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Terminally ill

April 21, 2013

It’s a typical day at Karachi’s crowded Civil Hospital. We see a child bitten by a rabid dog, the victims of an accident, a woman in labour, another severely haemorrhaging … patients just keep coming, in a never-ending stream. In some wards, with no room to spare, patients are sharing beds, or lying on the floor. Despite their best efforts, there are times when doctors have no alternative but to refuse patients. Nurses have an equally tough time: they are even fewer in number than doctors. Bomb blasts and terrorism strikes, targeted killings, all occur with increasing frequency; the tragic scenes that unfold are separate stories in themselves. Trauma centres are urgently needed, but there are none.

Beyond this are myriad other diseases: cardiac problems, heart disease, hepatitis, cancers and more. The required knowledge and treatment is there, but there is just so much that doctors and hospitals can do. Dr Shershah Syed, senior official of Pakistan Medical Association says, “We’re facing extreme shortage of doctors, nurses, paramedics, midwives; we are producing only one nurse for every eight doctors, though we should be producing one doctor and 15 nurses, midwives, paramedics. Shortages happen because of emigration and bad planning of the government.

Crowded hospitals, doctors and nurses run off their feet, minimal wages, unsatisfactory service structure, medicines and equipment in short supply — these are common enough problems in every urban centre. The rural picture is in need of far greater attention.

Each birth represents an increase in the need for healthcare. For a variety of reasons, the entire social sector — education, health, housing — has received short shrift. Health is allocated a mere 0.6 per cent of the GDP. Much of this goes to administrative expenses, leakages, mismanagement and corruption, leaving little for actual treatment.

For years there has been greater stress on tertiary curative medicare, rather than cost-effective primary and preventive healthcare. We have fancy medical equipment, but do not have access to safe drinking water or decent sanitation. The ostrich approach towards sexual health is widely practised, resulting in a proliferation of sexually transmitted diseases. Multiplying the damage are widespread quackery and fake medication. People lack basic knowledge of healthcare for themselves and their children. Today we’re caught in a situation where we need both — the complex medicare to treat the many illnesses that Pakistanis suffer from, and also the need to institute strong preventive and primary healthcare measures.

Health has now become a provincial subject; hopes are that this will result in improved healthcare delivery.

For primary healthcare, Pakistan does have a strong Expanded Immunisation Programme for children against communicable diseases. It’s another headache that many people are not convinced  of the efficacy of polio and measles vaccines, and mistrust even committed health workers.

There are countrywide programmes for prevention and treatment of malaria, tuberculosis, and HIV/AIDS, though these need to be stepped up further.

Lady health workers (LHWs) have proved to be a boon for outreach of rural healthcare. They visit homes, establish rapport with the family, and are able to advise them on simple basic health measures. But even this large army of LHWs is inadequate — the need is much, much more.

Young doctors especially are concerned about their future; they have few opportunities

for advancing their careers, and the consistently low salary scales are discouraging.

A young doctor who has recently left her work at a public hospital, sounds frustrated and disillusioned. “We enter this profession so idealistic… but the working atmosphere changes you. Hygiene and asepsis are inadequate; a colleague, who was treating a dengue patient, contracted the disease and died of it. Four years ago, junior doctors were paid only Rs6,000 per month; many doctors worked for free, just for the experience. Of course, doctors went on strike, so did I.

“Recently salaries have been raised to Rs42,000 per month, but did it have to come to this? Why couldn’t there be some sensitivity to these issues earlier? Young women doctors don’t even get maternity leave, or get just 45 days, as against the required three-month legally permissible maternity leave.”

“I don’t think junior doctors are overworked,” says Dr Shershah, “but health workers have no career path, neither in the general cadre nor in teaching. All teaching staff work on part-time basis, from Vice Chancellor to assistant professor, from 9.00am to 2.00pm, without commitment. Only the Aga Khan University has a service structure and a full time faculty.”

The future? According to Dr Shershah: “The outcome for health for the average Pakistani is very, very poor. Emergency and basic health facilities are not available, because of the government’s failure to organise an efficient health system.”