Sunday, 11 November 2012

We Survived Sandy

(A little background on this piece. I am visiting the United States these days as a fellow of "Emerging Youth Leaders of Pakistan" program, initiated by the Atlantic Council, funded by the Carnegie Corporation of New York. This post is a recollection of memories gained in New York, our first destination.)
Times Square
Ad for Newsies
Maine Monument, Central Park
Library of Columbia University
Seinfeld Restaurant
Cathedral of St John
NY Skyline from Rockefeller Center
View of NY from Empire state building

We Survived Sandy

Do you Speak Arabic?” and “Are you wearing a [suicide] vest?” were two of the questions I was asked when I told people that I was from Pakistan. It is usually said that you take some part of your country with you wherever you go and the first thing you do in another country is to confront their stereotype about you. Being in New York, that too during one of the worst storms in the history of the city, was a great experience to have. The first thing I noticed as soon as we reached JFK Airport was the large number of visitors, mostly from Eastern Europe, who were waiting to go through Immigration. I have heard nasty/creepy stories about Immigration at U.S airports but what I got was quite non-descript. No cavity search, no long interrogations, no suspicious looks or change in attitude. It was a bit disconcerting as well to know that they didn’t deem me important/suspicious enough to at least do a full body scan.!! 

As soon as we slipped out of the airport, we faced a gush of strong chilly wind which accompanied us throughout our visit. We reached our hotel after forty minutes of travelling(or sleeping, in my case) and were welcomed there by Mr. Shuja Nawaz and Huma from the Atlantic Council. After depositing our luggage in our respective rooms, we got a chance to wander out in the streets of New York. During that detour, I discovered that Cart food is considered good in New York, which is totally contrary to what we(or at least my family and medical fraternity in general) think about cart food in Pakistan. We got Shawarmas from “The Halal Guys” and later had a walk up the avenue to visit Times Square.

After our first visit of Times Square, we got addicted to it and we visited Times Square at least once daily. We got pictured on the camera feed present there, ventured up the red steps, got loads of pictures and what not.

In the preceding days, we were largely confined to our hotel due to the “Franken-Storm” named Sandy. We had two intellectually engaging sessions with Mr. Shuja Nawaz and I got to meet Prof Manan Ahmad at Columbia University. It was during the meeting with Mr. Manan that I realized where I was sitting at that time. It was the “Seinfeld” restaurant, the exterior of which was showed in almost every episode of my favorite television comedy show. It did not have the same interior design but it was nonetheless a great feeling for a die-hard Seinfeld fan to be at that particular Diner. We also got to visit Columbia University and had lunch at a nearby Japanese Restaurant. I still don’t remember what I ate that day(I was clueless while eating as well).

During the visit to Columbia, we went to witness Cathedral of St. John the divine, which is the 4th largest Christian church in the world and probably one of the biggest Gothic churches in the world. It had an exquisite exterior and I don’t think I have ever seen a building that grand and beautiful in my entire life. We encounter a shady(albeit Silver-Tongued) character there who, apart from detailing the history of the church and its reconstruction, also pestered us with Conspiracy theories and how different “signs” had already appeared on the walls of the church forecasting the future.

Being in New York City during Sandy was both a nightmare and an opportunity to witness emergency management in a “developed” country by ourselves. Early Warnings were issued and the local government responded to the storm as well as they could. A lot of difficulties had to be faced, including power shutdowns and absence of the Subway system, which practically paralyzed the city. Many of our plans had to be shelved because of these problems but we still managed to walk around the city, as much as we could. It was a unique opportunity for us to have a firsthand experience of how a “Developed Country” responds to national emergencies and disasters. We have seen what happened in our own country in the wake of Earthquake in 2005 and Floods in 2010 and 2011. Due to effective management and early warnings, the impact of the storm was reduced and less than a hundred people lost their lives due to the storm, which does not reflect accurately the gravity of the situation. 

While we were busy confronting our own stereotypes, we also discovered how wrong so many people have been about New Yorkers. It is usually said that New Yorkers are arrogant, detached and apathetic. I confess that one week is too soon to reach any conclusion but at least for this much duration, we(or at least I) found New Yorkers to be none of the above. I had previously thought that taking so many pictures and getting people to take pictures of us or with them would be at least a bit annoying for most people, but No sir, it was not the case. We got pictures with Cops in Times Square at 11 p.m., with paramedics on Broadway at 5 in the morning and asked a florist at 6 a.m. to take a picture of our group. None of those people even displayed a smirk. A taxi driver once refused to charge some of the fellows because he was a Pakistani while a Rickshaw driver gave us good enough discount on the ride. My beard was also supposed to be a problem for me but it never was, not at the immigration, not in the city, not in any of the offices that we went. 

It is also frequently said by travelers that a city can only be truly explored if you walk through it. I have done this experiment previously and have fallen in love with parts of Lahore because of this exercise. In New York, all we did was walking. We were fortunate that our hotel was located near so many memorable places and we got the chance to explore a lot just by walking. On a personal note, I am not a big fan of pets but the amount of cute dogs I saw on the streets of Manhattan reduced some of the strong feelings I had about this issue. Initially there was some problem with food, as after breakfast we had so many options but their “Halal-ness” was not verified so we were reluctant to experiment. I am already a vegetarian so it was not a big gastronomic shock for me but for some of our fellows, it was a very difficult time. I had Japanese food for the first time which I liked, not so much the American staple diets. 

United States is supposed to be the Land of Free so the first thing that I did upon reaching my hotel was to use YouTube, which has been blocked in Pakistan for the last few weeks.
My mind couldn't stop comparisons when I saw different things in the streets of New York. Cart Food, which is shunned by most well-off Pakistanis, is considered good enough in New York. Tap Water can be used for drinking purposes, without a second thought about any water-associated illness. Thank Yous and Sorrys are much more common. No one gives you a second look, whatever your skin color or dress might be. People get out of the way if you want to get pictures of a particular place. Zebra crossings actually work and vehicles would stop for pedestrians even if the pedestrians are violating the rules. No one cuts through the line, how long that might be. No whistling in theaters. People generally follow time for meetings and excuse politely as soon as the time finishes. These few little actions may not be thought of much by people in the U.S because they have grown accustomed to them but for folks from the "developing world" (thats a misnomer), they are fascinating.   

We visited a grassroots organization working for development of under-privileged South Asian children, named SAYA (South Asia Youth Action). It was heartening to witness active community participation in helping the community itself. We also visited an office of the United Nations Organization (UNO), where we met the Chief Knowledge management office of the UN. Later that day, we visited the Rockefeller Centre and Grand Central Station, both of which are among favorite tourist destinations.

One fine morning, we decided to visit Downtown area and ended up in Greenwich Village. To our utter amazement, there was no electricity in the area, reminding us of Pakistan. We even saw a utility store which was being run under the light of a solitary candle. Most of the shops were closed and streets were generally deserted. We saw a statue of Mr. Gandhi in the Greenwich area. It was followed by a spur of the moment decision to visit the Empire State Building which was nearby. I and another fellow were among the first batch of visitors to the Empire State building that day (tours start from 8 a.m. onwards). It was an out of the world experience to be standing on top of Empire State and finding the city of New York under our feet. It was really cold up there as well but the joy and excitement were overwhelming. It was a proper “Empire State of Mind”.

We visited the offices of New York Times, one of the most widely read newspapers in the world, on 2nd November, 2012. For an aspiring journalist such as myself, it was akin to visiting Heaven. The one thing that caught my eye apart from the exquisite interior design was the amount of books present on each of the staff's workstation. Despite being a bookworm myself (6 half/quarter-read books lying on my own side table), I was amazed. I don't know many journalists or press people in Pakistan who read such a huge amount of books (a few of them do, but they are exceptions not the rule). Douglas Schorzman, Foreign News Editor of NYT talked to us about various issues regarding NY Times. He was joined for sometime by Susan Chira, assistant managing editor for news of The New York Times. Mr. Douglas was eloquent in answering queries of inquisitive youth leaders from Pakistan and provided detailed answers. He also took us on a short tour of the News Offices. We were able to appreciate the “Open Culture” at New York Times which represents transparency on part of the Newspaper. 

To conclude our visit of New York, we got a chance to watch a Broadway Show. Two groups were formed, one of which opted for watching “The Lion King” while the other, including myself, opted for watching “Newsies”. It was one of the most exhilarating experiences of my life. No wonder the play won the prestigious Tony Award for best play. Performance of the actors was so good that one of my companions wondered if it were a 3D movie? I have seen and acted in semi-professional theater in Pakistan and have watched some good theater performances but Broadway was a different galaxy altogether. It was surreal, magical, and inexplicable, beyond the reach of words. It was the perfect ending to our Topsy-turvy tour of New York, a cherry on the top. 

Thursday, 11 October 2012

Brain Drain(Part 2)

(Published in The Friday Times on 12th October, 2012)

Dr. Adnan was the best graduate of his MBBS session three years ago. He had achieved the highest marks in almost all the annual exams during his five years of medical school. He completed his house job of one year and spent almost 6 months in preparing for the entrance exam to a Residency program in the United States (the USMLE or United States Medical Licensing Exam). He cleared the first two stages (it's a three-stage exam) with ease and applied for a visa, so that he could visit the United States and take the third and final exam of USMLE. But he was denied a visa for the United States. He has spent almost 300,000 rupees in fees for the tests, and it has taken him a year for him to reach this stage. But his efforts have been in vain.

126,931. That is the number of Registered Medical Practitioners (people who have obtained MBBS degrees and have completed a house job of one year) in Pakistan, according to the Pakistan Medical and Dental Council. Every year, some 8,000 fresh medical graduates join this list. A vast majority of Pakistan's medical graduates want to move to either the United States, the United Kingdom, Australia, the Middle East or other green pastures in the world beyond Pakistan. According to a report aired on Geo News on 8th August 2012, Pakistan has become the largest exporter of young doctors to Britain's state-funded National Health Service (NHS). The number of Pakistanis registered on the GMC (General Medical Council) data stood at 8,552 on 7th of August, 2012. Similarly, according to a research paper titled 'Pakistani Physicians and the Repatriation Equation', published in the New England Journal of Medicine, Pakistan has contributed approximately 10,000 international medical graduates (IMGs) to the United States. In a research conducted in 2007 titled 'Reasons for migration among medical students from Karachi', it was revealed that Over 95% of Aga Khan University (AKU) and over 65% of Baqai University (BU) final-year medical students intend to go abroad for their postgraduate training.

And all this while Pakistan is facing an acute shortage of trained doctors, according to reports by the World Health Organization (WHO).Pakistan cannot meet its needs for healthcare, given the current levels of production and dependency on physicians in the organization of the system. Although out-migration contributes to the problem, it is the growing demand for healthcare from increases in population and adverse conditions that generates ill-health. The most important question to ask about this mass migration is: Why are all these people leaving their country?

The answer is manifold and, speaking as a health professional myself, painful to state.

The survey done on medical students of Karachi's elite Aga Khan University and Baqai Medical University revealed that the two most important factors behind this intent as pointed out by the students are poor salary structure and poor quality of training in Pakistan. I can vouch from my personal experience that as soon as a medical student enters the medical school, the next big question regarding his/her life is the "plan" or path he/she intends to take after graduation. Even during the one-year training of the house job - something I am currently pursuing - the queries about the "future" are among the most frequently asked questions by one's seniors and family members.

It is an absolute travesty that in Pakistan the practice of "Career Counseling" for medical professionals is practically nonexistent. Most middle-class parents only have three or four career options for their kids: Doctor, Engineer, Banker/Accountant and if all else fails, Army. In a similar fashion, when a medical student enters medical school, it is from his/her seniors that guidance about any future plans is acquired. Traditionally, there are four ways to pursue post-graduation for Pakistani students. The first one is the FCPS (Fellow of College of Physicians and Surgeons, Pakistan) route, which involves four years of clinical training at a tertiary care hospital in Pakistan. After completing four years of training and passing the FCPS exams, you are considered a specialist in whichever field you chose to pursue. The second and most attractive option is that of obtaining a residency in the United States, where the training standards are the highest in the world. For that route, a candidate has to go through the three stages of the USMLE exam (the examination fee for each step is more than 1.5 lakh rupees), the third of which can only be done in the United States.

After the residency and an exam, the candidate becomes "Diplomat American Board" for the chosen specialty. It should be noted that the ratio of people who get their desired residency after passing the exams is around 50-60%, which means that despite getting excellent marks, you are not guaranteed to get your favored specialty (for example Anesthesia or Neurosurgery) in 50 to 60% cases. The time required to complete this whole process ranges between 3 to 5 years.

The third option is that of pursuing post-graduation in the UK. To follow that route, one first has to pass the PLAB (Professional and Linguistic Assessments Board) exam, which is a two-stage test. The examination fee for each stage is also more than one lakh rupees. After completion of PLAB, post-graduation courses are taken, based on available spots in the preferred specialty. The whole process of completing this route takes around 5-7 years. An alternate route to acquiring British certification is the MRCP/MRCS (Member of Royal College of Medicine/Surgery) route, which is a two-stage route, but the training can be obtained in Pakistan while exams have to be taken in the UK.

The fourth and latest addition to the options is that of post-graduation in Australia. For that, a candidate has to pass the entrance exam of the AMC (Australian Medical Council), which also has two separate tests. The examination fee for each step is in the range of the fee for USMLE. There is no guarantee of getting a post-graduate education in Australia even after getting excellent marks in the first entrance exam.

Most medical students in Pakistan don't know which path they will take, even whether they will be able to work in their desired field or if they will get a job where the salary is adequate after about ten years of medical training. And this, I am sorry to say, is the primary dilemma of the medical community, the so-called "cream" of the Pakistani nation.

Saturday, 15 September 2012

Doctors Strike: The Aftermath

Doctors’ Strike: The Aftermath

It has been two months since one of the largest strike by doctors shook the province of Punjab. It all started with the closure of Outdoor Patient Departments (OPDs) in all major hospitals across the province as a gesture to protest against the attitude of the Government of Punjab in provision of a better service structure for Doctors. It was a move designed to be of minimal impact because only ‘stable’ patients visit OPDs and there was no threat to patients’ lives. Last year similar protests by doctors led to a commitment by the Chief Minister to provide a new service structure and committees were formed to pave the way for formulating an acceptable formula. The closure of OPDs happened after one year of useless meetings with the representatives of Punjab government.

Last year, government was unable to control doctors and the chaos led to loss of many precious lives and ended with a truce. This time around, Khwaja Salman Rafiq (brother of Saad Rafiq and Special Assistant to Chief Minister on matters of Health) was designated the responsibility to ‘deal’ with the situation. Punjab Government started giving half-page advertisements in all major newspapers stating it had already done too much for the doctors and that doctors were essentially getting too big for their own boots. An estimated Rs. 1.6 million per day was given to newspapers and Rs. 450 million of public money was spent on advertising by ‘Khadim e Aala’s government. In addition, Essential Services Act was enforced by the govt, making it mandatory for doctors to do their OPD duties or else receive legal proceedings.

On 1st July, 2012(after 21 days of OPD closure), a police raid was conducted at Doctors’ Hostel, Services hospital Lahore, resulting in arrest of numerous doctors. The same night, hundreds of other doctors were arrested from their homes. There was another raid at Doctors’ Hostel, King Edward Medical College on the night of 2nd July. A total of 360 doctors were kept in Jails including Kot Lakhpat, Attock and Mianwali for four days. As a result of all this, emergency services were withdrawn from all major hospitals and any negotiations were made subject to release of all the doctors.

I want to recount some of the ‘stunts’ pulled out by the government during all this, apart from ‘Advertisement’ money from the public exchequer.  

1. ‘Medical Martial Law’:

As a ‘contingency’ plan during the closure of OPDs, Punjab government requested help of Army Medical Corps (AMC) to decrease patient overload. This was an unprecedented act of desperateness and expediency shown by the big-wigs of Punjab Government. This ‘experiment’ did not work out though. It failed miserably. Senior Doctors said it on record that the Army doctors were not trained to deal with such situations. Additionally, those doctors were paid Rs 2000 per hour of duty and special police contingents were employed outside hospitals where the Army doctors worked. For comparison, government of Punjab was paying Rs 800 per day to junior doctors and Rs 1400 per day to seniors whose places the Army doctors took for few days.
There were reports of those Army doctors misbehaving with the senior doctors and the ‘flexible’ duty hours practiced by our 'Jarri Jawans'. At the start of the Strike, Zaid Hamid's Baloongra's alleged that YDA punjab is actually “NGO funded Young Animal Association” and they work for money, not for saving lives. The 'Brave' Army Doctors that came 'to the rescue' didn't work for free though. This is the characteristic selective Amnesia practiced by Qibla Zaid Hamid and his followers.  For the Record, only 200 Army Doctors were deployed.!!!

The PCO Doctors

During the strike by Junior Doctors, Government hired around 500 new doctors (in place of around 5000 doctors) on ad-hoc basis. Those individuals are known these days as ‘PCO doctors’. They mostly include foreign graduates (who can’t normally get jobs at Government Hospitals as per orders of Chief Minister) and people who could not get job in ordinary circumstances. Some people, who had not practiced medicine for more than 10 years, joined the service just to get a paid Job. Chief Minister Punjab is fond of parroting the mantra of ‘Merit’ but these blatantly out-of-merit inductions did not gain his attention. All these people were hired against the rules and on ‘paid seats’ while more than 50% doctors work in government sector without getting any pay.

The legal Front

Apart from hundreds of doctors arrested without any justification, four doctors from Mayo Hospital were charged with Murder of a child that died in the Pediatrics Ward on the night of 1st July, 2012. The Strike was also challenged in court and it resulted in involvement of Lahore High Court in the matter. The court ordered to release all doctors who were arrested without any legal reason and granted bail to the four doctors alleged to be involved in the Murder. It was further ordered that matters pertaining to Service Structure should be solved amicably by the Punjab Government.

Lies and Damn Lies
Throughout the strikes, there was a continuous propaganda mongering done against the ‘Cream of Nation’. Government Officials lied on Television programs and press-conferences about doctors being greedy, selfish, hooligans etc. The entire Advertisements campaign consisted of Jacked up figures that were used to fool people.

The Aftermath

On 2nd August, one month after the strike, a follow-up meeting was called up by Young Doctors Association in Services Hospital Lahore. Dr. Amir Bandesha, member of the committee delibrating the future service structure, explained at length about the proposed changes to the existing structure and the points on which a consensus had been reached between Punjab Govt and YDAP. ‘PCO Doctors’ are still working in the hospitals despite resumption of services by young doctors and it is the demand of YDAP to transfer them to DHQs and RHCs.  After the meeting of general council of Young Doctors Association on 29th August, 2012, province-wide protests were held on 5th of September to exert further pressure on the Govt to solve our problems. Committees have failed to provide us any relief and even the Lahore High Court has been unable to enforce the writ of law. Another Protest/Dharna is planned for 19th September and a March to the CM Punjab House after that. Is another showdown between doctors and State on the way?

Friday, 14 September 2012

Brain Drain-1

(Published in The Friday Times on 14-09-2012)

,703 candidates appeared in the entry test for medical colleges in Punjab last year, competing for 5,271 seats in 40 public and private medical and dental colleges. Nearly 3,500 seats are available in 15 medical and 3 dental colleges in the public sector, while 1,850 seats are available in private medical and dental colleges. This suggests that the top 3,000 candidates would be able to secure admission in the public sector and around 2,000 more will get admission in Private Medical Institutes.

These figures raise the question: What about the rest of the 28,000 students who passed FSc (Pre-Medical) with more than 60% marks but were deemed not good enough to get admission into a medical college, either due to merit or financial issues, as Private Medical Colleges charge almost half a million rupees every year only in tuition fee? 

As the saying goes: where there is a will, there is a way. And that's another way of saying that students who want to become doctors should make use of opportunities to study medicine abroad.

Medical education in developed countries such as USA,UK, Australia and Canada is much more expensive than in Pakistan, so the options for most Pakistani students are either China or the ex-Soviet states such as Kazakhstan or Kyrgyzstan. Medical Education in these countries is imparted in English, so there's no worry about language barriers. Browse through any English or Urdu daily in Pakistan and you'll see advertisements for institutes in these countries. 

This trend of going abroad to get a degree in medicine started in the 1990s when Central Asian colleges became a destination for students who lacked good marks. It should be pointed out that the minimum eligibility criteria for the Medical Colleges Admission Test (MCAT) is 60% marks in FSc. Initially, students with marks as low as 35-40% were able to secure admissions in Central Asian colleges. It was a dream come true, a shortcut bypassing the system in Pakistan. Chinese medical institutes offering medical courses in English started in the last decade.

At present, around 2,000 Pakistanis are studying medicine in
various medical schools across Kyrgyzstan. According to the
United Nations, a July 2006 survey of medical students at nine
institutions in Kyrgyzstan rated their level of knowledge
between 2 and 2.6 on a five-point scale. In China, there are 6
 medical colleges and 1 dental college recognized by the
Pakistan Medical and Dental Council (PMDC). Each of these
medical schools has around 150-200 Pakistani students per
session. Nine hundred Pakistani medical students are presently
studying medicine in Cuba on scholarships awarded by the
Cuban government after the 2005 earthquake. But PMDC does
not recognize Cuba's medical colleges and the living conditions
of our students there are pathetic. Around 100 Pakistani
students are studying medicine in Bangladesh.

Vulnerable students are duped into some of these places with
fancy titles like 'WHO Recognized Medical Institute'. The fact
remains that WHO (World Health Organization) "has no
authority to grant any form of recognition or accreditation to
schools of medicine or other training institutions. Such a
procedure remains the exclusive prerogative of the national
government concerned." (This is WHO's own clarification.)

The Pakistani state has done little to stall this "business".
Pakistan's embassies in the respective countries do not own
the students if they face any difficulties regarding the whole
process. In Cuba, students live 15 Kilometres away from the
city in which their college is located. In China, many
universities which are not officially recognized enroll students
using paid agents in Pakistan. Every admission gets the agent a
fixed amount of money and the unsuspecting student can't get
out of this maze easily.

The big problem facing Pakistan's health system is the influx
of these Foreign Educated Doctors and their integration into
the system. These medical graduates are not at par with their
counterparts from Pakistan-based institutes and that creates a
chasm in their ability levels. In almost all the foreign
universities, clinical training, the backbone of undergraduate
programs, is seriously lacking because of obvious language
constraints. You can teach students in English but you can't
teach them all the required nuances of the local language in
such a short period of time. Without the necessary knowledge
of the local language, how can anyone get a good medical
history from a patient? (Around 70% of clinical diagnoses are
based on a patient's medical history.)

PMDC has made it compulsory for all international medical
graduates to pass a specially designed test to practice medicine
in Pakistan. This is the only intervention done on a
governmental level for these doctors. A lot of those who can't
pass the test end up working for private hospitals, as they
can't get jobs in the public sector. This alternate pathway for
medical education is going to flood Pakistan with a lot of
substandard doctors very soon.

Thursday, 16 August 2012

Diary of a young doctor(part 6)

(Published in The Friday Times on 17th August, 2012)

Medical Science, like other disciplines of science, is a constantly evolving subject. New discoveries are being made, new ways to treat and look at diseases are being researched and newer drugs are being introduced on a daily basis. But the medical profession in Pakistan is lagging far behind the rest of the word in innovation and research. Very little, if any, research is being done by public sector hospitals and medical colleges. Apart from the Aga Khan University and Shaukat Khanam Hospital, there are no recognizable research centers in the country. Due to this issue, most of the books we consult during MBBS are written by Western or Indian authors.
t may come as a surprise to the reader that doctors in Pakistan are required to do research as part of their curriculum, both at the undergraduate and post-graduate levels. The ground realities, though, are very different. Very few of the "researches" done by Pakistani authors are published in international publications. On the undergraduate level, the research is mostly very basic and does not require much critical thinking, nor is it up to an international standard. The Community Medicine departments (responsible for overseeing research) ask students to choose from a particular list of topics on which research can be done. No funding is provided for the purposes of research. Students usually take shortcuts just to fulfill the academic requirement, and the matter is over after the final exams.
n the post-graduate level, where research is an important tool in the rest of the world, Pakistani doctors do not spend enough time on research topics. Most of the topics are re-hashed versions of the same old 'traditional' things. A grand sum of Rs 2,200 can get you a good synopsis on your chosen topic. Plagiarism is not thoroughly checked, so liberties can be taken in that regard. I questioned some of the senior doctors about this trend and they pointed out a few factors responsible for this problem.

he foremost issue is financial. Most post-graduates do not have job security and often have to work at multiple hospitals. In addition, they do not get any kind of funding for the sake of research. In such conditions, all they do is look for shortcuts to fulfill the academic requirement. In Shaukat Khanam Hospital, doctors are paid handsome salaries and have job security, resulting in some serious research work being done there. The proposed Service Structure that was the demand of doctors during their recent strikes is a much-needed step as it would at least provide job security, if not lavish pays.

he second most important reason for lack of research is the absence of critical thinking from our curricula. Research is borne out of questions about persisting problems and requires finding solutions to problems. We, on the other hand, learn and see throughout our academic life that 'he/she who crams the most, achieves the maximum marks'. From nursery school all the way to the final year of MBBS, we learn how to rote-learn particular texts and then regurgitate them in our exams. Questions are discouraged at almost every level and many teachers think it a disgrace if they do not know the answer to a student's question. In addition, there are almost no research societies working in medical colleges. The only one that I encountered was a small society working out of Punjab Medical College, Faisalabad.

he third factor in this regard is the lack of teachers and instructors who can guide students about research. This problem is present both in medical schools and in the College of Physicians and Surgeons, the premier body that awards specialization degrees in Pakistan. In many cases, the supervisors for research are not well-versed in the art of evaluating a research paper as it is very different from an examination paper.

espite all these problems and glitches, there are still some success stories. Pakistani doctors, particularly surgeons, have developed many indigenous solutions to the problems they have faced over the years. The need of the hour is to promote critical thinking and research among the medical community so that Pakistani doctors can compete on an even keel with their international colleagues.

Friday, 27 July 2012

Diary of a Young Doctor(part 5)

(published in The Friday Times on 27th July, 2012)

"I am really thankful to you doctor sahiba, you saved my daughters' life today," said the mother of a young woman to one of my female colleagues.

The very next day, another attendant had this to say,

You doctors are murderers. You don't know how it feels when your loved ones die. You have killed our young brother. We will never forgive you."
Both of the above-mentioned statements reflect a common misconception in our society, that doctors are supposed to be messiahs who save lives. I may have to face the wrath of some of my fellow professionals for saying it out loud, but this can't be farther from the truth. During the five years of medical school, followed by countless years of medical training, all we learn are a set number of protocols to follow. There is no subject or even a chapter dedicated in any of our books on 'How to Save a Life' (excuse me for the reference to a song with the same name by the band The Fray). The main problem with this assumption is the immense responsibility it places on the shoulders of the attending physician/surgeon. Doctors, in general, safeguard the best interests of their patients but having the mantle of 'saviour' placed on their shoulders is more than a little unfair.
As a result of the 'messiah' label, doctors become the automatic fall guys when a tragedy occurs. Doctors are obliged to do their best, regardless of the expected results, and when their efforts fail, the first impulse of the attendants is to blame the doctor for the demise of their loved one. I am not saying that medical science is guesswork; but why is the medical profession considered a "calling from God"? It is high time we learned to differentiate between a profession and a calling from God. Doctors are "working" in hospitals. They aren't on a divine mission to save everyone who comes their way. They provide a service and in return expect to get paid for it. (And we know how that's gone done in our country.)
When doctors announced a strike to demand for a better service structure, the widespread reaction was that doctors should be philanthropists who put others before themselves and don't ask for a compensation package in return for the time they have invested.
To quote the columnist Ayaz Amir: "The young doctors' strike was not about doctors versus ailing and suffering humanity. In the Islamic Republic suffering humanity is a handy cliche, readily invoked to score a political point and as readily consigned to the upper layers of forgotten memory when the need passes. If anything, this strike was doctors versus a hidebound bureaucracy, one of the most ossified bureaucracies in the lands which can claim descent from the British Raj."

During the strike by doctors, one of the major objections was that doctors were supposed to provide health services in any condition, as they have taken an oath to do so. Let me make it absolutely clear that in the original Hippocratic Oath that was formulated around the year 425 BC, there is no provision that makes it mandatory for a doctor to provide health services to anyone who wants them. In the revised Hippocratic Oath, constituted by the British Medical Association, one of the points declares: "I will do my best to help anyone in medical need, in emergencies. I will make every effort to ensure the rights of all patients are respected."
Similarly, according to PM&DC (Pakistan Medical and Dental Council) Ordinance of 16th July 2011, Section 9, Sub-Section 2 (a) : "A medical or dental practitioner shall be free to choose whom to serve, with whom to associate and lay the timings and place of professional services to be provided."

While Sub Section 2(b) reads: "A medical or dental practitioner shall not be bound to treat each and every person asking his/her services."
In my opinion, one of the underlying causes of outrage against doctors during the strikes was the "messiah" proposition. How can someone who is supposed to "save lives" go on strike? As a nation, we are prone to miracles and magical rescues; we are always hoping for some messiah to come and save us from the "mess" we are in. This messiah complex has in the past led to acquiescence to dictators and demagogues. We, as a nation, need to mature and start believing in processes and institutions, not saviours. Bottom Line: Doctors are not messiahs; they are ordinary professionals doing the best that they can.

Monday, 16 July 2012

Reflections from Pakistan India Social Media Mela 2012

(an abridged version published by Express Tribune Blogs on 16th July, 2012)

Question: What is the one common thing between a writer from Mumbai, a Journalist from Delhi, a famous film maker from India and a Junior doctor from Lahore?

Answer: The fact that all of them loved hearing Iqbal Bano(it was actually Meesha Shafi, as pointed out later by Jugal Mody) sing 'Dasht e Tanhai main' on the radio, at wee hours in the morning while waiting to get CNG at a gas station in Karachi. 

For me, that one moment captured the spirit of Pakistan India Social Media Mela 2012. No wonder the slogan of the event said, “Faasla Na Rakhen, Pyar ho Jaanay Dain’(Translation: Overcome distances, Let love happen)

Organized in Karachi by PeaceNiche, in collaboration with the United States Consulates in Lahore, Islamabad and Karachi, it was supposed to be a gathering of social media enthusiasts from India and Pakistan. This being Pakistan, the criticism leveled at the event started much before the event itself. It was an invite-only affair and most people who were invited were recommended by other people. Participants from Lahore and Islamabad were sponsored by U.S Consulates in Lahore, Islamabad and Karachi for their travel and accommodation.

It was my first visit to Karachi and I was really excited by this opportunity. I boarded the plane from Lahore airport on the evening of 12th July, along with the rest of participants from Lahore. The visit was not only an opportunity to interact with new people but also to get a respite from the hectic schedule at the hospital. During the flight, I had a good, long chat with my seat mate whom I discovered to be a fellow participant. I got some flak after the plane landed, from assorted uncles who were unfortunate enough to have gotten seats around us. The first thing that I noticed after landing in Karachi was the wind. We were transported to Avari hotel and allotted rooms. When I reached my designated room, I had to pinch myself to judge if I was not dreaming. The rooms were spacious, comfortable and had attached baths separated by glass walls.

We were offered BBQ dinner at the top floor of the hotel. That was where we first met fellow participants from India including Onir, Karuna John, Jugal Mody, Venket Ananth, Sabbah Haji, Annie Zaidi, Raheel Khurshid and Sanjay Rajoura. I immediately struck cordial notes with one of them because of me being a vegetarian. Later, I took part in an interesting discussion about Marxism, Class Struggle and Pakistan Movement taking place at an adjacent table.

The next two days were one of the best that I've had.  Despite being an adopted Lahori, I didn't miss Lahore for a moment. I wouldn't have met many of favorite people at one place if I had not come to the mela, including Nadeem F Paracha (one of my mentors), Ali Chishti, Marvi Sirmed, Beena Sarwar, Mohsin Sayeed, Muhammed Hanif, Faiza S Khan, Musharraf Ali Farooqi, Declan Walsh, Amir Mughal, Murtaza Solangi, Hassaan Belal a.k.a mighty, Sana Saleem, Ali Arqam, Zebunnisa Burki and the wonderful people from across the border. At the start of first day's session (around 9 a.m. which was an inconvenience for many people) Senator Rehman Malik, usually at the receiving end of mockery by social media people, was generously praised for urgent attention to the visa problems faced by guests from India.

The sessions were mostly insightful and informative but I personally enjoyed the off-session activities where I got the chance to interact with some amazing people.

Some of the memorable sessions dealt with online activism, role of social media in education sector, use of non-profit for non-profit organizations, online activism, Pakistan-India relations, ‘Slactivism’, impact of party politics on Social Media, Internet Censorship, Cyber-Bullying and Twitter as the new Newsroom. 
 I was a panelist at the session 'Fight Club:Rise of the Troll' alongside Bina Shah, who had come fully prepared with research, Mohsin Sayeed, star of our show and a delightful presence throughout the mela, Raza Rumi and Rab Nawaz, editor of the magazine Laaltain and member of Khudi Pakistan. Some sessions were, indeed, boring but that is how things work usually. Due to my involvment in the recent doctors' strikes, I had plenty of questions to answer. I was branded 'the revolutionary doctor' by Sher Ali, an Express Tribune reporter and 'Hartaali doctor' was my nick name. After the first day, the event was declared open to everybody because of the quips about elitism and exclusion.

There was a Qawalli session after first days’ proceedings and it featured Fareed Ayaz and Abu Muhammad, the best Qawwals in Asia. They enthralled the crowd with their renditions from Sufi poetry.
There was a standup comedy act on the second day by Sanjay Rajoura and he left the audience rolling on the ground with his observational comedy about Facebook albums, Indian Cricket and some social peculiarities. He received a standing ovation at the end.

Contrary to popular expectations, the event did NOT offer a solution to the Kashmir Problem, brought an end to killing of Shias and Hazaras in Pakistan, decreased the level of radicalism in Pakistan or ended the hostility between Pakistan and India. Kashmir was mentioned, but only as a barter for Coke Studio by Sanjay in his stand up act. The issue of persecution of minorities was discussed in detail and panelists included members from Ahmedi, Hazara and Christian communities. It was a social media event, not a Track 2 diplomat meeting. There were many Hazara participants there as well, which was encouraging. It was not a kitty party and for the record, only two women were actually wearing Sari(Even if they were, Whats wrong with that?), so over-generalizations have to be avoided.

 It was a unique coming together of people who know each other mostly by twitter names and such events should take place at least once a year. It was a tremendous effort by Sabeen Mahmood and her team at PeaceNiche, and I would like to thank and congratulate the team at PeaceNiche and the U.S Consulate staff for their co-operation and hospitality. I would also thank my new friends from Karachi and India, for their love and company. I left the event with a heavy heart, new friends and acquaintances and countless good memories.  

A big shout out to my new friends
Faizan Lakhani, FurSid, Aroosa Shaukat, Sheru, Tuba, Shiraz Hassan, Osama, Faheem(@smokenfog), Yasser Latif Hamdani, Shahab(@UncleFu), Rab Nawaz, Sara Muzzammil,  Awais Aftab, Bilal Tanweer, Salman Lateef and Zeeshan Haider. 

Sunday, 15 July 2012

Diary of a young doctor (Part 4)

(published in The Friday Times on 13th July, 2012)

Pay Up
"Please give me some money, I'm hungry and don't have any money to buy food," said the beggar.

"I wish I could, my friend, but I earn less than you do," was my reply. And I was not bluffing. 

There is a simple basic rule that governs almost all professions in the world: you work and that earns you money. There are strings attached to this simple fact according to diferent fields but the basic notion remains the same. Soldiers claim to fight for the country, police officers risk their lives for maintaing law and order, public servants work (or at least they are supposed to work) to provide services to their countrymen. At the end of the day, however, they all get paid for it. From the highest offices of the country to the lowest, from generals to chowkidars, from CEOs to clerks, the maidservants that work in houses, sewage workers, technicians, sales boys, they all get paid for doing their job. But in present-day Pakistan we are making one big exception to this rule: doctors.

I have chronicled the lives of young doctors and have described the trials and tribulations associated with their job. It is hard to believe that despite all this hard work, most doctors working in public sector hospitals are not paid. Imagine a person with 17 years of education, working 28 days a month, doing 30 hr/48 hr duties, and earning a grand total of zero rupees per month. 

Imagine a life with no pay, no job security and no health insurance (given that we deal routinely with HIV positive and Hepatitis C infected patients). All that keeps us going are the 'thank yous' of patients and a hope that someday, things will be better. 

After the doctors' protests last year, pays were increased. This does not mean that everyone is getting that pay. In the department where I work, there are 28 people working as House Officers and around 30 as Medical Officers/Post Graduate Trainees (PGRs). Out of 28 House Officers, only 8 are on the paid seats while the remaining 20 are working on 'honorary' basis (there is not much honor involved; it is a euphemism). Similarly, out of 30 Medical Officers, only 15 are getting paid. The situation is similar or worse in other departments and hospitals across Punjab. People working on honorary seats perform equal duties, do everything as others do, the only difference is that they are not paid for doing that work. This is a unique and frankly disgusting way of treating a professional, and there is no precedent for it anywhere in the world. Apart from interns at offices, everyone gets paid for their jobs. At times, even the Senior Registrars, after 10 years of medical training, have to work on honorary basis. 

There is an inside story to this practice. Theoratically, the seats in wards of teaching hospitals are preferably given to the graduates of the institute that the hospital is attached to. This results in unequality at times because graduates of other institutes opt for institutes in bigger cities. In the case of Punjab, graduates from all over the province prefer to do their clinical training in either Lahore, Multan or Rawalpindi. There is also the issue of non-residents. If a resident of Lahore got admission in Rawalpindi Medical College or Nishtar Medical College, he/she would prefer to complete his/her post-graduate training in the native town. Due to this shuffling, there are more candidates for less seats and departments employ different people on honorary basis. The merit list for giving a job for post graduate training starts from graduates of the same institute. Second on the list are graduates of other government institutes and lastly, the graduates of private medical colleges, including the ones in China and Russia.

There are ways that people bypass the merit system, because in Pakistan there is a single key for every lock: Sifarish. If you have the requisite Sifarish, you can bypass the merit and get a paid seat in your desired department. 

To cope with the economic pressure due to lack of any pay, doctors from public hospitals look for jobs in the private sector which forms 80% of our health sector. As a result, most of the unpaid (and in some cases, even the paid ones) do jobs at private hospitals in the evenings and in public hospitals in the morning. After living for more than 25 years on the largesse of your parents, if you still do not earn anything on your own, it reflects poorly on you. Also, during post-graduation, a lot of doctors are tied in the knot of marriage and it is difficult to ask your parents for sustenance of another person while you earn nothing. I personally know some people who delayed their marriages because they did not have the means to support a new member of the family. In some other cases, the young doctors were the only source of income for their families and had to wait till completion of their post graduation to marry. 

This system of 'honorary' jobs should end as it is nothing but a kind of slavery.