KARACHI: over the past five years, there has been an alarming rise in a number of health problems in Karachi and adequate medical facilities do not exist to cater to this increase.

What we may be seeing within the next decade is massive over- crowding in public hospitals and a rise in rates charged at private facilities owing to the high demand for their services. This, however, would not translate into better medical care in the absence of any government initiative at coping with the problem over the next couple of years.

Both the number of patients and the variety of the health problems have jumped while there has been only a marginal rise in government spending on health and very limited expansion in the health sector itself.

No new major hospitals have come up in the past decade and the state of affairs at the present general hospitals in the city make patients run to smaller clinics, which are more expensive and also sometimes less capable of delivering the health care needed.

While the medical sector has seen a boom in terms of private medical care, the quality of these facilities is only marginally better than what is offered in the public sector. In many cases, it is actually worse as low-paid medics use short-cut techniques to try to cure life-threatening diseases and ailments.

What makes this problem more pressing is the spectacular rise in the number of young patients, particularly for diseases that were previously associated with older people. This includes heart disease, diabetes, asthma, liver problems as well as stress-related disorders. Younger people in the city are less healthy on an average as compared to their peers ten years ago let alone of a generation before, say medical specialists. There are a number of reasons for this, and most of which could have been avoided, they add.

Doctors start by blaming the sedentary lifestyle adopted by most young people in the city as a major cause for their medical problems as well as a rise in smoking. "It is common to see young men with slim thighs and fat bellies which is unhealthy and leads to bigger problems if not controlled," comments Dr Riaz Qureshi, an authority on family medicine, a new genre in medical treatment being pioneered in the city.

Most young men over the age of 30 in Karachi have the potential of being overweight or "centrally obese" which can be a cause of disease if not controlled through diet and exercise. Most of these people do not seek medical help till a major incident, like a heart attack, occurs. The same is the case with young women, although the tendency to fatten comes later in life, particularly after the birth of the first child.

Dr Qureshi points to three areas of concern: infection, chronic diseases and stress as major killers in Karachi. All three can be managed effectively given proper medical awareness and care.

Patient trends at the Jinnah Post-graduate Medical Centre (JPMC) gives some idea of diseases currently being witnessed in the city. Dr Tasnim Ahsan, a professor in the internal medicine ward, says that most of her patients suffer from stroke. For her, the main areas of worry are Type-2 diabetes, hypertension and heart disease.

In communicable diseases, the most common in Karachi are hepatitis B and hepatitis C which then lead to liver disease. Dr Ahsan says that about 15 per cent of Pakistanis now suffer from diabetes while about five per cent suffer from hepatitis. The culprit in hepatitis is infected blood that is usually supplied through unlicensed blood banks that screen a maximum 20 per cent of blood that passes through their facility.

The main victims of water-borne diseases are children and the incidence of Hepatitis A, typhoid, diarrhoea and gastroenteritis continues to rise. The deaths continue to occur as the quality of the city's water worsens.

Infections one also spread though the multiple use of disposable needles. The Edhi Trust plans a drive against reuse of syringes. Rizwan Edhi says that despite the fact that a new syringe costs Rs3, there is still rampant reuse in the community. In most city hospitals, there is also no provision for incinerating hospital waste with the result that much of what is discarded is re-used. Also, junior doctors at places like the Civil Hospital recall instances of cats fighting over human limbs not disposed of properly after surgery.

While the Sindh government has started a campaign to screen blood banks, the drive is being met with resistance. Dr Kamran Awan of the Sindh Blood Transfusion Authority has been facing threats almost daily ever since he spearheaded the campaign to shut down unregistered blood banks.

Even some major city hospitals are not registered and regularly use unscreened blood, as was seen in the case of Dr Sarwar Zubeiri, a medical authority who died after being injected with infected blood.

Another major killer is stress and depression, one of the main causes behind suicide. While accurate statistics are hard to come by, it is believed that the number of people who die as a result of depression are as much, if not more, than those who suffer from chronic diseases. The rate of depression in women in Pakistan is one of the highest in the developing world. One in every four women suffers from some form of depression in the country, say experts. In Karachi, it is feared that one in every five persons suffers from depression. However, there are very few medical professionals available to treat this problem and even fewer institutions where this can be done.

A recent study conducted by Dr Murad Moosa Khan, a professor of psychiatry, indicates that most at risk of committing suicide based on past trends are young men between the ages of 18 and 30 and young women who have recently been married.

In both these groups, the killer is depression caused by a number of factors: in case of men, it is usually economic reasons like unemployment while in women it is their inability to adjust to their new households.

Dr Moosa Khan says that the main problem in the case of rising suicides is the lack of professional help to deal with depression. About two per cent of Pakistanis suffer from serious mental illnesses. But a much higher number suffer from depression, which is not even seen as a problem.

An area of concern, especially among children, is the rise in asthma. This is now being diagnosed in as high as one in every fifth child in the city. Dr Shakil Rizvi, a leading paediatrician and neonatologist, says that the two things that worry him most amongst children are asthma and the problems caused by foreign body inhalation. "Both have seen a sharp rise over the past few years," he says. The main culprit in the case of foreign body inhalation is the consumption of 'chhalia' (betel nut) which causes choking or injury that leads to infection amongst children.

Asthma incidents are also on the rise owing to a number of factors. Part of the problem is the environment while another part is the inability of doctors to diagnose the problem in its initial stages and of the parents to accept the fact that their child has asthma. Most doctors treat recurring cough with cough syrup and this only makes matters worse. Parents sometimes go to other doctors or experiment with alternative medicine when given the diagnosis of asthma in their children. The longer the problem is delayed, the worse it becomes.

Paediatricians also say that there is a tendency towards over- medication, especially among children. At the first sign, doctors prescribe antibiotics for infants and minors on the premise that no chance should be taken. This is also true when treating adults, as many want instant results. Doctors agree that the overuse of medication, as is seen today in Karachi, will result in problems for patients later on in life.

Abuse of antibiotics is playing havoc, says Dr Nasim Salahuddin of the Infectious Diseases Society. A decade back typhoid or malaria could be treated with standard protocols. Today, thanks to overuse of antibiotics, doctors have to prescribe drugs that are less effective, more toxic, terribly expensive and hard to obtain. Some doctors advocate restricting use of antibiotics.

Doctors also warn against the massive misuse of steroids in treating patients, a very common problem in Karachi especially in homoeopathic treatment. Steroids are a favourite with toothpaste makers as well, including some leading brands, with the result that users think their teeth can be cured by using only toothpaste. Dr Najib Siddiki, a dental surgeon, says such toothpaste are responsible for a number of dental problems as some patients only come to him when things are beyond repair. The government, however, has turned a blind eye to the sale of such toothpaste.

In many areas, the government is seen to be lacking in its efforts. There are some "ghost" hospitals in the city. Governor Ishratul Ibad, himself a medical doctor, says that he came across one such abandoned government hospital recently where everyone was being paid salaries but no patients were being seen. "I took immediate action to have the hospital working but there are many more where this problem remains."

Breast cancer has also seen an alarming rise, particularly among women over 40. But average age of diagnosis is 64. Now there have been cases of young females in their early 20s being diagnosed as well.

Karachi is also the major transit point for the spread of AIDS in Pakistan. This is because most of the carriers were Pakistani workers from the Gulf states. However, there is little awareness in the city of this problem despite the rise in the sex trade here over the past few years. The UN says that Pakistan has now become a high-risk country for the spread of AIDS, with some suggesting that the epicentre would be Karachi.

For all practical purposes, the government and medical regulatory bodies seem to act as bystanders as the medical sector continues to function without direction or control. Take for example the mushrooming of medical schools, most of which are not recognized by the Pakistan Medical and Dental Council (PMDC). This has not stopped thousands from taking admissions knowing that once they graduate, they would be accommodated. The problem is that most of these new schools do not have the teaching faculty or the right equipment on campus to train doctors. And yet, they continue to function.

In government medical schools like the SMC and DMC, there is a rise in the incidence of "proxy" examination taking under which one medical student sits in place of another. Most teachers know about this but look the other way due to threats issues by political, ethnic and religious student groupings.

In all this, the reluctance of the government to come forward and regulate the industry where the private sector has taken healthcare to extreme forms of commercialization is appalling. With no one willing to take on the medical mafia, the situation in Karachi is expected to get worse. In a city with a population exceeding 10 million, the absence of a proper medical infrastructure is a matter of shame. The fact that many of the doctors and medical institutions coming up are sub-standard only adds to the problem and indicates that for which there no solution in the near future.