I have had the privilege and honour to work in the hospitals of Karachi during and after my studies. While I served my patients to the best of my ability, my experiences opened my eyes to much that’s wrong – and the little that’s right – about the state of healthcare in Pakistan.
I learnt the importance of public hospitals, which even in the abysmal state they are in, continue to serve some of their intended purpose. Private hospitals, on the other hand, taught me about the inherent unfairness of privatised healthcare. But I also witnessed some great work being done by selfless individuals and groups, which gives me hope for the future.
On the occasion of World Health Day, I would like to share what I witnessed.
Public hospitals have some utility
Public hospitals offer medical, surgical and emergency care to a huge number of people absolutely free of cost. What many people do not realise is that they also provide specialist care 24 hours a day. During the first month of my house job, and my second overnight call, I had just returned to the call room of my ENT ward when I heard a loud knock on my door at two in the morning. It was an elderly man and in his arms was his three-year old granddaughter.
The gentleman was extremely worried and told me that the child had accidentally put something into her ear. I asked him to go to the small procedure room as I grabbed my instrument box and headed to examine the child.
I sterilised my equipment and asked the gentleman and my ward assistant to hold the child as I proceeded to remove the foreign object from her ear. Two small rosary beads came out of the girl’s ear.
After a week at my house job, cases like these became routine. But what surprised me was the grandfather’s reaction. The old man fell on his knees and broke down in tears. He told me how thankful he was and what a blessing it is to have public hospitals where there are ENT doctors at late hours of the night.
“Where else would a poor man go, if not to a government hospital at this ungodly hour? We cannot afford private hospitals where we would be charged thousands of rupees to get an ENT specialist to come from home.”
He was absolutely right. In my experience of working at a private hospital’s emergency room, I was told that an ENT surgeon charges Rs 25,000 to come to the emergency room from his home. This is just his personal fees. Add the charges of the emergency room (per hour), the procedure room (minor operation theatre), and other expenses, and you can expect a common man to go in debt.
I had another case a few days later of a five-year old girl who had swallowed a coin. The availability of 24-hour radiography at our hospital helped me determine the location of the coin and, after consultation with a postgraduate trainee, we admitted the child to monitor her.
The next morning, we located the coin – it was in the upper esophagus – and took her to the operating room where the consultant guided me in removing the coin.
I still remember the father’s tearful eyes. He told me how he had struggled to find a rickshaw at night to bring his daughter from Steel Town, more than an hour from our emergency unit, because he could not afford an ambulance.
These were just two very small cases. The emergency wards of public hospitals deal with far more severe cases and are a lifeline for those who don’t have anywhere else to go.
Lack of quality and facilities
Nonetheless, serious problems remain. From what I saw during my time in public hospitals, the quality of service was substandard. There was shortage of sterile equipment, lack of technique, and postoperative care was not at the level it should be. As a result, there is a high infection rate in patients who have surgeries in these hospitals, and mortality rates are higher as compared to private hospitals.
Doctors sometimes did not trust departments of their own hospital. I remember a domestic worker who brought his eight-month old child with high fever and drowsiness from a village near Nagarparkar. He had to come to Karachi since there was no other hospital between Karachi and his village that offered infant care.
Tests confirmed that the child had deadly meningitis. He was treated and survived. The IV antiviral therapy was free of cost. Although the treatment was free, the hospital’s staff asked the father to get laboratory diagnostic tests done at a different hospital, as they did not trust their own lab, especially for a critical case like this one.
Corruption and unethical practices are rampant
Public hospitals also don’t escape the routine ills that plague the rest of the government institutions. Considerable corruption and nepotism exists.
For example, at the diagnostic lab of one of Karachi’s biggest public hospitals, security guards demand money in return for test results, which otherwise would be absolutely free. Similarly, security guards posted at wards fleece visitors.
The nursing staff abuse their power as well. Once I found a discrepancy in the medication that we had ordered for admitted patients, which got me in a bad patch with the nurses.
I also witnessed a number of postgraduate trainees treating their relatives and acquaintances with drugs that were meant to be for the patients admitted to the hospital.
During my ENT rotation, our toolbox containing equipment worth thousands of rupees was stolen from the office in the presence of office employees. The instruments were donated by several pharmaceutical companies as well as doctors for the care of poor patients. We could never recover the lost items.
It was very common to receive phone calls from the office of the Deputy Medical Superintendent, ordering the house officer to go see a casualty immediately in the emergency room. These were patients who had made phone calls to the higher-ups – often the Interior or the Health Ministry – to get priority visitation from doctors.
These phone calls from our Deputy Medical Superintendent office were rude and offensive. When seeing these patients in the emergency room, there was always potential for verbal and physical abuse towards the doctor.
Lack of security is a big issue at public hospitals. There are countless cases where the staff is verbally, physically, and even sexually, harassed and abused.
We had a similar episode in the surgical ward of a hospital where I was working when workers of a political party attacked our team, blaming us for the death of their party worker who was admitted with gunshot wounds.
The incident resulted in a horrific assault on one of the senior members of the surgical unit. The young doctors demonstrated, called for the boycott of Out-Patient Departments and even went on strike, but were only given temporary security guarantees. Within months, such incidents became common again.
Despite the overall dismal situation, some improvements have been made in certain areas during the last few years. The Civil Hospital Karachi has received much needed assistance in form of gifts by the alumni of Dow Medical College on the respective silver jubilees of their graduation. Some of these outstanding contributions include the Dow OT Complex (batch of 1978) and the CHK Central Lab (batch of 1983).
Another inspiring unit at the hospital is the Children’s Emergency Triage Unit (Batch of 1989 II), which is supported by the ChildLife Foundation. When I was a student at Dow, this building used to be a dark, dilapidated structure that housed the pediatric emergency unit as well as the Thalassemia transfusion unit. Today, the new unit claims to have raised the survival expectancy from 15% to 70% for the children who are treated here.
Public-private partnerships have also emerged in recent years at several wards in large public hospitals of Karachi. These partnerships help provide the necessary funds to run the wards and also help eliminate political influence in hiring of staff, for example.
The improved administration, sanitation, discipline and postoperative care should go a long way in improving the quality of healthcare at these hospitals.
The Shaheed Mohtarma Benazir Bhutto Trauma Center at the Civil Hospital has eased the burden on several specialty units of the hospital. The Center, if run with dedication, should usher an era of improved mortality and morbidity for victims brought to the Civil Hospital.
Private hospitals are no models to emulate
My experience at one of the most elite hospitals of Karachi taught me a lot about the cruelty of class differences and healthcare based on affordability.
The emergency rooms at this private hospital were available only for those who had the money. The staff was trained to recognise which patient could pay, while those whom they felt would not be able to clear their dues were bluntly asked if they could actually afford treatment at the hospital. If someone was unable to pay, they were told to leave.
If any care was somehow given to those with less money, they were required to deposit their Computerised National Identity Card, which was only returned after they had paid the bills. It is extremely unethical and immoral to ask a patient if they can afford treatment, especially at the emergency, when they are in their most vulnerable state.
The hospital did not have any charitable funds set aside for this purpose and doctors were often pressurised to get the patient moving so that the bed could be emptied for those who could pay.
At the emergency room, we once received a patient who had a bleeding toe wound that required suturing. As he was being turned away at the reception, a lady, who was visiting a patient, noticed what was happening and got extremely upset. She instantly paid for the man’s treatment and left another Rs 1,000 to help any other patient who could not afford treatment. The receptionist promptly returned the money, saying that there was no such fund at the hospital.
On a different occasion, I received a trauma victim, a teenage girl, who had fallen off a motorcycle and had a severe head injury. She was brought in by another citizen who had witnessed the accident. I rushed her to the minor operating theatre and performed the ABCD’s of trauma care, but the staff kept pressurising me to have her shifted to the Jinnah Postgraduate Medical Centre.
She needed a CT scan, for which I was willing to pay from my salary. But then what? The staff asked me if the victim could afford to call a neurosurgeon.
The girl was accompanied by another teenager, who introduced himself as her brother. He was barely 13-years-old and could not make the decision to take her to another hospital. It took two hours to reach the victim’s father, who took her to a different hospital after he finally arrived. This incident taught me that although private hospitals boast about their 24-hour emergency care, their services are never free.
The man who lost everything
I witnessed similar situations at another private hospital, which also happens to be one of Karachi’s most well-known and respected establishments.
A young man was referred to us from the Civil Hospital and Jinnah Postgraduate Medical Centre as they did not have a bed with a ventilator available.
The patient, who was riding his motorcycle on his way to appear for his exams, was hit by a speeding car. He had severe head injuries as well as multiple bone fractures. His helpless father, who hailed from a village outside Karachi, in a state of despair, admitted his son to the ICU of our hospital.
During the admission, his patient’s leg was infected from a common, yet deadly, infection from the ICU and required amputation. After 11 days in the hospital, the young man passed away, leaving his father in debt worth Rs 1.7 million.
The hospital would not release the son’s body until his father had paid the dues. He paid some of the amount by selling his small plot of land where he lived. Since it wasn’t enough, he borrowed from his family and friends. He then had to sell his last possession – a camel – to pay the remaining Rs 75,000. He lost a place to live, his livestock, and above all, his son.
Physicians who continue to inspire
While discussing healthcare, it would be unfair to not recognise the incredibly humanistic endeavours of physicians like Dr Adib Rizvi, who have proved to the world that quality healthcare can be provided for free.
At the Sindh Institute of Urology and Transplantation, there are no VIP patients. Nobody takes bribes or shower favours. Each patient is seen on a first-come-first-serve basis. From admission to transplantation and immunotherapy, everything is free of cost.
The Indus Hospital is another example. Being the first paperless hospital in Pakistan, the project is the vision of Dr Abdul Bari Khan, who was also involved in the formation of Patients’ Welfare Organisation in Civil Hospital Karachi.
These inspiring individuals and many other hospitals, donors, philanthropists and social workers are an indispensable resource of benefit to our healthcare system. Without them, whatever little support the poor and the underprivileged have, will not exist.
In the end, I would say that Pakistan’s healthcare system should entirely run on the motto of Dr Rizvi: “We cannot let them (patients) die, just because they cannot afford to live.”
This article first appeared on Dawn.