Almost half of the area in Sindh is occupied by rural population which not only lacks basic health facilities, but are also located farther away from them. An initiative in Thatta, Sujawal and Mirpur Bhatero is filling in that gap. You! takes a look...
In Sindh, somewhere between Mirpur Bhatero and Jhok Sharif, is a small village by the name of Goth Ja’far Khan Chandio. The goth exists in what looks like a middle of nowhere and the only way of reaching there is through an unmade and uneven rocky path. The path is challenging to cross even if you are seated in a comfortable car, let alone if an elderly, a serious patient or a pregnant woman has to travel in a substandard vehicle to a far away hospital. Especially when it comes to deliveries, a situation can become critical at any point. In such circumstances, an elderly woman (commonly known as a dai) would try to use age-old methods to help the patients, which can sometimes cause fatal complications.
Haji Chandio, the leader of the tribe, had to bear the loss of more than one family member due to this ordeal. “I lost my first wife before delivery and then my second wife the same way. I can show you the graves of the countless people we lost due to the unavailability of medical services in our vicinity and the poor infrastructure of our area. However, six months ago, my present wife gave birth to my daughter, with no complications as she was taken in an ambulance. My elder daughter also gave birth to twins easily due to this ambulance service that recently started. It came as a blessing to us that helped us in such conditions,” he tells the scribe.
Almost half of the area in Sindh is occupied by rural population and it is scattered around in clusters of small villages or goths all over the province. Like Goth Ja’far Khan Chandio, there are many more areas that not only lack basic health facilities but are also located farther away from them.
Seeing the gravity of the situation, in 2016, Sindh Government and Aman Foundation started an ambulance service, in a public private partnership, in Thatta, Sujawal and Mirpur Bhatero to provide pre-hospital care, free of cost, to the locals. Sindh People Ambulance Service (SPAS) is a fleet of 25 medical dispensaries - ambulances equipped with some emergency life-support equipment and basic medical essentials - that is playing a key role in saving lives of the sick and injured.
Dr Mansoor Ahmed, Manager Operations SPAS, is a resident of Karachi but comes all the way to Thatta on a daily basis to manage the affairs at these centres. “There were 53 non-functional trauma centres which were previously being utilised in the wrong way. Some paramedics were using them as residential areas. There were animals tied up here and they were in the worst form. These centres were allocated to us by the then-minister to utilise them for healthcare in these districts,” says Dr. Ahmed.
The area that SPAS covers is approximately 2400 sq km, which is awfully scarce in health facilities. If a facility is available in Makli, then the next one would be at least 30 to 35 km away. Moreover, with 70 per cent rural population in this region and the remaining 30 per cent urban, which is nothing compared to the metropolitan cities of the country, the service has managed to carry out thousands of interventions. Out of these, 100 deliveries, including twins, were carried out inside the ambulance.
Among the many dedicated members working for the project, Nousheen Iqbal is rendering services as the supervisor of Command & Control centre at SPAS. Nousheen was the first female to have been inducted for SPAS and has been working here since November 2016. She overlooks all the agents that are on-call with the callers in distress, and provide them with the necessary guidelines, “The Command & Control room deals with two districts, Thatta and Sujawal. Out of 25 ambulances, 22 are on-road and three are for backup; and we get an emergency call at every fifth minute,” she shares. “As soon as we get a call, we follow our protocol MPDS (Medical Priority Dispatch System) according to which we start our interrogation. We inquire about the emergency, after which we judge its severity. If it is a life-threatening case, then we have zero minutes to dispatch. We immediately dispatch our ambulance from any nearest spot and then carry on gathering information on call. However, if it is a serious or normal case then we follow the full protocol first. Overall, we don’t have any mechanism for refusal as we are here to serve and there is no other organisation that provides pre-hospital care,” she adds.
One of the greatest struggles for a patient in pain is to make movement. And if they have to move from one facility to another, that too in areas where there are rugged pathways instead of smooth roads, which aggravates their situation. Majority of the patient transfer ratio in the region comes from government hospitals or setups. And since all these setups are so far off, people have now realised that if they require emergency services, they can call up an ambulance instead of managing on their own. “So far there have been 42000 plus interventions where our average response time has been 16 minutes. It is an achievement for us in an area where health facilities are at a minimum of 30-35 km away. For life-threatening cases, we have an average time of 12 minutes, but we try to further reduce that timeframe. This has only been possible because of the acceptance by the communities. They now realise that they can dial 1036 and avail emergency medical services (EMS) free of cost with a speedy response. We are also trying hard to make them realise that this service is for their own benefit, we also encourage the children to make the call if they see someone in distress,” explains Nousheen.
When it comes to childbirth, the situation is very sensitive since there are two lives involved. One wrong move can cost either one or both the lives. According to Nousheen, in Pakistan, 70 out of 1000 women die during delivery. To handle such delicate cases, she explains the protocol her team has to follow. “As soon as we get a call for a delivery or any case related to gynae, we tell them how to make the patient sit, not to stop the delivery forcibly etc. However, if it is an imminent delivery - rapid increase in labour pain is an early sign of delivery - we start to give them Dispatch Life Support (DLS) guidelines which are given by our agent on call Emergency Medical Dispatcher (EMD). They constantly give guidelines and instructions to the caller, and our crew is alerted to move. Wherever there are no medical services available, people call in a Trained Birth Attendant (TBS) who tries to deliver the baby. If an untrained dai is trying to deliver and the patient goes in haemorrhagic shock, there is a chance that the mother and child would die immediately. This is why we give all the little instructions as our crew gets prepared with the gynae kits. Every ambulance has two gynae kits because in most cases we have twin deliveries as well.”
Apart from carrying out the procedures, one of the protocols also involves them getting consent from the family of the patient to avoid any legal issues. “There are many reasons for maternal mortality like postpartum haemorrhage, anaemia and no proper check-ups. Due to lack of awareness, people don’t know that there are certain tests to be done before delivery to make sure everything is alright. Unfortunately in this region, the habit of eating gutka, pan and chaliya is quite prevalent in men and women both, which is also the leading cause of anaemia. Around 35 per cent of the females die during childbirth because of anaemia, and this we are only talking about Thatta district,” she elaborates.
So, the first thing the crew does is check all the vital signs and see if the water has broken. Then they ask the family for consent. Sometimes, the agents on call also act as counsellors. They persuade the family to prioritise their patient’s health. “For the consent, we prefer to have a male attendant because it is easier to get consent from a male to male. There are only 20 per cent females who are educated up to primary level, as per the survey report by Alif Ailaan - a non-profit that works for education in Pakistan. So, we speak to the husband first so that we can stay in contact with them. If it’s not the husband then we try to contact any other male attendant with the woman,” elucidates Nousheen. The job for the team doesn’t end here. After the delivery is carried out, SPAS also offers them counselling and guidance after childbirth as well. They also make follow-up calls to ensure the well-being of the child and the mother.
Every life is important regardless of the fact it belongs to a metropolitan city or a marginalised community, initiatives like SPAS serve as a ray of hope in their darkest hour.