Staying safe in Lahore

As I write I can still hear shop shutters being slammed, the volume of TV news channels going up, the clatter of people going out onto the streets and of protests echoing full and loud. Later rage erupts into violence as vehicles are smashed and the air is thick with the smoke of burning tyres.

The reason for all this? The collapse of the leading political party in Punjab, one of the four provinces in Pakistan, and the countries leading opposition party, the Pakistan Muslim League Noon lead by the ex-prime minister Nawaz Sharif.

My thoughts run back to conversations with my friends, tutors and hospital consultants back in England. Everybody I told about my plans to go on elective in Pakistan had told me to "just be safe, please".

Apart from nearly drowning I did my best to avoid dangerous situations whilst there. But I was staying in a house with three generations of a highly politicised family, perhaps not the wisest thing given the febrile state of Pakistani politics right now. Given the level of risk I did spend a few days "in hiding" in another town.

My desire for a late night desert treat almost dropped me into tricky situation the night before my return. Liberty Market, ten minutes away from our house, was where terrorists were preparing for the failed hijacking of the bus carrying the Sri Lankan cricket team early the following morning. In the shootout eight members of the cricket team were wounded, seven policemen were shot dead and many others injured.

But what about my clinical experiences? The World Health Organisation's latest report on Pakistan* reveals that maternal and child malnutrition and rates of infant, child and maternal morbidity are high. It also reports significant mortality and morbidity from preventable diseases such as measles; hepatitis and neonatal tetanus constitute 'major public health challenges'. And the unrelenting presence diarrhoea, malnutrition and TB are amongst the leading causes of death.

I was interested in finding out more about clinical medicine in Pakistan and how it compared to that in the UK. I also I felt that I would gain a better understanding of symptomatic medicine where facilities are limited, and of disease that are uncommon in the UK but rife in Pakistan.

My six-week elective was split between hospital medicine and peripheral clinics, with four weeks being spent in the Shaukat Khanum Memorial Hospital & Research Center a specialist oncology hospital and the remaining two in the, Saad Children & Family Clinic a specialist paediatric unit.

The Saad clinic provides paediatric care at a consultant level on an outpatient and home visit basis, seeing approximately one hundred patients daily. Its facilities included ultrasound scanners and minor operations equipment, emergency resuscitation area and isolation areas for infectious diseases, in addition to an in-house pharmacy. As well as seeing patients on a private basis, those from less well off backgrounds were assessed and treated free of charge. The doctor adjusted his fees depending on how he assessed the patient to be financially, and prescribed medicines and treatment accordingly.

A lone specialist service

Shaukat Khanum, based in Lahore, is the only specialised oncology hospital in Pakistan at the moment with complete facilities to provide diagnosis and treatment to patients with cancer, so patients come from all over the country.

Some 70% of its patients are financially supported by the hospital, mainly through charitable donations, with a proportion of these receiving completely free care.

It was heart wrenching to see patients travelling from extremely poor, often rural parts of Pakistan for days, not just hours, and sleeping out in the open due to not being able to afford accommodation in Lahore in order to be able to see a doctor for a ten minute follow-up appointment, which often brought with it bad news.

The elective provided an opportunity to improve my examination skills and reinforce my knowledge of clinical medicine and interest in paediatrics, especially in examining young children and taking collateral histories.

I had the opportunity to examine the patients and carried out practical procedures in both the adult and paediatric age group like passing cannulas, checking the blood pressure and giving injections etc.

Late presentation

The disease burden I saw in Pakistan was high. Many patients presented at late stages, with inflated clinical signs and symptoms. For example, having done a general practice placement in the UK just before my elective I saw a lot of seasonal flu in both the paediatric and adult age group, however clinical signs were limited and chests on the whole clear on auscultation. Flu here in Pakistan gave a strikingly different impression; no chest was without a rattle or wheeze.

The same delay in presentation was seen at Shaukat Khanum, with patients presenting for the first time with severe cachexia, shortness of breath and / or bone pain from distant metastases.

From the patients I spoke to, late presentation appeared to be for a number of reasons including ignorance of disease and its presentation, belief in alternative therapies and spiritual causes for illness, previous treatment from poorly experienced physicians and sometimes due to fear of the cost of seeing a doctor and obtaining treatment.

A case of a young girl comes to mind, the eight year was diagnosed early with right arm sarcoma at Shaukat Khanum, she had surgery to clear the tumour, however her parents refused chemo at the time due to beliefs regarding its side effects, the girl presented some months later with symptoms of distant metastases.

 I found the doctors in Pakistan to be hard working, and committed, with a drive and ambition to get somewhere in their field, despite not always intending to work in that speciality initially.

Doctors are encouraged to get research papers published and to attend international conferences. However this may not be generally representative as I was in a hospital affiliated to a research centre.

As in the UK junior doctors were treated like junior doctors, although due to the hierarchical structure of medicine, maybe seniors in Pakistan are more stern and authoritative.

I was impressed by how all the staff treated all patients with equal respect and kindness irrespective of ability to pay.

What did concern me however was the number of junior clinicians I encountered who were aiming to get jobs abroad, possibly because of better pay or working conditions.

As someone born and brought up in the UK perhaps I don't appreciate how difficult life is abroad, or how easy it is for me?

During a presentation to the clinicians I had worked with regarding my elective I did however bring up some points to consider. The first was patient privacy; histories were being taken with clinic doors open and often two doctors seeing patients in the same room.

On the other hand I understood that this was the only way the volume of patients coming in could be seen with the facilities and room available, patients themselves did not expect it to be any different.

This brings me onto my second point; it was rare to see a patient question the doctor, in fact even when the physician asked the patient's opinion for example regarding two therapeutic options the answer was pretty consistently 'as you say, doctor'. I wonder if this doctor-patient relationship will change in the years to come, much as it has done in the UK, with increasingly authoritative patients?

A valuable experience

All in all, the experience was valuable, both clinically and also on a personal basis.

However, although I fulfilled the aims of the elective, namely to improve my examination skills and learn more about resource allocation, both sectors I worked in were ultimately private and well funded.

Patients told me stories of government hospitals with two patients to a single bed and re-used equipment. I wonder whether what I have experienced is the cream of clinical medicine in Pakistan rather than the day-to-day reality. Some day I would like to go back to find out.

Although there was some relief when I returned home, there was also a little sadness. There is something about Pakistan, its community, culture and heritage, and the hospitality of the Pakistani people that captivates.

* World Health Organisation - Pakistan

This page was correct at publication on 05/10/2009. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.