Time to pray for doctors

[Ahmed Mateen]

The nation’s health

By Ardeshir Cowasjee

IT is bad. But it is one of the many ‘core’ issues facing us and must be addressed. Generally recognised is the fact that Pakistan has a damaging dearth in areas in which it should not have a dearth and equally damaging surpluses in areas in which there should be no surplus. Let us, for the moment, just take two of these extreme areas – population and doctors.

The country is grossly overpopulated and the number is growing at the frightening rate of 2.1 per cent – it is estimated that there are now over ten births per minute. (As an aside, it must be admitted that far too many members of the population are illiterate, bigoted and terrorism-geared but that is another story.) As for doctors, there is a serious dearth, with a very low ratio of doctors to population, and projections are that the shortfall is on the increase.

A large number of the Aga Khan University faculty (of which 63 per cent are foreign qualified) got together last year with a large number of experts from various international health and medical institutions, and printed in the December 2006 Supplement of the publication ‘Academic Medicine’ was a paper written by two AKU professors, doctors Jamsheer Talati and Dr Gregory Papas entitled ‘Migration, Medical Education, and Health Care : A View from Pakistan.’

Pakistan has a current ratio of 0.473 physicians per 1000 population – the US ratio being 2.93 per 1000. There was at the end of 2005 an estimated 73,890 physicians practising in Pakistan, and some 1,700 physicians per year are lost, for various reasons, from this practising pool. Over 1000 are emigrants to greener pastures, where they earn more, have a far better lifestyle, better prospects for their and their children’s education, and international exposure. It is a move for betterment, an inbuilt right, and can benefit human society at large. Migration of our doctors is a problem but it cannot be halted. One other factor spurs emigration in our case – the poor self-image of the native land and the inordinate admiration of all things foreign.

Pakistan is the third leading source of international medical graduates in affluent countries. In 2005, a survey showed that there were 12,813 physicians from Pakistan in the US, the United Kingdom, Australia and Canada. There were a further 12,200 in other countries, mainly in the Arabic-speaking nations. Saudi Arabia alone requires an additional 20,000 Pakistani doctors and we have been asked to send out to that country as many as we can spare.

We lost many good doctors to migration and bullets in the closing years of the decade of the 1990s and at the start of this century when there was a spell of targeted killings of doctors on sectarian grounds. This has now luckily given way to a more rational flow – to advanced technology-inventing nations for post-graduate studies and citizenship, and to the Arabic-speaking countries for service and lifestyle.

The main cause of physician deficit is the country’s inability to educate an adequate number of doctors for a burgeoning population with a complex burden of infectious and degenerative diseases, cancer and accidents, all of which are on the increase. Pakistan’s total health expenditure in 2004 was 2.4 per cent of the gross domestic product – less than on education and pathetic in comparison with defence and debt servicing.

Then there is the gender factor. On an average 50 per cent of those admitted to medical schools are women. They have a high pass rate, but they also have a high drop-out rate because of marriage and childbearing. Only 38 per cent of our practising doctors are women – they are an annual continuing loss from practise. Other losses to practice are doctors who practise part time, teach in basic science departments, work in government offices, or who become governors, chief ministers, members of parliament or waft their way into other elevated lucrative positions.

Apparently, there is no serious dearth of medical colleges – only a dearth of teachers, facilities and teacher training institutions. Class sizes are also a problem as in many public institutions they exceed 300 which impedes efforts to improve learning. And even access to medical education, despite income disparities, is not limited by poverty or educational or geographical disadvantage. The average total cost of providing five years of medical education is, according to the Talati-Pappas paper, approximately $100,000, split between government and private colleges.

The conclusion reached in Doctors Talati and Pappas’s paper is that Pakistan cannot meet its needs for healthcare given the current levels of production and dependency on physicians in the organisation of the system. To quote :

“Looming physician workforce shortages cannot be easily met by increasing the number of medical schools or by enacting legislation on migration. The shortage of physicians is a problem that Pakistan shares with the developed world. The need for physicians is rapidly outstripping production globally and is forcing us to rethink medical education in both resource-rich and resource-poor countries. At the current levels of production, Pakistan and other developing countries cannot meet their current needs and will not be able to meet the needs of the developed world. . . .

“Residency programmes could be improved through better assessment of inductees, a basic core programme common across nations, and free movement of residents between programmes, especially those in different countries, for part of their education. Migration causes critical impact even when numerically insignificant, but it is inevitable. It is unreasonable to expect the diaspora in high-pressure advanced environments to leave their demanding environments to work in Pakistan, unless work environments in their adopted homes provide time for engagement in their parent country. . . .

“Above all, an engagement of society is essential, as technologies radically disruptive of conventional approaches and current ethics have arrived and will consume physicians’ time. Universities need to develop graduates’ sense of altruism and the need to serve resource-poor settings.”

High hopes! None of the 80-odd who sit cramped around the oversized cabinet table with prime minister Shaukat Aziz and attempt to govern this country will rush to Doctors Talati and Pappas () to ask questions. However, a copy of their report is being sent to Health Minister Mohammad Nasser Khan who is said to be ‘pro-active.’

[tammyswofford]

The issue of inadequate medical care extends beyond doctors and also taps into a worldwide shortage of nursing professionals. For instance, in America we have many nurses being recruited from the Philippines and the African continent, especially nations such as Nigeria and Kenya. It becomes an ethical dilemma because the law of supply and demand which fuels the migration draws a talent pool from poor toward rich nations. The human talent pool of medicine is flowing to the West. I read an article once which stated that an Egyptian doctor could come to America and earn more driving a taxi than he could earn as a medical professional in the nation of his birth. So in a sense, can the professional be blamed for seeking out a better life?

So what can be done? On the one hand there is a need for more government monies to be invested in creating "Centers of Excellence" such as we have in the U.S. to provide their physicians with state of the art equipment so that their art of medicine is not frustrated by constraints of outdated equipment. I have a friend who is a physician who traveled to the Sudan and was appalled at the medical conditions. Having traveled to Mongolia, I can say the same for what I observed there. How horrible to be a physician longing for an MRI or a CT scan and know that your only diagnostic tool is an AP and Lateral chest x ray or that your antibiotic options post-operatively are limited to Cefazolin and you will never get your hands on Clindamycin or Vancomycin.

Can legal constraints be placed on physicians trained at government expense? There are doctors who are funded through medical school in the U.S. at government expense in exchange for a required period of service to an underserved area of the governments choosing to "pay back" their dues. Does Pakistan have an ability to deny doctors with government-funded training migration status until having served in the host nation for a season? It sounds Draconian, but combined with an infusion of monies into facilities and subsidies to increase the standard of living for physicians serving in Pakistan, the tide could slowly turn.

We appreciate our Pakistani doctors in the U.S. But I believe they come to us for the benefit of pay packages and use of state of the art technology.

Tammy Swofford
Texas