Beyond healthcare disparities

As darkness descends on the NORI hospital for cancer patients in Islamabad, the tumult of activity witnessed inside its gates during the day also grinds slowly and systematically to a halt, almost as if someone had pulled a lever somewhere to the ‘stop’ position. An eerie silence permeates its corridors that are now only partially illuminated, with most lights turned off after dusk.

The nursing staff is down to skeleton strength, deemed sufficient by the hospital authorities to steward the hospital and its hapless populace of extremely sick and very poor patients through the gloom of the night. The hum of the radiotherapy machines can also be heard no more as the final patient, my father, has been wheeled out, having received his allotted dose of radiation – a last-ditch attempt to stabilise his collapsing spinal column, the victim of an aggressive cancer emanating from the prostrate.

Navigating through the maze of the in-patient wards in search of the head nurse, I’m weighed down with an incurable despair, begotten perhaps by the dull white, tube-lit luminescence of the hospital, flickering and bouncing off the faded and peeling plaster of its grey walls and combining with the ubiquitous, thick silence – punctuated only with the occasional moans of mostly unattended cancer patients, desperately seeking life from drip tubes and cannulas – to create the atmosphere of a nightmare mausoleum.

The head nurse is gruff, matter-of-fact and in a hurry as she administers an injection. To my queries on my father’s reactions to the radiotherapy, she is as monosyllabic, non-committal and irritated as the head doctor who prescribed the dose during the day. “What are the prospects, doctor?” I remember asking him. “Minimal,” he snaps back. “Will there be much pain?” “Of course! What do you expect from cancer?” he retorts. He then advises me to bring at least two attendants for the radiotherapy. “We have little or no nursing staff here you see. You’re on your own”.

At the Shifa International Hospital – possibly the best in the capital in terms of quality and range of medical professionals, not to mention compliance with international standards and protocols for healthcare – I will experience the inverse, I’m told, as long as I have the pocket to pay for it. And sure enough, the hospital’s financially-driven ethos of medical practice is immediately apparent as I wheel my father into the emergency room and proceed to the cash counter to make my first advance deposit. Beginning with at least a hundred thousand, I’m informed, I’m likely to hike up my bill beyond the five hundred thousand mark should I have no alternative but to obtain the hospital’s in-patient services beyond a week.

As the days progress, I realise that while public sector medical care is horrifying with its absence of standards, requisite infrastructure and staff, the private hospital system in Pakistan is a money-making machine, where a financial crisis may only be avoided through connections with medical specialists either within or outside the hospital system. The private hospital is further devoid of any concept of palliative care – particularly relevant in ‘end-of-life care’ situations that are common to any treatment of advanced diseases – which counsels minimally invasive medical intervention, seeking only to make the patient comfortable in their final days.

Should a person struggle to fight the private medical system in such an event, he or she will have to battle through a barrage of unwanted emotional blackmail as medical specialists and their assistants growl and bully patients and their families into acquiescing to their demands for unnecessary medical tests and forced medical interventions, seeking to profit from ignorance and despair. Palliative care in advanced diseases is the cornerstone of medical practice in any good healthcare institution worldwide, but is perhaps practiced only at the Shaukat Khanum Memorial Hospital in Pakistan, which draws the line for patients deemed more appropriate for conservative treatment.

Such is the state of our healthcare system that offers quality health services to some degree only in the private domain and at no less than an exorbitant cost. In the public sector, despite big names such as PIMS in Islamabad, the Mayo Hospital in Lahore and the Jinnah Hospital in Karachi, there are few other institutions that are capable of providing quality healthcare, nationally.

With abysmal funding at both the federal and provincial level, public hospitals are a cornucopia of malpractice, poor hygiene, understaffing and underpaid and overworked doctors who are toiling to climb the ladder of financial security with dreams of eventually establishing thriving private practices to secure the returns that they deserve from years of hard work and laborious study.

Defeated at every turn by an inept system and earning a pittance, it is no surprise that eventually these doctors discard the practice of evidence-based medicine and choose instead to deceive the public with all manner of false diagnoses and unnecessary medical advice. Just this week, there was a petition filed by a doctor in the high court highlighting more than 100-hour work weeks with night duties, leading to disgruntled, stressed, fatigued doctors who are naturally prone to committing serious medical errors.

In addition to inadequacies of funding, another problem is the absence of quality nursing care. For quality allopathic medicine, the most research proven healthcare system in the world –despite claims by competing traditional medicine systems peculiar to different parts of the world, such as osteopathy (the US), homeopathy (Germany), Hikmat (Pakistan and India) and Chinese medicine (the Far East) – one needs to begin with quality training institutions in the fields of medicine and nursing.

While Pakistan has no dearth of renowned medical colleges – such as the Aga Khan University, the King Edwards Medical College and the Allama Iqbal Medical College, among others – it has no quality nursing institutions that comply with international standards, with the exception of the nursing school at the Aga Khan University.

The result is a force of well-trained doctors with an international demand, but complemented with a poor supply of quality nursing – which is as essential, if not more, in a well-integrated healthcare system. Many countries around the world, including third world countries, are renowned for producing quality nurses. These countries include the Philippines, India, Sri Lanka, Indonesia, China and Malaysia. Our concept of nursing still largely revolves around a woman– a maasi or a mai in rural areas in particular – who is poorly trained, lacking in personal hygiene and thus fitting in hand-in-glove with the poor standards practiced by the institutions that employ her.

This sad state of affairs warrants attention immediately from the powers that be who must recognise that across the world the institutions of excellence in healthcare are either government-funded or private non-profit ventures, which are supported by charity. The former has no examples in Pakistan while the latter only includes the Shaukat Khanum Memorial Hospital for cancer patients and a few eye care hospitals, such as the Shifa Eye Trust Hospital (run by personnel of the armed forces) and the LRBT eye clinics. Meanwhile, the Edhi Trust is renowned only for their ambulance service in the healthcare arena.

A hybrid of public sector funding and private charity, one of its kind and internationally acclaimed, is SIUT in Karachi and can provide much insight into how an efficient hospital may be run with maximum outreach and through no compromise on quality healthcare. But this requires foresight, political will and a sense of duty and responsibility of living up to the calling of public office.

The writer is a freelance columnist.

Email: kmushir@hotmail.com

Twitter: @kmushir