost non-existent.
Nonetheless, the staff at the SIUT despite limited resources tries their best. They save many. They comfort several. This is what gives hope in a sluggish system. Affording patients have the liberty to have all needed investigations done. Even then, many abuse the system by showing up at the SIUT’s OPD to obtain expensive investigation straining an already stressed budget. Several of them have had their liver transplantation at India, Hong Kong, the UK and the US costing any where between four to 20 million Pakistani rupees.
The SIUT is a centre of excellence for kidney transplantation. Recently, low weight children have undergone kidney transplantation successfully. The cute kid who underwent liver transplantation at the SIUT two-years earlier remains lively. Much has been done and much needs to be done at the SIUT. It is not an ideal system but many in this institute are committed to be the best in their field and wish to bring their medical specialty at par with kidney transplantation. Such individuals find reward in matters other than monetary. Training young physicians is a joy as one can see them spreading their influence across the city. Many feel distressed at referring patients to India for liver transplantation. Why not in Pakistan?
The competition with India has to be taken to other fields besides cricket. The white-headed Dr Rizvi has built up the institute with the help of his team and strongly believes that health is a right and not a privilege. Nobody should suffer because of the lack of money. Many share his vision. I have not yet lost hope. The future can still be bright for the committed.
After spending almost 15 years in the US, a potential return to Pakistan created both excitement and anxiety for me. Whether I could adjust to such a drastic change was the imponderable. Nonetheless, the time was ripe because my goals of receiving training and experience in gastroenterology and liver diseases in the US had been fulfilled. The expertise attained could be possibly utilized better in Karachi than a much well-served Phoenix, Arizona where I had shouldered the responsibilities of liver transplant director followed by section chief of gastroenterology (GI) successfully. Besides providing care to the needy, research on basic medical problems is rewarding because it can make a real difference rather than used solely to perk up the bio-data. Finally, one can participate in building up a rudimentary medical system of Pakistan.
