Canada: Some say it’s not a country, it’s winter. In some parts of it, for about eight months of the year, the dog shit is too frozen to worry about. But what worries me most is that my fellow Pakistani taxi drivers are on the road all year round. The time has gone when Sikhs used to dominate the taxi business here; now it’s the Pakistanis who rule. From Yellowknife, a city near Arctic Circle, to the eastern cities, I can’t recall a single major city where I haven’t come across Pakistani taxi drivers.

Many of these drivers are those who jumped to the north of the border after 9/11. But a majority of them are highly qualified professionals who migrated to Canada during the past decade for a “better future for their children”. They include doctors, engineers , lawyers, professors, students, journalists and retired civil or military officers.

I also have some friends in the taxi business and many of you might not agree with me on how I see their lives. A majority of these skilled professionals came to Canada on the point systems, also known as the skilled category. Then, there is a large number of those who came here to study and ended up driving cabs. These skilled immigrants wait up to five years to obtain resident visas. However, the moment they land here, their degrees become worthless and the immediate need for survival changes their priorities. There can be no denying the fact that most of these professionals do not get a job even if they have the requisite skills and qualifications. And many of them with a Canadian Masters degree or even a PhD can be seen driving cabs.

The stated reason: No Canadian experience. So, what is Canadian experience? For most employers, it means exactly what it says — you do not have work experience in Canada. But it can also mean that an employer does not know how to evaluate the work you did outside of Canada with how it is done in Canada. It can also mean that an employer doesn’t think you’ll fit into their corporate culture. Or, it can even mean that the employer is discriminating against you. “If you are a person of color, you are seen differently,” an immigrant worker, who knows several skilled migrants engaging in “precarious” temporary employment, told me.

While employment in different fields requires fulfilling some kind of criteria, it seems rather unfair that employers insist on Canadian experience as opposed to thoroughly evaluating and examining a prospective employee. This is also why several skilled immigrants end up driving cabs instead of doing what they have been trained to do. Once, on a -35 degree Celsius cold winter day in Saskatchewan, a taxi driver pulled over near me and greeted me saying: “In Pakistan people call me “Dr. Iftikhar”, but here I am “driver Ifti”. Seeing a Pakistani doctor driving a taxi in freezing prairies was certainly not pleasant for me. Although, this was not the first time I came across a case like this: my first roommate in Canada who was a university professor in Pakistan was forced to work as a cab driver here…

continue reading Dr. Taxi

But in this debate someone has taken the other side of the issue too. I do not know if Dr. Anjum Altaf’s article, which was forwarded to me as an email attachment, though I hear it was published in some newspaper, was meant seriously or not. But it did take the position that we currently in fact have too much research output in the area of social sciences. He even took the example of the ‘poverty-line’ industry to elucidate his point.

I will come to Dr. Altaf’s arguments later. Let us first take a look at the arguments that show the poverty of the social sciences in Pakistan. Here I draw upon my own experience as a teacher and researcher in the area of economics, as well as work done by others like Mr. Akbar Zaidi. I also take up the area of economics as it is considered to be the most developed social science in Pakistan. In the area of economics, there is not a single university in Pakistan that has a well-established and reputed graduate or doctoral level programme in economics. The state of undergraduate teaching, in most places, is quite poor. The quality of teaching, again in most places, is quite bad, and even post-graduates coming out of most local programmes are not in a position to enter doctoral programmes in most top universities of the world. Of course there are gifted individuals now and then, but they succeed despite the system and not because of it. I am talking of the majority here who depend on good teaching to gain expertise and knowledge.

On the research side too, we have little to boast about. There are no reputed research institutes in the area of economics, there are very few Pakistani journals, and none of them are really very highly rated. There are few Pakistani economists, and very few who do research, and even fewer who publish in established journals. There is almost no Pakistani economist, working out of Pakistan, who is widely cited at the international level, and who is considered to be an authority in any sub-discipline in economics. There are no ‘gurus’ in the area of economics in Pakistan who have fathered an area or made fundamental contributions to an area. Most Pakistani doctorates in economics have chosen to work outside of Pakistan and mostly with multilateral agencies, and on this side, there have been few places in Pakistan to which they could have returned. Most of what is called research in Pakistan is either consulting for policy-making that multilateral and other agencies underwrite for their purpose, or it is empirical work that does not require much thinking. Economics research has to start a dialogue with the various stakeholders in the area, and Pakistani research does not do that.

What can an economist do in Pakistan? She can come and teach and if she teaches in the public sector, she will be poorly paid, and she will have to take up consulting to have a decent life. If she teaches in the private sector, she will be teaching a lot and will still have to take consulting assignments to have a decent standard of living. If she does not like teaching, she will have to join one of the multilateral or one of the bilateral agencies and mostly do administrative work, or do policy related work only. There are very few places where one can do research. Even the few research institutes that are there have to rely heavily on consulting projects to make ends meet. So quality research, in a race to do more consulting projects and more ‘policy-relevant’ work, suffers. Finally, she can join the government, and forget about doing any (research) work at all.

If this is the situation of economics, the king of the social sciences in Pakistan, what can we say about the others? Is there anyone who can argue that we have too much research in political science, sociology or anthropology? But surely, Dr. Anjum Altaf, an economist of some repute, must know these facts, and probably better than me. How can he then argue that we have too much research in the social sciences in Pakistan then? He is right in one very limited sense of the word ‘research’. There is indeed a tendency in the Pakistani ‘research’ market to overdo things, and ‘kill a fly on top of a fly’. If donors want to know about Small and Medium Enterprises (SMEs), then everyone is in the market with a ‘research’ project on the SMEs and everyone is keen to take on one. The result is many studies producing roughly the same sort of results. The same is the case with the example of poverty lines that Dr. Altaf made his test. But clearly, as argued above, this is just consulting. And more importantly, even this problem of duplication could be easily resolved if the donors, the government, and/or the consulting firms could coordinate the work. But the real issue is that this abundance at this level does not show overproduction, it actually shows the poverty of social sciences in Pakistan, in the way explained above. Dr. Altaf’s example is actually the biggest counter example to his case. 

Once we were discussing the problems of social science research in Pakistan in a group consisting mostly of economists and Haris Gazdar, a well known economist and quite a productive researcher, had raised the point that the points mentioned above, which were rehearsed in that discussion too, were all ‘supply’ related. All of the above had to do with the dearth of economists, research activity and opportunity and such like. But where was the ‘demand’? His point, and a very pertinent one, which I am now putting in my own words, was who wants research in the social sciences? And if the society does not want it, how can we expect to provide an unwanted good at decent rates? I think this is the crux of the issue. Social sciences and social scientists have so far not been able to convince the government, the people, the businessmen, the Non-Governmental Organizations (NGOs), the various stakeholders who consume the more applied forms of research, and even the public at large, that research in the social sciences in something that we should pay for and nurture and nourish. Specialist doctors are not paid more than ordinary doctors because they know more, but because they know more in a way that a society values, and is pertinent for it, and because specialist doctors have the supply of such doctors nicely controlled. Social scientists have not been able to do that in Pakistan so far. Prior to the 1980s MBAs did not have a high market value, but then the society realized that professionals were needed to manage business, and this has made a market for MBAs. So, social scientists of Pakistan, unite.

Social sciences are not overdone. They are severely underdone. In the term of economists, we are confined to a low level equilibrium with low supply, low demand and low quality. This can occasionally lead to overproduction, on donor demand, for one low quality product. But this does not make the case for ‘excess research production’ in the social sciences in general. The real issue has to do with finding if the society wants to know more about social issues, and convincing the society that it indeed needs to know more about social issues. With the increasing professionalism of the society, this realization is going to come, and the need is going to be felt. We are already seeing some growth in the number of consulting/research outfits around the country. The increasing role of the private sector, realization of the importance of health/education and other social sectors, increasing role of the NGOs and increasing focus on ‘expert’ advice is going to lead to more demand for social scientists and social science. We, as a people, a government and a society have to just see if we need to pre-empt this process in any way. Finally, there are links of social science with the democratization of the society as well, where both feed on each other, but we will take this up some other time.

“If all the drugs were thrown into the ocean, it would be all the worse for the fishes and all the better for mankind.”

What would you give for a pill that made you happy or thin or helped erase the pain of losing a loved one?

As anyone who reads a newspaper knows, some of these pills already exist, others are on the way. Is it wrong to take a pill to change the way you feel, any more than to change your blood pressure or treat an infection? Does it make us somehow less ourselves, less human?

There are legitimate concerns about our knowledge of psychotropic medications (i.e. medications that affect the brain). However, those who take the position that this is an either/or proposition fall into the same reductionistic trap that they are criticizing. The fact that medications are not as effective, or as benign, as advertised on TV or touted in popular journals and magazines is hardly news. It takes very little effort to find information that contradicts every claim of efficacy and safety. Dig a little deeper and one can enter the slightly paranoid world of ‘antipsychiatry’. In fact the debate about the efficacy or otherwise of psychotropic medications is as old as the field of psychopharmacology itself.

Some people, however, conclude that all medications cause serious problems and that their benefits are entirely a placebo effect (i.e. the medicine itself is causing no appreciable benefit; rather it is the patient’s perception that helps them).
Are these conclusions any more scientific than what they are criticizing?

It’s true that our knowledge of mental functions is, in fact, extremely rudimentary and the current tools at our disposal, crude. The basic building blocks of the central nervous comprising the brain and spinal cord system are cells called Neurons. The number of neuronal connections in the brain exceeds several billion and the possible combinations of each are several orders of magnitude greater than that.

Is it any wonder that we are mostly in the dark about how our brains function? On the other hand, compared to even 20 years ago, we have come a long way towards a basic understanding of neurochemistry and neurophysiology. We know more today about neurotransmitters, localization of brain functions, effects of trauma on the brain and the effect of degenerative changes on brain structures and function than we have ever known and our knowledge is accumulating at an accelerating pace.

I often describe medication for mental illness with an analogy of a broken TV. You can unscrew the back panel, get inside and fix what’s wrong or you can give it a swift kick on the side and hope for the best. Our current approach to psychotropic medications is, at the moment, more akin to the latter.

This does not mean that using medications for mental illness is a useless exercise. There are strong and ever growing research data on the effectiveness of these medications. Also, the placebo effect is not confined to medicines only for psychiatric or emotional illness, it occurs with drug trials for all kinds of medicines including those which are, at least to the lay person, beyond reproach, e.g. antibiotics and pain medications.

I have seen again and again in my practice that medications do help, albeit for a short time and sometimes with unpleasant side-effects. The ‘poop-out’ syndrome is a common occurrence in all patients taking psychiatric medications. It refers to the phenomenon that happens with a majority of antidepressant medication (particularly the SSRIs or Serotonin Specific Reuptake Inhibitors like Prozac, Zoloft etc. It is also being increasingly recognized in newer medications such as Effexor etc). Most people on these medications for more than a few months will, at some point, experience a diminishing effect on the same dose of medication, even though they may be taking it religiously.

The issue of non-compliance aside, there is a perfectly reasonable scientific explanation for this. The principle of homeostasis is a well known one. It refers to the tendency for the human body to attempt to move towards equilibrium in the face of an applied stress. This is the reason muscles grow bigger if exercised regularly. It stands to reason then, that if we alter brain chemistry by introducing foreign chemicals into the body, the brain will attempt to compensate by trying to move towards homeostasis. If the baseline (i.e. usual) state of brain functioning has been depression, anxiety or what have you, it will move back towards that state in spite of medications.

This is the reason that non-medication interventions such as psychotherapy, exercise, social skills training etc are crucial. Medication provides a ‘window of opportunity’ which can be anywhere from a few weeks to a few months during which the patient has to try and change the factors in their life that led them to the dysfunctional state in the first place. This may mean psychotherapy to deal with past abuse and trauma, marital or individual therapy to deal with relationship or occupational problems or group therapy to deal with socialization or substance abuse problems etc. The problem arises if people assume medication to be the end per se, rather than a means to an end. It is this group of people who will make endless rounds of doctors for more and different medications.

Regarding the research that claims that medications cause brain damage, irreversible and/or disabling side effects etc, once again, one needs to have some perspective. The commonly prescribed antidepressants are some of the most widely prescribed medicines in the world. In the US, of the ten most prescribed drugs across any specialty (not just Psychiatry), three are antidepressants. This translates into millions of people taking these medications at any given time. Prozac was first approved in the US in 1987. This means we are in year 20 of the SSRI era. If we add the older antidepressants (which came out in the late 50s) into the mix, the antidepressant era has now been around for close to a half century. Of course people have experienced side effects, some quite serious but the proportion of these is small compared to the number of people who have taken these medicines. One needs to be circumspect about drawing premature conclusions.

The same can be said about the other major classes of psychiatric medications, the so-called antipsychotics, used for more severe mental illnesses like Schizophrenia and Bipolar disorder, the benzodiazepine group or ‘nerve medicines’ like Valium, Xanax etc and the most recent group, the ‘mood stabilizers’ like Lithium, Depakote etc.

So, do medicines help people or not? The answer is a qualified yes. If a person is willing to work hard to change the factors that led to their illness in the first place medicines can provide the necessary initial impetus to get a person moving in the right direction. Subsequently with continued hard work in therapy, groups, vocational training, avoidance of drugs and alcohol etc, the illness can be kept at bay. However, mental illness, I often tell my patients, is more akin to other chronic illnesses like Diabetes and Hypertension rather than acute illness. It can be controlled but usually not eliminated.

Our goals with therapy and medications are the same. Remodeling and refining those neuronal connections in the brain that control certain emotional states, hopefully eliminating or greatly reducing the negative ones and allowing the positive ones to flourish. Both psychotherapy and medications accomplish the same goal albeit in a different way and with different time frames (one can also argue that meditation, prayer, yoga, exercise, talking to close friends and loved ones etc can have similar effects).

Psychiatric medications can be a useful means to an end. They can help people begin their path to recovery and, used judiciously, can be lifesavers. However, as with everything else in life, ‘Caveat Emptor’.

Recently a young man started chatting to me at the gym about his career options and prospects. He had just gotten his results for the intermediate examinations and wanted some advice on what he should do at the next stage. I asked him what he wanted to do with his life and what were the options that he was considering. He said he wanted to either do a Bachelors in Commerce (B.Comm.) or a simple two year Bachelor of Arts from one of the colleges linked to the University of the Punjab. His basic ambition in life was to go into politics as he had a ‘family background’ in it, and thought being a member of the national or provincial legislatures would be a ‘cool’ thing and a lucrative enough career. I suggested that he could get a degree in law or an advanced degree in management before entering politics as this would give him some expertise as well as maturity. His reply was very revealing. He said he already knew more than enough about life and everything else in the world. All he needed was a ‘degree’ that would satisfy the legal requirement for being a graduate so that he can enter politics. Given this the only thing I could suggest was that then he could do any degree he wanted and all of them will serve the purpose. As we went out he was more or less convinced that the two year bachelors was his best bet as that would allow him entry into politics the quickest.

I narrate the incident as it is quite symptomatic of the general state of things. Students, and sometimes parents, do not know what to do, they do not have a good idea of what education is all about or should be about, but modern living and exposure to the internet and western media has given them the false impression that they do know what the world is all about.

Education definitely has a vocational element to it and since most students and parents find that to be the main purpose of education let us tackle this issue first. Education should prepare a student for making decent choices about careers and should help in getting expertise about particular vocations. A law degree that does not prepare a student for all that lawyers are supposed to do would be a poor law degree, and the same is true for other vocational degrees like medicine, engineering, management and so on. But one should be wary of two things. The decision for a vocation should not be based on just market fads alone as there are many options now open to students that were not there a couple of decades ago. And parents and students should be wary of reducing the value of education to its vocational aspect alone.

When we were growing up everyone wanted to be either a doctor or an engineer. A little later everyone wanted an MBA, and then everyone wanted to be a computer expert and now even that is out so everyone tends to be more confused. But do we not need doctors, engineers, MBAs and computer experts now? Of course we do.

It is true that when a new profession opens up the returns to early entrants are high but this phenomena is very transitory and as soon as a large number of people enter that profession the returns come down towards the average (adjusting for differences in training and all that). This will keep happening as human ingenuity will keep creating new fields, new demands and new ways of doing things and so there will always be need for people in these new professions. If one is lucky enough to predict such a wave one could benefit greatly by riding it through. But clearly only a few can be early entrants, and for most the choice of vocation has to be based on other criteria.

Two very simple yet very important criteria for choosing a career are aptitude and interest. If you like something and are fairly good at it, that is what you should go for. If you can find something to do that you like and people are willing to pay you for doing it, what can be better. You will not consider that to be work and so, in a way, you will never have to ‘work’ in your life.

Similarly if there is something that you are fairly good at, that might be the career for you. Again your interest and aptitude make it an obvious choice for a career. The problem arises if you are interested in one thing but good at another. Then there is a problem and the choice is much harder. Personally I would go for interest more than aptitude in such cases, but this is a personal choice.

In choosing a career one should not be swayed unduly by ‘fads’ and what current returns are in a profession. All professions go through highs and lows. At the same time we also know that we will always need doctors, engineers, teachers, and so on. So the question is more whether you can make your space in the profession you choose, whether you are good at what you do and have a passion for it rather than what the returns are. Returns for exceptional workers, whatever the vocation, tend to be high. One of my cousin’s son had gotten a $100,000 plus job in the US as soon as he finished his bachelor’s degree from a Pakistani university a few years ago. Some of the elders in the family had chided me on my career choice of teaching then since I was not making a tenth of what this young man started making immediately after his bachelors even though I had a doctorate. Three years down the road this person has been unemployed now for a number of years and has been thinking of going back to school for more advanced work, while the tortoise of my career has been holding steady. Of course this is not to say that this sort of thing is bound to happen. I am sure my relative is going to have a wonderful future and career, but what I wanted to bring out was just the arbitrary nature of fads and the futility of making career choices based on them.

There is a larger issue involved here too. Education, especially at the bachelors level, has another purpose to it as well. Education is supposed to make the individual more literate, more aware, more reflective and able to acquire more depth as a person and as a citizen in a society. Education has a social function as well. It should make the individual a better citizen as well. In most countries the bachelors level is supposed to achieve that. Undergraduate degrees are not supposed to be overly vocational. They are supposed to help the students in becoming a more complete and well-formed person and citizen. They are supposed to develop the individual so that he/she can think on their own and can stand on their own feet.

In most education systems this is achieved by making students go through a core curriculum that is taken from a number of areas so that the holistic approach can help develop the overall personality. Students are asked to take courses in the humanities (literature, philosophy, religious thought, art and so on), in social sciences (economics, politics, sociology, psychology), pure sciences as well as mathematics. This helps in better career choices later as well, but the main benefit is that this introduction allows students to connect with what humans have thought about in the past, what they have discovered, what they have found to be worth preserving, and thus this gives us the ability to make students into better human beings.

Few universities in Pakistan offer this sort of curriculum. There are schools that offer good vocational training (the medical schools, most of the engineering schools and some of the newer universities for management and IT education), and students should not have trouble getting decent vocational training in these institutions, but it is the more general training and education that is missing from most schools. Parents have to get into the habit of demanding this education at the bachelors level. Otherwise we will continue to get young people who will believe that they know everything after their intermediate.

The Delphi was right: Socrates was indeed a wise man. At least he knew that he knew little. Most of our students think they know it all when they know almost nothing. The reasons for this are clear. We look at education as vocational training only, and we are only looking for good career fads. We do not look at it as a necessary tool for being a better human being and citizen and we do not look at it as a way of finding one’s calling. This has to change. If we do change it then only will our choices make more sense and the world will indeed be our youths to explore.

Maybe some figures would help. According to the WHO, the Infant Mortality Rate (IMR) in the U.K. for the year 2004 was 5.3, while it was 6.7 in the U.S. and a dismal 80.2 in Pakistan. Similarly, the life expectancy in the U.K. for the year 2004 was 78.5; it was 77.4 for the U.S. and 64.9 for Pakistan. U.S. data – although vastly better than Pakistan – still occupies the bottom rung of the Western world much to the chagrin of public health experts here and amidst much public disapproval.

This may come as a surprise to some that think that the U.S. healthcare system is the most advanced and sophisticated in the world – which it is. What could possibly explain this disparity? The US spends 15.2 % of its GDP on healthcare, the UK only 8% while Pakistan spends a paltry 2.4%. What is the underlying reason for the U.S. to lag behind other Western nations despite a very robust healthcare budget? The answers to these lies in the manner healthcare resources are allocated in the U.S. In this case, it is the lack of universal and basic healthcare in the U.S. that sets it back.

Public heath experts in the U.S. have long argued this point. According to the U.S. Census Bureau, about 16% of the Americans are uninsured. According to the same source, with an uninsured rate at 19.0 percent among children in 2005, children in poverty were more likely to be uninsured. While the in the U.K. healthcare is universal for at least basic health services. Contrast that to Pakistan where there is no health coverage at all. According to the WHO, 72% of the total healthcare expenditure in Pakistan is private expenses, of which 98% are out-of-pocket expenses. This factor alone puts a damper on the frequency and extent of medical care sought by the public. These disparities in health insurance translate into poor health outcomes as noted above.

Lack of universal healthcare in the U. S. and Pakistan highlight the same fact – albeit in starkly different ways. The U.S. with all its excellence in tertiary care and R&D is still a laggard in basic health numbers in the Western world. No matter how much you spend on fancy medicine, basic health coverage for all (or lack thereof) still makes a difference. In Pakistan as in any other third world country, the conclusions are more straightforward – no health coverage means very poor collective health.

Whereas in the US healthcare has become a juggernaut that is becoming more and more unruly, it is in dire need of a jumpstart in Pakistan. Experts have pointed out various reasons for that ranging from lack of political will to poor resource allocation to inept allocation processes. On a psychosocial level, the greatest impediments to a better health care system in Pakistan come from general public malaise and institutional cynicism with the deep-rooted belief that our moribund system is incurable. Unless we can overcome these psychosocial and political hurdles through a strong leadership or grassroots effort or both, the future does not look too good.

Reactions from members of the medical profession to my column last week on the sorry state of the medical education scenario in Pakistan and the worries of the British General Medical Council about Pakistani doctors employed in the UK were, with one exception, totally in agreement with the assessment presented.

The ‘exception,’ however, did agree that a proper reply must be sent to the GMC. But who can write what?

According to one doctor e-mailer, Pakistan produces far too many mediocre doctors. His calculation is that of the 10,000 doctors sent out from our medical colleges each year, some 100 are excellent, some 500 are good, and around 1,000 average. The rest are, he suggests, a hazard to public health.

His reading of why the United Kingdom has a problem with Pakistani doctors is that it gets what he terms the ‘leftovers’, as most young doctors try to get to the US. Those who are unable to go there, accept jobs in the UK and Ireland doing ‘scut’ work in some mediocre hospitals where training is unstructured and delivered in dribs and drabs.

This may be so, but it is certainly no justification for the state of our medical institutions and for the ineptitude and corruption of many who run them. To take the premier institution, the Pakistan Medical and Dental Council, the controlling body from whence all powers medical flow. It is run from behind the scenes by a Council member, who manipulates his fellow members and the man he props up as president.

Syed Muhammad Awais, Professor of Orthopaedic Surgery, King Edward Medical College, and Associate Dean, Postgraduate Medical Education, University of Punjab, sent me the following message on the subject of the Council which I have his permission to reproduce :

“First of all I thank you for your very clear article published in Dawn of 8th Jan 2006, on recent developments of the PMDC, I hope this will help in sorting out this problem.

“I have been a member of the PMDC since 2000, and was also executive member from 2001-2005. Despite all my efforts to bring quality assurance in the functioning of the Council, I could only contribute to the writing of a new Code of Ethics for medical and dental practitioners and guidelines for authors, editors and reviewers of research papers, in 2002. In the day-to-day decisions, I would like to see improvements in PMDC affairs.

“The internal politics which you have briefly touched in your article is largely responsible for not allowing the PMDC to become transparent and standardized and to function as a 21st century ‘professional regulatory body.’

“The PMDC Ordinance of 1962, and Act of 1973, required the PMDC to develop ‘regulations for its different operations’ and to further develop transparent ‘Operating Procedures’ (based on the world’s most modern knowledge) and to improve them from time to time so that the institution could perform well. Only this could have allowed inspection / review of the PMDC itself. Unfortunately, despite the repeated efforts of a few members this could not take place.

“As you have very rightly mentioned in your article, the freedom to express enjoyed by us today, is much more than in the past, and this facility must be used in a right way to promote/support the truth for protecting the rights of the public rather [than] looking after the interests of a few selected ones.

“We should with courage admit that mainly responsible for the inefficiencies of PMDC in the past and present crises are its own members (including me). PMDC exercised its autonomy without accepting its full responsibilities in many areas, including, inter alia : (1) protecting the public from bad medical and dental practitioners. (2) Maintaining the registers of database regarding medical and dental practitioners and inspecting whether practitioners are practising without registration or when retired or dead. (3) Launching minimum health care standards for different health care delivery organizations. (4) Revising the schedules of medical and dental qualifications which were written before partition. (5) Developing the modern systems of accreditation of undergraduate and post-graduate medical education, and implementation of its calendar of periodic evaluations. (5) Creation of legal cover for its examination and fee charged for re-examining foreign qualifications.

“The lack of modern standards of transparency, quality assurance, democratic decision-making and accountability are common problems of most of the public organizations in our country, and the PMDC is certainly no exception.

“The people and government of Pakistan, in the best interest of the state and society, must (1) launch modern concept of public policy, thereby allowing participation of the public and stakeholders in decision-making; (2) respect and enjoy the freedom we have while accepting the responsibilities of efficiency, quality and accountability; (3) devolve the powers to lower but collective levels (committee work) so that the king-pins cannot ever ‘hijack’ an organization; (4) discourage the selection of leaders by the state establishment and encourage public and stakeholders to choose their own leaders; (5) strengthen the rule of the law instead of the rule of the ruler. These measures could enable the PMDC and all other public organizations to function well.

“I have heard that there is a new ‘Law of the PMDC’ in the making which will be presented in the Assembly. This bill (law) has not been subjected to public / professional debate (not even discussed among the existing PMDC members). Such bills are always polar, and do not serve the public correctly. Where the PMDC and other public bodies must function correctly, the law-making should also follow the right path. We must willingly accept our rightful roles. (Ameen)”

Dr Asim Hussain, Chancellor of Ziauddin Medical University, frankly and openly admits that medical education in this country “has gone to the dogs.” Junior doctors, the leaders in an emergency situation, are grossly ill-trained both in knowledge and in expertise. And, according to Dr Hussain, the blame for the decline in this country’s health system rests squarely on the PMDC and on the CPSP and its president.

He reminded me that on January 6, a four-member bench of the Supreme Court, headed by our proactive Chief Justice Iftikhar Muhammad Chaudhry, directed the PMDC to cease its discriminatory practices vis-a-vis applications for the recognition of degrees and to formulate an authentic principle. The PMDC’s dual and discriminatory standards are illegal and unconstitutional and create mistrust among the public.

It is not only the medical authorities of the United Kingdom and Ireland who have worries and concern about Pakistani graduate doctors obtaining employment in their countries. Feedback has it that Malaysia has found that post-graduate students have been shown up to be inadequately trained, and in Australia medical authorities treat Pakistanis with the utmost suspicion, given their known proclivity for mischief when it comes to their CVs and such matters. One Pakistani doctor, who is trying to get on with his life in Ireland, has decided to identify himself as an Indian for employment purposes.

We, and the president and prime minister, need to get our act together all round, in all fields of education, administration, business practices — you name it. But we could make a start somewhere and where better than in a profession whose members are under oath to save the lives and limbs of others — and not to maim or kill them.

On November 19 2005, a report in the national press under the headline ‘President may intervene in ministry’s row with PMDC’ told us that “credible sources confirmed that even the presidency was watching the war between the Senate, health ministry and the Pakistan Medical and Dental Council with ‘concern’ . . .”. This concern related to “an unusual communication” to the General Medical Council (GMC), London.

On April 1 last year, Professor Sir Graeme Catto, the president of the GMC received a six-page letter on the subject of “Junior doctors trained in Pakistan — Issues regarding fitness to practise” from a gentleman who requested anonymity “considering the fact Pakistan has a dictatorial rule, unfortunately freedom of speech is not a privilege and the exposition of truth in particular is considered to be a threat to the relevant authorities.” (One must disagree with this statement as the freedom we have today we have not enjoyed in the past.)

The writer of the letter, who has “worked in Pakistan for many years in various capacities, finally opting for an early retirement [for] personal and professional reasons,” stated that he is a “witness to the decline in the standard of medical education and health services over the years and in particular to the extremely rapid deterioration which has taken place over the last 10-15 years …” Copies of his letter were endorsed to the presidents of the Royal Medical Colleges, England, the Royal College of Surgeons and Physicians, Edinburgh, the Royal College of Surgeons, Glasgow and the Royal College of Surgeons, Ireland.

The letter was widely circulated by its recipients to many other relevant institutions within the United Kingdom and Ireland.

The serious issues raised was the steep increase in fraudulent measures adopted by junior doctors trained in Pakistan in order to gain employment in the UK, including concocted CVs, false titles and tenures of jobs, fabricated testimonials, publications and presentations and other numerous acts involving plagiarism — all encouraged by certain senior doctors of Pakistan.

The letter gave details of how Pakistan’s medical colleges and teaching hospitals function (or rather malfunction), and how doctors obtain house jobs certificates without spending a single day in their wards. It described Karachi’s Civil Hospital as a “complete shambles” and “a den of corruption,” it blamed the PMDC, “a puppet of the federal ministry”, for letting medical education fall to the despicable standards it has reached today, it accused the College of Physicians and Surgeons of Pakistan (CPSP) of being out of control of the PMDC as the president of this institution runs it “on a commercial basis collecting exorbitant fees and has been in the chair for more than 20 years.”

Giving credit where credit is due, the writer did say that “there are still a few institutions such as the Aga Khan University, SUIT, etc, that have managed to maintain their professional standards.”

Suggestions were made as to how the British authorities should control the registration of doctors coming from Pakistan so as to ensure that fraudsters and unqualified people are not let loose to do their worst for the health and welfare of the citizens of the UK.

In May last year, the head of registration of the British Medical Council requested permission from the writer of the letter to forward a copy to the PMDC in order to seek its members’ views. Permission was granted by the writer, on condition of anonymity, and he forwarded to the head of registration a dozen copies of cuttings from our national press (this newspaper included) of news items and columns written on the shenanigans and shortcomings of the PMDC and the Pakistan medical scenario.

Una O’Rourke, the senior executive officer, registration, on August 5, 2005, addressed a ‘strictly private and confidential’ letter to Dr Nadeem Akbar, deputy secretary, Pakistan Medical & Dental Council, Islamabad : “I am writing to you regarding the enclosed letter with attachments which has been anonymized and the writer’s name withheld on request. The registration committee has considered the documentation and would appreciate receiving the observations and comments of the PMDC regarding this correspondence at an early date.”

On November 9, the same officer sent a reminder, again attaching a copy of the original correspondence, to Dr Nadeem Akbar requesting a response to her earlier letter, which in typical Pakistani bureaucratic manner had been ignored. She also sent an e-mail on the same date to Dr Akbar asking him to respond. There the matter rests. How can Dr Akbar, or for that matter anyone concerned here in Pakistan, respond? It would be futile for them to deny the charges levelled as the truth is no secret to us here in Pakistan or to those abroad who have a problem to deal with.

It is no wonder that the state of medical education and medical practice in Pakistan leaves much to be desired. This is the case in each and every aspect of education ; the systems are falling apart. Not only are those who run many of our educational and professional institutions unqualified to do so, but they are by and large expert practitioners of graft, nepotism and fraud.

The writer of the letter to the GMC, who wishes to remain anonymous, has cited the example of the president of the CPSP who has sat in the same chair for some 20 years and supervized the on-going degradation of the institution. This gentleman, whose medical academic record does not even glimmer, also wields enormous influence over the PMDC, of which he is a member, and he has a free hand to meddle in all matters, including, inter alia, appointments and recognitions of private medical colleges.

Last year, another council member addressed a letter to the chairperson of the standing committee on health of the honourable and august Senate of Pakistan, which at that time was in the ostensible process of reviewing the alleged malfeasance in the PMDC.

He related, inter alia, how the affairs of the Council were actually run by the secretary under directions from the president. As he put it, “during the years I have served on the Council, the tail has been wagging the dog and the servant of the Council is its de facto master.”

He also, inter alia, related how the secretary, instructed by his master, “pursued a narrow course of serving the interests of an influential group of medical politicians,” and how he has “been a witness to the regular manipulations of minutes of the Council and selective implementation of decisions.”

Now, one would have thought that the Senate committee, had it any commitment to its cause, would have taken some sort of action to rectify matters. It obviously did not. Last November, the Upper House was still wrangling acrimoniously over the subject of the PMDC and the health ministry’s rotten relationship. This is when it was mooted that the President of Pakistan, General Pervez Musharraf, may be called to intervene.

He should, particularly in view of the fact that the matter of doctors trained in Pakistan not being qualified or fit for employment in the UK has now been taken up by the British General Medical Council and various other medical bodies in the UK and Ireland. All power flows from the presidency and from GHQ — from nowhere else. Health is not a joke, neither are quack doctors. The general needs to wield his stick — and swiftly before more damage is done.

This drama reached its crescendo when a senior health official who had been instrumental in rallying support for the polio drive was recently killed. All this comes at the heels of a fatwa by a local cleric who declared war on the United Nations, the World Health Organisation and the NGOs aiding and abetting these ‘foreign organisations’. The Northern Areas of Pakistan have witnessed many political upheavals, especially in the days of the British Raj, but they have seen few sincere outsiders who understood their problems and culture. From a public health perspective some parallels can be drawn between the attitudes of the tribal people in Pakistan and African Americans in the US against organised medicine. The Tuskegee Syphilis Study continues to fuel African American distrust to this day. It took only a few hundred study-subjects in the Tuskegee Syphilis Study to lose the African American community’s trust in medical establishment. In the case of Northern Pakistan, it was the loss of more than a dozen lives in Bajaur Agency, among other incidents, that alienated the people.

However, there is one stark difference between the two communities. Whereas the collective American conscience seems to sag under the burden of heavy guilt when it comes to African Americans, it is quite the reverse in the Pakistani case.

The media has been quick to malign the tribal community in general. The ignorance and biases of tribal people undoubtedly played a part in all this. However, to see this refusal as a war of religion, as some are trying to do, seems a little bit of a stretch. Local attitudes have been shaped by recent events like bombings, especially the one that resulted in the killing of innocent civilians and children when the US forces were on the hunt for Ayman Al Zawahiri. Similarly, one of the clerics who most vociferously denounced the vaccinations had recently lost his brother during an attack on a madrassa by the Pakistani army.

But all is not lost in this struggle. For one thing, the proportion of kids that have not been vaccinated is small. According to a government report more than 5.7 million kids were vaccinated in January and another 3 million are due very soon. The area affected by polio, part of the North-West Frontier Province of Pakistan, is also the area where vaccination refusal rate is the highest. It is small enough to make covering it a feasible project administratively and logistically for public health officials. Also, leaders from major religious political parties in Pakistan have endorsed the vaccinations. Moreover, general public opinion about the vaccines is favourable even in the tribal areas, as evidenced by the overall success rate of the number of kids already vaccinated.

Despite all this, public health workers in the tribal areas face an uphill battle. Squeezed between tribal misgivings, Western biases and the recent loss of their colleagues to terrorism, they still need to get the job done. Public health officials have to expand their role from simple vaccines pushers to community builders. It will take patience on the part of the WHO, courage and dedication by the public health personnel and, above all, acceptance from the local tribal leaders to make any headway on this issue. The challenge is unique but not insurmountable.

I remember once one of my friends talked to me about his harrowing experience about going to a doctor back home. The ailment started as a simple backache but soon culminated into a recalcitrant pain syndrome that just would not go away. It got to the point where it was affecting his quality of life. Thereafter started his ordeal entailing doctor visits, a plethora of tests that yielded nothing except cash and kick-backs for physicians and a host of failed therapies. After a few visits my friend had a flash of brilliance. He was going to this joint specialist and nothing had worked so far. Moreover, the rheumatologist’s explanations about the diagnosis and treatment left much to be desired not to mention the hefty bills that were accumulating for those five-minute consultations. So he gathered the courage and asked the specialist if he could get a second opinion. Let me pause here for a moment and explain to you the rationale behind my friend’s move. In the US (and I am sure elsewhere in the Western world as well) it is quite common to ask for second opinions in difficult cases and physicians really do not mind this practice. My friend had lived in the US for some time and probably had a little spell of amnesia that day as well. Needless to say, the consultant took quite an affront to that and as they say the rest is history. The patient was summarily discharged from the doctor’s care and was eventually left stranded.

This story is by no means an exception or an outlier – it is the norm back home. The question is why are doctors the way they are? Why are doctors rude, perfunctory and dismissive to their patients back home? The answer to the problem is complex. The transformation starts at medical school (or as some would contend much before that). A starry eyed teenager enters the medical school with a resolve to find cure for cancer and a few years later he is transformed into an incurable cynic and a skeptic. However, this is a topic for another day. For now I am going to focus more on immediate causes instead of long-term theories. As far as I am concerned this behavior can be explained on the basis of three things (I am sure there is a myriad other causes one can think of as well). First, the way the health care system is financially structured in South Asia. Second, the way mechanisms for accountability, regulation and legislation are in place for physicians and hospitals in South Asia. Last but not least the way the public in South Asia perceives physician roles and duties has a bearing on this matter as well.

In South Asia like the rest of the Third World the health care system is still overwhelmingly fee-for-service. This means that unless you pay the physician you do not get treated. Admittedly, government hospitals do a respectable job of taking care of the indigent population; the out-of-pocket expenses are still sizable. Just to give you an example. If a patient needs surgery the OR, physician and hospital charges are more or less waived. However, the patient is still responsible for the antibiotics, intravenous drips, dressings, suture material and so on. All this can pile up to a pretty hefty sum in the end. The downside of this set-up is that it gives the physicians an unfair advantage in terms of their bargaining power. This is manifest in the type of patients they see, the fee structuring and scaling and the quality of care they impart to their patients. Due to this, health care access, cost and quality all suffer. Part of this has to do with the overall condition of the judicial bodies in this region the discussion of which is beyond the scope of this article.

Second, the state of bioethics and its implementation is still in a deplorable condition in South Asia. It is a fact that medical counsels and physician organizations in South Asia have not been proactive in nurturing this oft neglected but extremely important medical discipline. To be fair it should be admitted that this field is relatively new in the Western world as well. (1) Moreover, the principles of bioethics that emanated from the West may not be wholly cognate with Eastern values. For example in Eastern setups that are more parochial and family oriented the concept of privacy does not have the same implications as in the West and is often more difficult to implement.

If in this case the physicians are to be blamed for the most part then the society does not go scot-free either. Doctors are esteemed so highly that the public is willing to overlook any shade of deviancy on their part – from frequent gaffes to overt criminal behavior in certain instances. Therefore, you rarely see doctors go on trial for malpractice in this part of the world. I remember once when I was in medical school we were attending an Ear, Nose and Throat outpatient clinic run by a senior doctor. This gentleman was not only at the pinnacle of his career but had authored some kind of book of poetry in English as well. With this impressive dual qualification he was really the king of his little hole. He was seeing a lady with a sore throat and after he was done the patient meekly asked him what she should eat. This was a perfectly legitimate question but our attending thought it otherwise. In a rather irate tone tinged with haughtiness he exclaimed, “chicken-a-la-Kiev”. He then looked triumphantly at us. The sad part is that back then we thought that his retort was quite impressive and funny. The patient left quietly after that reply. This rather forgettable incident is just another example underlining the fact that doctors are routinely involved in unconscionable bioethical practices ranging from verbal to even sexual abuse without any serious repercussions. The doctors however choose their victims carefully from among the indigent population, people without power base, retired and elderly people etc – which incidentally is the majority of the patients. What is equally surprising is that most patients would take this abuse without any recourse – verbal, physical (not recommended of course!), legal or otherwise.

So in the end what options are we left with? Not many I would confess. Just go see the physician (if you must), tell him your symptoms, get the prescriptions, pay his fee and get out of his clinic. If you know an MNA call him first. However, next time you see a physician and he seems a little paternalistic or slightly dismissive or a tad bit hasty and irate at least you would know why he or she is like that. Knowing the diagnosis is half the cure – sometimes.
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Notes:
(1) It was only as recently as 1978 when in the Belmont Report an outline of three most important ethical principles was delineated. (Those were respect for persons, beneficence and justice).

This article was published at The Pakistan Link website. It was also published at the Daily Times with some modifications.

But then she got some sort of an infection. She ran a fever for a few days, had to go on heavier medication, and her recovery slowed down correspondingly. She stayed in the hospital 3-4 more days more than she was scheduled to.

The private hospital charges, despite the fact that the family had major family-based connections with the hospital, were not nominal by any means. A five-day stay, with the operation, cost about Rs. 40,000. This was without any food or medicine expenses. Nursing and other support was also only minimal so that the family had to ensure that there were a couple of attendants in the hospital all the time.

The quality of post-operative care in even the top private hospitals is quite poor. She should not have contracted the infection. But since the hospital does not really mind the longer stay, does not get a poor reputation by having a relatively low quality post operative care, and does not have any regulator that can credibly force the hospital to provide better care, we have to live with the situation. The hospital management and staff does not ensure that instruments are properly sterilized, their hands are clean and scrubbed or they have gloves on, and that rooms are kept squeaky clean and disinfected regularly. In fact to the contrary, it is usually the client who has to insist on getting cleanliness.

Another aspect of this problem has to do with the quality of nursing and janitorial/other services that these hospitals provide. The nursing staff tends to be overworked, by design or by default, they are also not monitored properly and are not held accountable to the clients. The staff that provides janitorial or other services is subject to these issues even more. And in addition they usually also have low skill levels and very low hygiene standards.

Both of the above not only usually lead to longer stays in the hospital, recovery tends to be more painful and the chances of contracting infections become significantly higher.

Lack of proper service structure also imposes substantial other costs on the patient and her family. They have to ensure that at least a couple of attendants are in the hospital all the time: one to do the running around and the other to provide care to the patient. They also have to ensure that there is an attendant who has to stay overnight as well. This becomes a big cost for families who have to pull people out of their work to be at the hospital.

In the case discussed above the cost, in terms of the additional pain and worry that the family had to go through, and in terms of money, was not very large. There are plenty of other cases where people have not been as lucky. A friend’s father went to the hospital for heart related issues. He died a week later due to some infection that he caught from the Intensive Care Unit
(ICU) of this leading private hospital. At the time there had been another patient too at the ICU who had caught this infection.

But the hospital people did not close down the ICU for dis-infecting the place, did not tell people about it, did not even own up to the problem and certainly did not give the families any consideration, financial or otherwise, in lieu of what was after all their mistake, and a very costly one. These are hard facts to prove in a court of law in Pakistan, which is one reason hospitals get away with murder, but if we did have the wherewithal to do the investigative work, one could have good cases of criminal negligence or more against these hospitals.

Sometimes, it is not just negligence, but out and out criminal intent that these hospitals exhibit. In one case a patient died during an operation but the family members standing outside the operation theatre were not informed of this. In fact they were told that the operation was successful and that the patient was in the recovery room. If it was not for one honest paramedic, the family would never have known the truth. They would have been told that the patient died due to post-operative complications and in the recovery room. The intention, supposedly, was to both get the full payment for the operation, and to continue the good surgery ‘record’ of the doctor in question. But this is simply criminal. It is wrong legally, and it is odious morally. How can these doctors and hospital management people live with themselves after such acts of callousness?

I am focusing on private hospitals here only since we already know what the conditions are like in public hospitals. One study, done by doctors in a large public hospital in urban Pakistan (it is an unpublished study of
course) showed that almost 50 percent of the patients who came to the hospital for operations, over a six month period or so, later developed diseases that could only have been given to them through infected blood, infected instruments or un-sterilized utensils. The spread of hepatitis is partially explained through this, and this also makes the fear of the spread of AIDs very real. This is just one aspect of things in public hospitals, and there are plenty of other as worrisome ones, but even this single fact amply shows the poor condition that things are in.

It is to escape the conditions in public hospitals exactly that people go to private hospitals. And private hospitals charge monopoly rents for their services. So if they are going to charge top bucks for the service, they are obligated to actually provide the requisite standard. If they do not, they stand in breach of their contract. This aspect is not there for public hospitals.

I have only mentioned a few problems. But given the general nature of the problem, the problems must be much more prevalent and common. The question is how do we handle the issue. Essentially, from an economist’s perspective, the problem has to do with market failures due to information asymmetries (the lemons problem ala Akerlof). Hospitals know the quality of care they deliver, the patients and their families are not fully informed, and have no way of knowing and checking the details, and therefore the hospitals have an incentive to lower quality and lie about the quality they offer.

This characterization of the problem also suggests some remedial measures that the society can take. Legal recourse has to be developed further. If all parties know that they can invoke the judicial system at any time, and the system will deliver a fair verdict in decent time and at decent cost, there can be no better deterrent than that. The hospitals will pull themselves up knowing that if they do not, they might face penalties imposed by courts and adjudication mechanisms. Knowing this the people can also be more confident that the hospitals are not fleecing them. The existing judicial system is clearly not delivering the goods. The courts do not have the relevant expertise, we do not have specialized courts or adjudication procedures for such problems, courts take too long to decide cases and the quality of decisions is also questionable. So better judicial outcomes have to be ensured, but given the current system we also need to see if there can be other ways of addressing the problem too.

The medical profession itself has to have regulatory mechanisms too. These are needed since it is the reputation of the entire profession that is sullied when one member makes a mistake or acts criminally. But here too the profession has not been very active or forceful. We have not heard of many doctors or hospitals that have been hauled up or punished by the profession.

The government and its regulatory agencies also have a role here. Not all cases can be taken to the courts even if the courts were decently responsive. Most routine breaches of contract and other problems should be dealt with through effective regulations and regulatory authorities. The problem with this solution is that our government has had a poor record at regulation. So recommendations for regulation can easily be taken up to set up ineffective and corrupt regulatory agencies. These will hurt the development of private medical care instead of helping it. Hence, though the role of regulation is there, and a good agency could do wonders here, the fear of excessive and bad regulation makes me reluctant in recommending this course of action.

The people have to be more forthcoming as well and have to cooperate with each other and share information more readily, on good and bad practices. People should use newspapers and other popular media to share their experiences. This will form a large network and hospitals will worry about losing their reputation if they do something wicked since the network will ensure that information is widely disseminated. This might, in the ultimate analysis, be more important than even regulation as a way of addressing the problem.

Hospitals deal with life and death issues, and in conditions where they know more about things than the patients and their families. They thus bear a huge responsibility for acting legally and ethically. But some people get carried away by the possibilities of large profits and act immorally and even illegally. We have to discourage such behavior. This can only be done if we have a responsive, fairly cheap and fair judiciary working in the country. In addition we also need good regulatory systems to deal with smaller and more routine issues. And finally, citizen groups, or people connected though the popular media, can act as deterrent too. All three are needed to keep hospitals in line. If any part is missing we will have the kind of experiences mentioned above.