Wednesday July 06, 2022

Public healthcare in Pakistan

April 18, 2019

I saw a hospital as an insider when I was 11 years old. A ruptured appendix that (surprisingly) felt like irritating twinges till the third day when I became completely immobile. Rushed to Emergency in a state of half-consciousness, I remember asking the surgeon if I would make it to my friend’s birthday party that same evening. I missed the party but a few days later, the doctor took time to explain the CT scans that showed a pool of abscess in my abdominal cavity. I was lucky to have kept my intestines intact but I stayed a guest at the hospital for several days... an interested spectator to my own treatment, curious about the tube dangling out as it drained residual fluid, comforting my attendants through clogged cannulas, and experiencing the miraculous if exhausting effect of third-generation broad-spectrum antibiotics. That is where I had my first and most serious lesson in biology and my first step into the world of medical science.

Since then, I have been back several times. A football injury that got me the title of Captain Hook because of the metal hook attached to my fractured toe. The gaping wound that was laid bare to anti-rabies injections after an encounter with an unfriendly dog and other less memorable visits meant the imposing red building remains a familiar place. But what one sees as a patient in a private room at the country’s most premier hospital is not representative of the wider health industry in the country as I learnt first-hand during summer internships in two large public hospitals in Karachi and Abbottabad.

At Jinnah Hospital in Karachi, the situation of thousands of patients is unbelievably difficult although, even in the most harrowing of surroundings, there are some centers of excellence manned by doctors, nurses and paramedics working tirelessly and with almost no resources. The hospital takes five thousand patients in a day, treating everything from gun-shot injuries to brain surgeries for free or at a fraction of the cost involved. An MRI that costs Rs. 30,000 elsewhere is done for Rs. 4,000 and that too waived in deserving cases. The only cyberknife in the country is available free of cost for thousands of people who flock every day for major non-intrusive surgeries. The hospital feels like a city on its own, with barracks upon barracks of emergency rooms, clinics, surgical wards and theatres, laboratories and research units; yet hundreds sit in the open, waiting their turn even if they are breathing their last. Despite having the largest ER in the country that can treat up to 2000 patients in a day, emergency cases are routinely turned away because there is no way to accommodate them all while still others die on stretchers. A very far cry from what I was accustomed to in my bubble of fortunate privilege.

Takeaways from my experiences in Ayub Medical Hospital in Abbottabad and Jinnah Hospital in Karachi during two consecutive summers point at wider problems stemming both from poverty and complete failure of successive governments to address the needs of the poorest segments of society. Those denied the right to an education make poor choices.

The man who came from a remote fishing colony in Sindh with a maxillofacial tumour that was as large as his face had relied on the power of prayer and ‘taweez’ and by the time he found his way to Jinnah, the growth was too far advanced. The young man with XDR Typhoid, that cannot be treated even with the strongest antibiotics, was on his death bed. He was only one of thousands of people exposed to dangerously stubborn salmonella typhi because of unhygienic food or sewage contaminated water in Sindh. The woman with end-stage cancer who was not allowed to seek treatment by her mother-in-law came when the pain became intolerable. So many cases were backed by superstition, ignorance, poverty and misplaced ideas of honour. But Jinnah Hospital is also a place that inspires hope. General Surgery Ward-26 stays awake and alert all the time. One stood through a laparoscopic cholecystectomy to remove a gall bladder damaged by unbalanced diet, followed by a lumpectomy to remove a breast tumour, followed by extraction of a bullet from a collapsed lung and so forth. The procedures went on endlessly, doctors working 12 hour shifts that easily morph into 18 hours with grit and positivity. In fact, my direct supervisor often put in extra hours not because he had to but because he wanted to. These doctors would only have one day off, and sometimes not even that.

Some surgeries were easy to watch. Others, like manually removing fecal matter from blocked small intestines, were an exercise in resolve. Later, I asked my supervisor how everyone appeared unconcerned by the unbearable stench and he explained nothing registered in surgery but the surgery and I understood why doctors are a breed apart.

Our healthcare suffers from problems that have as much to do with being a poor country as general indifference of the government functionaries. In Ayub Medical Hospital, people from all the surrounding valleys flock to this big town for medical emergencies. My first experience of death was seeing the body of a baby who was barely a few months old. His father had first trekked it from his village in Kohistan and then taken a bus to Abbottabad but by the time he reached us, it was already too late.

The conditions that lead a parent to carry a critically unwell child for emergency care over a journey that takes almost 24 hours are hard to imagine. But that was only a glimpse into the horror of the pediatric ward where children of all ages regularly died of easily preventable dysentery and dehydration. Another case that I doubt I will ever forget is the teenager who had been attacked by a rabid dog. Vaccines were available for free and within reachable distance in the district heath office but because the dog appeared normal, the patient was brought to the hospital only after the virus had advanced to his brain. I was told dozens of people die of rabies every year because they are unaware of the importance of immediate vaccination, or at times because the vaccine itself has expired.

As the days turned into weeks, I saw fatal injuries, cancer patients, suicidal ones, and those who found release in death after a great deal of suffering. For inexperienced eyes like mine, these sights were traumatic not just because of obvious human suffering but also because so many instances were preventable and treatable. At least one part of the enormous burden on health services can be reduced through awareness. An early visit can make the difference between life and expensive disability or death. If the government cannot afford to or is not able to invest in better healthcare, it must look for viable alternatives. The cyberknife in Jinnah hospital is a successful case of private-public partnership where private individuals and companies invested in equipment and provide oversight of operations while the government provides free land, utilities and covers doctors’ and other staff salaries.

This is a great idea but it relies on the goodwill of concerned citizens. In the end, it is the responsibility of those who collect taxes to make sure everyone has access to health services as a matter of right and not as a favour or donation. If they cannot meet this critical responsibility, they have no right to govern.