© 2014 Marina V. BAKANOVA
2014 – №2 (8)
Key words: medical anthropology, medicine in Pakistan, health, disease, organization of medical education, organization of medical care, Pakistani laws in the public health sphere.
Annotation: This article deals with problems of genesis, evolution and prospects of official medicine in Islamic Republic of Pakistan. It looks into the problems it encounters at present, analyzes both its positives points and drawbacks. The article discusses significance of official medicine for Pakistani society, relations between state-governed and private practices, levels of education of medical personal. It also touches on the question of why alternative methods of treatment are still in active use.
Modern Pakistani medicine includes three independent parts: official medicine (called “engleez” – English), “homeopathy” (that includes phyto-therapy and herbal medicine) and spiritual & religious practices. We can also single out a separate medical care system of Pakistan which consists in semiprofessional assistance to women with gynecological or obstetrics problems conducted by hereditary midwifes – daya.
One of the causes why alternative medicine in Pakistan still holds a strong position is historical. Modern European medicine arrived to its territory by the rules of British administration at the time when India was a little part of the British Empire. It did not grow out of local methods of treatment.
Modern medicine started its own practice in Pakistan around 150 years ago. It was mostly practiced by army doctors who arrived to Lahore with units of British army. Some years later they settled down also in Karachi (after an international port was opened there in 1869 it grew rapidly from a little town to megalopolis). The British army founded a resort place in Himalaya (near modern Islamabad) in the little town of Murree with mild climate like that in South Europe.
In 1860 the first medical college was founded in Lahore, now known as King Edwards Medical University. It was the fourth college of professional medical education opened up in South Asia. It had a serious reorganization in 1911 and got the name of “King Edward”. In 2005 it was awarded the rank of university. Mayo Hospital for general and surgery patients, as well as Lady Aitchison Hospital for woman care were affiliated with the university. In Karachi the first Medical High School and hospital were opened up in 1881 (now it is called Liaqat University of Medical and Health Sciences); Lady Dufferin Hospital for women care was founded later, in 1898.
De-facto, these new centers could not solve the problems of public health sphere. European medical care was available only for Europeans and Europeanized groups of population. In 1920-2930s the system of health care got some impetus to develop, when foundation of many hospitals, medical schools and centers was sponsored by British or Indo-British philanthropists.
The division of British India into two parts – India and Pakistan – aggravated the problems in medical sphere. Some doctors and medical personnel were moving from Pakistan to India and backwards, a lot of them went to England or other English-speaking countries. From 1947 on, Pakistan had the minimum number of doctors. All sectors of the health care system needed reformation.
Health care was greatly boosted during the reign of Zulfikar Ali Bhutto who was trying to build Islamic socialism in Pakistan and invested in developing all parts of the social sector. Medical students who graduated in 1970s were the ones to open up multiple high-quality medical universities in 1990s and 2000s. In the mid-90s a lot of women got a chance to obtain medical degree.
Contemporary Pakistani medicine is based on the British-founded healthcare system. It is divided into state and private sectors. The later one is of primary importance for the healthcare sector. Big private hospitals provide to Pakistani people high-tech medical care like IVF/ICSI, neurosurgery, cardio surgery, orthopedic surgery, etc. However, this type of high-tech medical complexes can be found only in big cities.
Medical education in Pakistan lasts 5 years (after 10 years of school and 2 pre-university years in college), after which students go through a one-year hospital practice (in therapy, surgery, pediatrics and gyn/obs departments, 3 months in each) called ‘House Job’. After that every doctor receives MBBS degree of General Practitioner and s/he can start their own career either in state or in private sector. Many doctors combine these two, because the obligatory work time in state hospitals is only 6 hours daily (with two weekends). To specialize in one particular field young doctors need extra education in medical universities or postgraduate colleges. Admission to them is not easy, weak candidates cannot pass entry exams. This education continues 1 to 4 years and after final exams doctors get a specialist license. The best specialists who perform high-tech surgeries and manipulations receive additional education in foreign countries. Pakistan does not have a system of defense of Master’s or PhD’s dissertations; for last 2-3 years only King Edward Medical University has been trying to make first steps in this direction.
Pakistan has a great shortage of state hospitals. Some of them are very big city complexes, but many of them are just small rooms in villages. Typical of them are long queues, paperwork (this can be tricky, as some Pakistani people don’t have passports), and delay in admission that can reach 4-12 hours in emergency cases, and from several months to 1 year in case of planned hospitalization. The state hospitals can refuse to admit a woman in labour if she does not have a medical card from this hospital. Many drugs and pieces of medical equipment are absent, that’s why patients are forced to buy them out-of-pocket. Tests (blood and other) are officially free, but the results are often several days late. Many hospitals sell kits to draw blood and other medical test to patients (plastic containers, test-tubes, syringes) earning money in this way.
Even so, state hospitals are overcrowded. They are full of poor patients and those who have state health insurance. State hospital rooms are usually big and can fit 25-30 patients plus patients’ relatives (one relative allowed with patient for admission to care for him/her). Postgraduate students stay and provide consultations in the same room; they also sleep here during night shifts. Obstetrics departments are organized even worse: in one big room divided by small screens stay both women on bed rest (to prevent miscarriage), women in labour and women with newborns after delivery. Quite often due to abundance of patients 2 or 3 people lie on one bed (they sleep in turns or head-to-toe). Another problem is that in Pakistani culture it is common to arrive to a hospital with a lot of relatives, including newborns, small children and elderly. All of them stay, eat and sleep in the hospital’s halls and community parks.
De-facto, Pakistani private medical care has decreased the burden placed on state hospitals. Only 20-25 years ago patients in state hospitals overcrowded all available spaces, not leaving space to walk down the halls. In addition, government sector of medical care is the perfect provider of patients for private hospitals. Many doctors have their own private practice and suggest well-to-do patients to switch to private hospitals, as they provide faster and better services.
Private medicine in big cities and big hospitals is identical to European or American, where leading Pakistani specialists have studied. Treatment and service conditions vary according to how much a patient can pay for the medical care. That is why private hospitals have both VIP services and mid-class services. Nevertheless, in every case quality of treatment in private hospitals is better than that in state hospitals.
The biggest problem of Pakistani medicine is a catastrophic shortage of personnel. At present the proportion of doctors to patients is around 1:1500 (in Russia it is around 1:240). However, this is only a national average. De-facto, in big cities and in central Punjab situation is better. But the lowest number of doctors and the biggest deficiency of them is in Baluchistan, Khyber-Pakhtunkhwa and mountain areas. That’s why in the suburbs of big cities, in little towns and villages there are many hospitals which don’t have doctors, only paramedics. They provide all doctors’ functions, from medical check-ups to surgeries, which cost low, but are also of quite low quality.
Let’s stress the difference in education types of nursing staff. We can divide them into two unequal groups: with medical education (minimum) and without it. In state hospitals and in big private hospitals all the medical personnel have diplomas. Most colleges for paramedics are private, and are opened up by doctors having education licenses. The other part of paramedics only get practical experience in hospitals, where they are employed as assistants of nurses without salary and study nursing on site. It is worth noting that to work as a paramedic for young men from mid- and low-class families is quite prestigious, because it gives them a chance to open up their own small private practice in the future. However, the attitude towards female nurses if often ambiguous. Sometimes they are associated with prostitutes and leave this job after getting married.
The situation with drugs in Pakistan is quite normal. A lot of foreign pharmaceutical companies open their branches in Pakistan; there are also many local companies. Some of them provide drugs by high quality standards, others are mere placebos with very low dosages of active substance. The government of Pakistan tries to fight with low-quality drugs, but not always successfully. Many companies which manufacture fraud drugs move the manufacturing facilities to Peshawar, where law enforcement is very weak. The good-quality drugs are often expensive, so many patients choose cheaper analogues, sometimes recommended by pharmacists. That’s why the effect of some drugs in many cases is doubtful.
It is also worth noting that a doctor’s salary in state hospitals is quite high, the base rate not counting additional payments is around 700 USD (for comparison, teacher’s salary is around 400 USD). Moreover, many form them have some sort of private practice. Nevertheless, many doctors leave Pakistan to find job in other countries: USA, Saudi Arabia, countries of Persian Gulf, Great Britain, Canada, Australia. 17 000 doctors from Pakistan have legal jobs in USA hospitals.
Traditionally, a separate and exclusive place in Pakistani medical system is occupied by military doctors. Besides, the army has perfect hospitals for officers, soldiers and their families, the best medical equipment. The best graduates of medical universities are suggested jobs in these hospitals. Military doctors have much higher salaries, housing and transport provisions, maximum pensions, their children get education in best schools.
Although a doctor in Pakistan is a representative of the upper strata of the society with high and extra high incomes, all doctors are members of several labour unions which fight for their rights. Local doctors hold rallies and strikes on a regular basis that lead to pauses in work of all hospitals in a small town or a district. The government prefers to satisfy doctor’s claims, rather than provoke a full-fledged revolt of patients and their relatives.
The system of the emergency care works also both on state-cased and private levels. The main problem is that the ambulance car can not provide on-the-spot emergency care and de-facto it just performs transportation services. Another nuance is that road conditions in Pakistan do not allow cars with “Red Crescent” to arrive to patients on time. Some functions of the emergency care are performed by the Department of Resque (analogous to the Russian Ministry for Civil Defense, Emergency Management and Natural Disasters Response). However, many patients arrive in hospitals with their own transport (including the one driven by animals). Many bedridden patients are delivered to hospitals with their own beds by vans or trucks. Around 5 years ago it was impossible to call any doctor home. Nowadays, some doctors visit and check their patients at home, but only those who are permanent and can pay high amounts of money.
Contemporary medicine takes roots in Pakistan in a quite problematic fashion, as its passage in this country was not that long. These days the government of Pakistan is taking measures for optimization and activation of medical care, but they are not effective. For example, a government program devoted to registration of hospitals was initiated 3 years ago. It rigidly regulates quality and quantity of medical personnel and equipment depending on the class of the hospital. However, even the most well-to-do state hospitals can not go through registration process, as the standards were adopted ‘blindly’, based on ‘American system of standards’, without being adjusted to Pakistani situation. Analogous law was approved for pharmacies in February 2017. This initiative led to a series of rallies in Lahore, which ended up with explosions and deaths of several people. Fulfillment of this program is still questionable.
I think that optimization of Pakistani healthcare system is not only possible, but also necessary. However, for these purposes more fundamental research into this field is needed in order to identify real economic opportunities of Pakistan. It is obvious that “blind coping” of Western standards does not fit Pakistani official medicine.
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