Bad doctors by the dozen
Who are these doctors accused of administering steroids, admittedly afraid of police raids, and yet running successful practices?
Asifa, a frail woman in her mid-20s, recently resumed her job after taking a week off. She works as a house maid in Lahore and regularly experiences palpitations and severe weakness. But instead of a prolonged treatment, she prefers quick doses of “energy waves” through injections, from a small, nondescript clinic near Cavalry Ground.
“After the doctor gives me a course of three injections, I feel completely revived,” says Asifa breathlessly. She remains out of breath through the conversation. “But since I work day and night, and raise three children of my own, I need the treatment every month or two. My employer took me for a blood test, which showed that I have an iron deficiency. She even gave me multi-vitamin tablets. But sometimes I forget to take them”. And so, to cope with her rigorous routine, Asifa depends on taaqat kay teekay (energy boost injections) from her local doctor.
These quick fixes are one the few ways people like Asifa are able to find temporary medical relief without visiting state health care centres, which despite being affordable are time and effort consuming. But some experts eye such sudden energy boost injections with suspicion, fearing that they may include steroids.
“Steroids have an immediate effect, which is why patients who take them are instantly pleased,” explains Dr Areeba Farrukh, a Pediatric Resident at National Institute of Child Health (NICH) in Karachi. “But patients are only made aware of the ease, not the side effects of steroids. Continuous use of steroids may cause obesity, stunted growth, hair loss and a harmful impact on all the systems of the body,” warns Dr Farrukh.
To confirm whether Asifa was administered a steroid injection, Soch Writing contacted Asifa’s doctor, but he was persistently ‘unavailable’.
Another doctor, who runs a similar, small, private clinic in Cavalry Ground, Lahore, also politely refused to comment. He complained that whenever he answered journalists’ queries, these interviews were followed by police raids due to an alleged complaint of unhygienic conditions or some other pretext. But despite his frank admission of past police action, his clinic is operational, with a long queue of patients waiting for their turns.
According to the World Bank, the average value for Pakistan between 2000 to 2016 in terms of health spending as a percentage of Gross Domestic Product, was a mere 2.69 per cent.
So who are these doctors allegedly administering steroids, afraid of police raids, and yet running successful practices?
“Such doctors, if qualified, are mostly holding only an MBBS degree with no specialisation and yet, instead of referring special cases like that of dermatology or paediatrics to specialists, handle the patients themselves,” says Dr Areeba Farrukh.
In simpler words, medical graduates with minimum or even no experience of serving with a reputed, senior doctor, or graduates practicing without a medical registration would be included in the list of unqualified doctors. In Pakistan, to pursue his or her own medical practice, a person needs to acquire a license of Registered Medical Practitioner from the Pakistan Medical and Dental Council (PMDC).
A more threatening category would be of those practitioners who do not have medical degrees. These often include pharmacists or medical assistants at pharmacies and clinics, and are sometimes called ‘quacks’.
According to the PMDC, there are over 600,000 non-registered medical practitioners in the country. This year, The Economist magazine, reports that a health-care census conducted earlier this decade found that in Punjab alone, Pakistan’s most populous province with 110 million inhabitants, there are between 70,000 and 80,000 unqualified practitioners. Therefore, it can be understood that medical graduates with minimum experience as well as pharmacists, homeopaths and herbalists, often pose as General Physicians.
Moreover, these ‘doctors’ are also known to treat complex medical issues, such as cancer, liver and renal failure, infertility and impotence.
Such under-qualified doctors are affordable and accessible, with their clinics mostly set up in nooks and corners of residential areas across the county. Patients say they have a friendly and warm demeanour and they customise their method of treatment as per the suitability, requirement and demand of their patients.
But the biggest reason for a large part of our population depending on such unregistered doctors, is the lack of state-run health care centres; and with low allocations in the fiscal budget for the health sector, the situation is unlikely to improve. According to the World Bank, the average value for Pakistan between 2000 to 2016 in terms of health spending as a percentage of Gross Domestic Product, was a mere 2.69 per cent.
Public healthcare institutions that address critical health issues are often only located in major towns and cities. Due to the absence of these institutions and the cost associated with transportation, impoverished people living in rural and remote areas tend to consult private doctors. In urban areas, the situation is only slightly better.
“Pooray din dhakkay khanay aur waqt zaayeh karnay say behtar hai aadhay ghantay main dawai lay aayen,” says Mohsin Ali. “Who knows what will happen tomorrow? At least we can live today in peace.”
In Karachi, the most populous metropolitan city in the country, Jinnah Postgraduate Medical Centre, Abbasi Shaheed Hospital and Civil Hospital are the only government-run health care facilities which provide treatment either free or at a minimum cost. National Institute for Communicable Diseases caters to children free of cost. Lahore, the second most populous city, has five centres with relatively large-scale facilities provided and run by the state: Mayo Hospital, Services Hospital, Lahore General Hospital and Jinnah Hospital, along with the Children’s Hospital.
While in the developed countries, education and health care are among the facilities provided by the state to all citizens irrespective of their social status, in Pakistan, it is uncommon for privileged classes to avail public sector facilities. It has become a status symbol for the wealthy and even the middle-income class to approach specialists and institutions of repute in the private sector, who charge an outrageous fee. To make a comparison, a General Physician of considerable repute in Lahore can charge around Rs3,000 only as a consultation fees. Supplementary tests, further check-ups and cost of medicine is additional.
For the general public across the country, day-long queues, limited staff and overpopulated beds in state health care centres, along with long commutes, often prompt even low-income class citizens to turn to private sector for relief.
“If one does not possess their own transport, like a motorbike, the first hurdle is the cumbersome ride to a government hospital,” shares Mohsin Ali, a man in his 30s, working as a driver in Lahore. Interestingly, this ride is also taken using facilities from private sector, like a rickshaw or cab, mostly through ride-hailing apps. Here also, public transport is deemed unreliable.
“Then after entering the gate, you have to get in queue to receive a token slip mentioning which ward should the patient be sent to. Upon reaching the designated place, the normal waiting period is anywhere between a 1-4 hours. On the contrary, our local doctor in Lahore Cantt sees the patient within minutes!” says Mohsin.
Even the difference in cost is not a deterrent for poor citizens to avail state sector health facilities. “At the Hospital, the token slip may cost around Rs20. Check-ups by doctors are free and so are medical tests and medicine, if provided by the hospital. On the other hand, the doctor near our home charges Rs200. If he gives some medicine or administers an injection from his clinic, that is part of the fees. If we come the next day for a check-up and more medicine, we again pay the same fee,” explains Mohsin Ali.
The law and public health
But the spread of unprofessional medical practitioners forebodes higher risks. The Economist while quoting Punjab’s health-care commission, says these unregistered practitioners are threatening public health. The publication warns that, “Reuse of unsterilised syringes and other implements is spreading blood-borne diseases such as Hepatitis C. This scourge is especially alarming because many backstreet clinics specialise in pick-me-up steroid injections for almost any ailment. Lax prescription of antibiotics is helping to breed bacterial resistance to them.”
In the wake of the latest HIV outbreak in Ratodero and Larkana, where over 700 people, mostly children have been found infected with the viral infection since April 2019, healthcare commission authorities have launched a province-wide crackdown against unregistered doctors. It had earlier been learnt that reusing syringes and intravenous solution drips by doctors was the major cause behind the spread of the HIV infection.
The Sindh Health Care Commission’s Anti Quackery Department’s head recently said that they have sealed 350 clinics and laboratories, while over 50 clinics had been issued with warnings to improve their infection control and meet other requirements. Last month, the District Health Authority in Sargodha sealed 188 clinics and 150 unregistered medical stores during an ongoing campaign, in the city area.
Medical malpractices are covered under the Health Care Commission Act, which is a provincial legislation, with each province having its own act.
“It is primarily the responsibility of the Health Care Commission officers to check and curb practices by unqualified doctors. But the weight usually falls on the police,” explains SP Shah Nawaz, who has recently been transferred to Karachi after serving in Lahore.
Laws governing medical negligence under the Sindh Healthcare Commission Act 2013 and the Punjab Healthcare Commission Act, 2010 prescribe a maximum fine of Rs500,000 as penalty in case medical malpractice is established against a doctor. Section 26 (2) of the Sindh Act gives it the power to refer a case to a governmental authority or a law enforcement agency for appropriate action.
“The problem, however, lies in the arbitrary manner in which these powers are exercised,” says Barrister Muhammad Ahmed Pansota, referring to cases where grave negligence by a doctor may result in the death of a patient.
A doctor running a small, private clinic complained that whenever he answered journalists’ queries, these interviews were followed by police raids.
Recently in Karachi, the death of a young child, Nashwa, due to medical negligence of the doctors gave rise to many questions about their accountability. Nashwa passed after a wrong injection was administered to her. Nashwa’s father withdrew his case on the condition that the hospital administration would establish a state-of-the-art paediatric ICU at their health facility by May 2020. According to the agreement, the hospital owners would annually pay Rs5 million to the “Nashwa Fund”, established by the girl’s parents for the treatment of needy and deserving patients. It adds that the hospital will provide at least one scholarship to a medical student on an annual basis for their MBBS or BDS education.
“Rarely do commissions refer a matter to the police, and in cases where it does the police usually charge the accused with punishments for committing ‘Qatl-i-khata’ and ‘Qatl-bis-Sabab’. These laws insist on an absence of intention,” explains Barrister Pansota. He argues that since MBBS graduate doctors are expected to know about effects, side-effects and dangers of medicines which they prescribe and use for patients, doctors against whom a charge of medical negligence stands established, must be prescribed a punishment of death penalty.
Other experts, however, suggest that instead of relying on capital punishment, the government should take preventive measures to avoid major health accidents. “Local governments should check the documentation and registration of private clinics on a routine basis,” suggests Dr Areeba Farrukh.
With regular checks on medical malpractices, vigorous campaigns educating the public about health issues and provision of facilities by state in local areas within the reach of people, a shift can be made from taking advice of local, ill-experienced doctors to those that are reliable. Moreover, stricter legislation and its implementation by law enforcement agencies can also help curb the proliferation of medical malpractice.
However, for the average citizen, unconcerned about long term impacts, a temporary but quick treatment usually suffices.
“Pooray din dhakkay khanay aur waqt zaayeh karnay say behtar hai aadhay ghantay main dawai lay aayen (Instead of wasting half of the day in stressing oneself, it’s better to get medication within half an hour),” says Mohsin Ali. “Who knows what will happen tomorrow? At least we can live today in peace.”