'Maternity homes' take advantage of lack of legislation, wreack havoc with lives
By Rabia Ali
A woman in labour screams for help in a small, dingy room in a maternity home near her house in Banaras Colony. The maternity home in question, however, like many others, does not guarantee her survival, nor does it give any assurance of her to-be-born child seeing the light of day.

'PMDC has no power to check quacks, unregistered doctors'
By Saher Baloch
The mushroom growth of unauthorised maternity homes found in every nook and corner of the city and a bevy of unregistered doctors who work there unabashedly, has raised questions regarding the credibility and the role of the Pakistan Medical and Dental Council (PMDC) in countering the situation.

Beware 'cure-alls'
By Samia Saleem
Across the city, on walls and temporary signposts, one sees banners promising cures for all sorts of diseases -- even those with which medical science is still grappling. Impotence, infertility, diabetes, broken limbs and bones, cataracts, weight or height issues, you name it, and these 'cure-alls' -- better known as quacks -- claim to be able to 'heal' it.

Amidst the usual cacophony that greet visitors to the emergency ward of the Civil Hospital Karachi (CHK), three angry voices barked the loudest. One of the men flashes a card with a political party's logo engraved on it at the in charge, a man in his late 60s, and orders him to "recheck" their patient. His logic: they do not trust the doctor's diagnosis.  

The men demand of the in charge to do as they say, otherwise, they could not be held responsible for the consequences.  The in charge quietly takes the man's card, and tells him firmly to go and do whatever he can, and that a complaint will be filed against him. Another round of argument subsequently ensues. 

"It happens everyday, but at least I have stopped reacting to such people's nonsense," the in charge, Senior Medical Officer (SMO) Dr Asif Farooq, calmly told Kolachi. Pointing towards the man whose family were threatening him of dire consequences some moments ago, he explained that in most cases, angry relatives or close associates harass doctors working in the emergency department despite there being nothing major wrong with a patient. 

"The problem with his brother is that he has gas, and because of that, a patient is bound to feel heart burn or pain in the chest. But this gentlemen thinks that it is a heart problem, for which we should immediately admit his brother. Doing that would be completely senseless," Farooq said. 

The SMO's approach is premised on the fact that the emergency ward of CHK provides first aid and other treatment to around 1,000 patients on a daily basis, while over 2 million people visit the out patients department (OPD) of the hospital every year. CHK was set up in 1895 as a 250-bed hospital for the poor, but it now caters to patients from not just Karachi, but interior Sindh and Balochistan. "CHK is not a posh hospital, it provides tertiary care to thousands. We cannot admit patient after patient just to earn extra money. If a patient is fine, we let him/her go home immediately after prescribing the required medicines."  

On the other hand, those who come to admit their relatives, complain about the lack of coordination between hospital staff, as most patients are kept waiting for as long as six hours to get a bed. "Where should a poor man go? I cannot even fight anymore, as I do not know where to take my children or wife if they get sick," claimed a labourer, whose son was admitted minutes after the ruckus created by the angry men subsided.  

The situation in CHK, however, is mirrored at Jinnah Postgraduate Medical Centre (JPMC). Established in 1938 in a building which was a part of the Army barracks, JPMC's emergency department provides treatment to around 277,184 people in a year. On an average, the emergency department receives and checks around 650 patients per day. Similar to CHK, JPMC is also burdened by a heavy load of patients but not corresponding infrastructure. 

"Most of the time, patients that come to the hospital are referred from private hospitals. We take referred cases mostly because there is no other choice," said JPMC Accident and Emergency Department In charge and Deputy Director Dr Seemin Jamali. 

Jamali told Kolachi that in a recent case, a patient kept going from one ward to another for around 4 hours with his daughter in his arms, but the staff were as helpless as the hapless man. "Most of the times, there are no beds available and even wish our best of intentions, we cannot do anything. The patients will have to wait, unless he/she needs immediate attention. In that case, we treat the patient first, as that is our priority," she said.  

The JPMC presently has a bed strength of 1,185, but despite being funded by the federal health ministry, expansions to the facility are not under consideration. "Expanding it further is not on our agenda right now, as that not only means adding more patients, but there is tremendous responsibility attached with it too."  

Both CHK and JPMC have a large number of postgraduate trainees and other paramedical staff working in three shifts, but senior doctors seem to be overburdened with numerous responsibilities. For example, at CHK, SMO Dr Farooq is not just the in charge of emergency, he also has to look after the management of patients, doctors, help out trainees and at the same time, answer the queries of patients that queue up in front of his desk. Even while speaking to Kolachi about the emergency ward and it's working, Dr Farooq kept checking prescriptions and referring patients to the required wards.  

CHK Medical Superintendent Dr Saeed Qureishi told Kolachi that the hospital receives a budget of Rs1.5 billion, which is distributed on the basis of priority. "Our first and foremost responsibility is towards the emergency ward, and then come the in-patients that need to be treated."  

Apart from that, 95 per cent of the patients that come to CHK are poor people. These people are given treatment free of cost, excluding operations and surgeries, for which a Zakat fund is allocated. How much money is actually distributed is not known, as the hospital administrators do not want to reveal information on the distribution and allocation of funds.  

Speaking about complaints from patients and their attendants regarding the patronising attitude of the hospital staff and domestic sweepers, he said that they are trying everything on their part to provide good service. "In our case, we receive thousands of patients, and if some minor mistake occurs, I think it should be looked over." 

Last week, news of a girl injected with a wrong vaccine at a hospital in New Karachi was reported in the media, and Jamali claimed that such coverage makes it very difficult for them to receive referred cases."Patients are brought to us in a very bad condition, and in case they die, a huge hype is created by the media without asking doctors what actually happened."  

Similarly, a report printed in a daily newspaper claimed that there were lapses in the working of both the CHK and the JPMC on the day of the Ashura blast on M.A. Jinnah Road (December 28, 2009). Both Jamali and Qureishi asserted that not once did the emergency staff fail to meet the standard operating procedure (SOP).

'Maternity homes' take advantage of lack of legislation, wreack havoc with lives

A woman in labour screams for help in a small, dingy room in a maternity home near her house in Banaras Colony. The maternity home in question, however, like many others, does not guarantee her survival, nor does it give any assurance of her to-be-born child seeing the light of day.

Approximately 300 maternity homes, which have mushroomed in every nook and cranny of the city, play a major role in pushing the maternal mortality rate higher. According to leading gynaecologists, around 30,000 pregnant women are lowered into the death trap during delivery; of these, around 20 percent fall prey to 'maternity homes' and untrained midwives. To make matters worse, there is no law, nor are there any set criteria, to gauge the functioning of these 'hospitals'. In the absence of such checks and balances, no action can be taken against them.

"Anyone can set up a maternity home since there is no authority or board in our society which has defined rules for the functioning of these places, or regarding the training of midwives," Shershah Syed, an eminent gynaecologist, told Kolachi.

According to Dr Syed, a properly-trained midwife is one who has undergone two years of training; most women posing as midwives today, however, are neither properly trained, nor do they practice safety.

Around 22 women have died at the State-run Qatar Hospital where Dr Syed works. Of these, 14 to 15 were cases which came to the hospital after untrained midwives at "maternity homes" worsened their cases beyond repair or hope. "These maternity homes keep women cooped up till last moment, so that they can keep minting money. Only when the mother's life is in serious danger, do they refer the case to other hospitals," Dr Syed said.

His viewpoint was proved during discussions that Kolachi had with staff at some 'maternity homes'. Dr Shaheena, the physician heading one such home in a thickly-populated area of Pathan Colony, SITE Town, proudly claimed that she and her staff first try, on their own, to solve the complications of an expectant mother who is about to give birth. They refer the case to other hospitals only when the condition of the woman deteriorates.

"Every month, we receive some 30 to 40 patients for delivery. However, when we feel that we cannot deal with the patient, we forward the case to some other hospital," Dr Shaheena claimed, adding that her "years of experience" of dealing with patients give her the right to deal with the patient "till the end".

Though Dr Shaheena admits that two women lost their lives at her maternity home, but she is quick to place the blame squarely on the shoulders of, in her words, the woman's "lazy attendants".

"We had informed the family members of those women that we cannot treat them but they were too slow in shifting them to another hospital, which resulted in the loss of their lives," she maintained.

The current situation of Dr Shaheena's maternity centre, however, does not give much credibility to her claims. Although she said that the maternity home doesnot perform Caesarians on woman, but keeping the patient with them "till the end" often proves deadly for both, the mother, and the unborn child.

Dr Shaheena's maternity home charges Rs3,000 -- a hefty sum for most residents of the locality -- for normal delivery. The place can house only four women at a time, while the labour room is small, ill-equipped and unhygienic. To add to this, the staff have been trained only by Dr Shaheena, who did not share where she herself was trained.

Meanwhile, a doctor at another nearby maternity home alleged that most 'hopeless' cases that they receive are ones which are "spoiled and then referred" by Dr Shaheena's staff. "The women who come to our clinics are the ones whose condition was worsened by the inexperienced staff of Dr Shaheena's maternity home," she said.

A midwife, Meera, who had undergone a training course at the State-run Qatar Hospital, told kolachi that most midwives in the city cannot even carry out simple procedures. "This, however, does not stop them from running maternity homes and minting money," she added.

The materials required to set up a maternity home include a delivery table, a suction machine with vacuum, basic instruments such as scissors and forceps. All of these are cheap, and setting up a maternity home therefore does not involve much of a hassle. The reason women continue to go to them, despite all risks, is the cost factor. Maternity homes, while charging much, are still much cheaper than gynaecology wards at proper hospitals.

Meanwhile, there is a dire need for proper legislation to protect the lives of these expectant mothers and their unborn children. "Nurses at maternity homes work as domestic help, and there is no respect for women's privacy at these homes," Dr Syed said. "Similarly, these midwives don't care for the lives of the mother or the child."

Thus, not only do the authorities concerned need to evolve a system of checks and balances to discourage quackery in gynaecology, the powers-that-be also need to bring down the costs of childbirth, especially at government hospitals.

The mushroom growth of unauthorised maternity homes found in every nook and corner of the city and a bevy of unregistered doctors who work there unabashedly, has raised questions regarding the credibility and the role of the Pakistan Medical and Dental Council (PMDC) in countering the situation.

The PMDC was established as a statutory regulatory authority under the Pakistan Medical & Dental Council Ordinance of 1962. In theory, its functions and duties are to prescribe a set standard for medical institutions, by inspecting and formulating recommendations for medical institutions which provide training to undergraduates and postgraduates. Apart from this, its job is also to decide cases against 'registered' practitioners for infamous conduct and professional negligence. After reading the mandate of the PMDC, however, one wonders about its role in taking action against unregistered doctors and clinics, which continue to provide cheap and unsafe "healthcare" to hundreds of people.

"In practice, the role of PMDC is quite limited in asserting its authority, because this authority is not much to begin with," PMDC Secretary General Sohail Kareem Hashmi said. Speaking candidly about the role of the PMDC, Hashmi said that the basic objective of the council is to look after the registration of medical doctors and to set a standard for medical institutions. "The responsibility of the council is to make sure that trained and skilled doctors are registered, and to cancel the licences of only those who have been registered with us. We cannot take action against a quack or a fake doctor; closing down an unauthorised clinic or maternity home is the job of the provincial government," he said

The council, he says, is not impressed with job titles and designation and has so far cancelled many licenses after receiving complaints -- the most recent one being the case of a doctor who was brought to a court in Sindh on charges of needlessly amputating the limb of a minor.

Hashmi said that the general perception among people is that the PMDC is the inspecting authority which has the power to barge into hospitals and ask for doctors' registration papers. "This is not so. The council is toothless in that sense. We have a disciplinary committee which looks into cases and forwards them to a court of law if the need arises," he explained.

One drawback in the role of the PMDC, according to Hashmi, is that a group of doctors looks up a case against another doctor; in other countries, this is the job of an ombudsman in other countries. Hashmi referred to this as a "serious conflict of interest," and said that in Pakistan, it becomes a matter of great concern if one does not have a good working relationship with people in authority. "If you don't, a small case of error can be stretched into something gruesome and you won't know what has hit you," he said.

Recently, the Punjab government proposed a bill in the senate, according to which, a doctor will be tried under the Article 302 of the Pakistan Penal Code (PPC) if a case of negligence is brought up against him or her. This outraged many doctors in Punjab as well as Sindh, who called it a "barbaric bill" for medical professionals. What created such a furore among the doctors was the fact that they will be charged with criminal negligence."It is really interesting that nothing is being done against quackery and unauthorised clinics but registered and well-reputed doctors will be charged under the criminal offence of 302," Pakistan Medical Association (PMA) Karachi Secretary General Dr Syed Amir Raza Abidi said.

Dr Abidi added that such extreme punishment for negligence was completely uncalled for because a doctor will never "intentionally try" to kill his or her patient. He added that no doctor can deny or run away from accountability. "I am all for the accountability of doctors; they should be questioned, but it should not be a one-sided decision," he said.

Citing the same fears as Hashmi, Dr Abidi said that such laws can be greatly abused by people who have nothing better to do than see a doctor hanged without a chance to speak for herself or himself.

Dr Abidi said that a few days ago, Barrister Aitzaz Ahsan, who is also a part of the PMDC disciplinary committee as a legal expert, said in an interview on a TV channel that Article 302 was not applicable tp a doctor. "Error of judgment and medical negligence is possible but it should not be portrayed as something intentional," he said.

As for those who practising in unauthorised clinics, Hashmi said that on August 27, 2009, during the hearing of a human rights case, the Supreme Court of Pakistan gave a judgment in which it asked the PMDC and the federal and provincial governments to put in concerted efforts to counter quackery and illegal clinics.

"The need of the hour is to form an independent authority which can impartially look into cases and complaints against doctors and make an informed decision at the end of the day," Dr Abidi said, adding that the need for an ombudsman has also been added in the Punjab Health Bill of 2010, which is a good sign as it will be considered by other provinces as well.

The Sindh government, meanwhile, is busy compiling a proposal for a bill under which accreditation, registration and licensing of public and private health institutions will be carried out by an independent authority. Sindh Special Health Secretary Dr Majid told Kolachi that according to the bill, public and private hospitals will be given licences to operate in the city and the clinics (including maternity homes), will be issued a certificate. He added that the bill was currently being worked on, and "amendments will be made till the time it is passed by the assembly and even after it, the accreditation authority will have the power to inspect and raid hospitals and clinics which work illegally."

Across the city, on walls and temporary signposts, one sees banners promising cures for all sorts of diseases -- even those with which medical science is still grappling. Impotence, infertility, diabetes, broken limbs and bones, cataracts, weight or height issues, you name it, and these 'cure-alls' -- better known as quacks -- claim to be able to 'heal' it.

According to American research, quackery is the promotion of false and unproven health schemes for a profit. According to Pakistan Medical Association (PMA) Secretary General Dr Habib ur Rahman Soomro, however, quackery in Pakistan goes far beyond the circle of medicine alone. Dr Soomro maintains that any form of deception is quackery.

The whos and whats

Former PMA Karachi Secretary General (and PMA anti-quackery committee chairman) Dr Aziz Khan Tank is a veteran who has been working against quackery in Pakistan for the past 30 years. The number of quacks, he says, has multiplied rapidly over the decades. "There were around 60,000 quacks in 1986; now there are more than 0.6 million," he told Kolachi.

Quackery now is present in all forms of healing medicine, including herbal, homeopathic as well as allopathic. These illegal practitioners abound in every nook and cranny of the streets, audaciously flashing fake degrees and certificates. Alarmingly, Karachi is home to the largest population of quacks (40,000 to 60,000) in Pakistan. This includes people with illegal medical, herbal and homeopathic degrees, as well as "house physicians" who heal by herbs or even a mixture of prayer and occult practices.

With no means of being kept in check by law-enforcement agencies, frauds find it easy to gain respect as well as income in society. These quacks include laypeople, as well as medical staff, paramedics, and physiotherapists who start their own clinics under feigned names and degrees, Dr Tang said, adding that these people sometimes even take up the names of doctors who have died or moved abroad.

Cheeni Waaley Babey

These imitators trap people more via argumentation and nostrum medicine than by genuine methods, Dr Soomro said. A very famous art is the use of placebos, where patients are given inert medicine while being promised a cure. The placebo acts psychologically, making the patient temporarily believe that he or she has been cured. The "Cheeni Walay Baba" is a famous example.

The shortage of doctors in the country is one of the main reasons why quackery continues to flourish. "There are a total of 2.6 million doctors in the country, out of which 1.6 million are general practitioners," Dr Tang said. This makes a ratio of one doctor for every 1,600 patients. In such a situation, people have to resort to any signboard near their house in times of need or emergency.

Besides, illiteracy also plays a role in people's inability to distinguish between a quack and a real doctor. "Quacks advertise through emotional appeal," said Dr Tang. They also charge less money than qualified doctors, thus ensuring a steady supply of poor and gullible patients.

Brazen killers

"These illegal practitioners have killed millions of innocent people by their wrong diagnosis," said Dr Tang. Doctors not only lose their genuine patients but also have to face difficulty in dealing with patients who have been misdiagnosed by quacks, he added.

He told Kolachi that he has been researching quacks in Pakistan for 30 years and has traced thousands of cases of frauds, all but in vain because the Pakistan Medical and Dental Council (PMDC) cannot take any action against them. "So far I have given about 30,000 cases to the PMDC, but no action has been taken against them," he said. "This is not the fault of the medial organisation; there is still no law against quackery in Pakistan."

The biggest drawback in dealing with these illegal "doctors" is that since they are not registered, they cannot be brought into the purview of the law or punished. "While a doctor can be sued against negligence, incompetence and human error, these quacks are not accountable to anyone and can easily change their office without any fear of even being traced or caught," Dr Soomro said.

How should this be tackled?

This life-threatening practice needs to be curbed as soon as possible, Dr Tang maintained. He said that in the early 1920s, quackery was common in the US, when "curing tonics" were extremely popular. The United States, however, passed a law against quackery in the 1930s, and later continued to upgrade the law. As a result, quacks have been completely eliminated from the country.

The only way to fight this menace in Pakistan is also through legislation, he said. "We want quackery to be defined. Legislation should then be adopted to ban the illegal practice in any form, so that innocent people can be protected," Dr Tang demanded. "Also, the government should keep a compulsory rotation of doctors for a year or two to the rural areas."