Revisiting Pakistan's healthcare in 2019: more challenges, fewer opportunities
This is how I started a blog for the Express Tribune a
few years ago. I wrote it then because I felt I had to speak out. A sweeper in
Karachi had been rushed to a nearby hospital after he succumbed to noxious
gases while trying to clear a sewer. The shocking bit was that the fasting
doctor on duty refused to treat the critically ill sweeper covered in
sewage water, claiming that doing so would have broken his fast.
Interestingly, it is Ramazan again, so perhaps an apt time to
remind my fellow healthcare professionals to recall their primary responsibility
– the patient.
Fast forward two years, and I’m
once again recalling primum non nocere,
the starting phrase of the Hippocratic Oath – a solemn promise exhorting
freshly minted medical and nursing graduates to heal their patients, but prior
to that, to do no harm. I am again reminded of the oath, as there’s been a
recent upswing in alleged cases of medical negligence in Pakistan.
First, there was Nashwa Ali, a nine-month infant who lost her
life due to alleged negligence and improper delivery of a medication. Then
there was Shadab Khan, a young cricketer who contracted hepatitis C from putatively
unsterile dental tools at his dentist’s office and may end up losing his spot
at the 2019 Cricket World Cup. Lastly, an HIV-positive doctor allegedly spread the disease among several of his
patients (primarily children) by reusing syringes.
Medical negligence has become an enormous
issue in Pakistan, and these recent incidents only shed light on just how big
the problem is. After all, these are just those cases that have made
recent headlines. There are likely many more cases of negligence, errors or
malpractice that are not being revealed or reported for whatever reasons. Taken
together, there’s clearly a strong cause for concern.
The question that arises then is how something of this nature
could repeatedly be allowed to happen? Why don’t we have better checks and
balances when it comes to healthcare, that go past medical boards or councils
simply issuing or renewing medical licenses or certifications to hospitals and
staff respectively?
Even from the perspective of
the Hippocratic Oath that I mention for the third time now, it is clearly not
evident to healthcare professionals how the death of a patient in alleged cases
of negligence, error or malpractice is an
immensely serious issue to contend with. While protests were taking place after
Nashwa’s death, the staff of the hospital responsible protested against
the hospital being shut and those in charge arrested, instead of raising
concerns over the death of a child under their care.
Healthcare
professionals in Pakistan are seemingly apathetic to their patients, and thus
it is unsurprising that negligence is rarely taken seriously here. Hospitals continue
operating the same way as before, while patients and their families are either
blamed or, if they don’t have enough money, voice or clout, are simply ignored.
Medical
errors or negligence are not unique to Pakistan or developing countries either;
they are major problems for the developed world too. A high rate
of mortality from preventable medical
errors or negligence has been reported for at least two decades now,
and is referred to as the third-leading cause of death in
the United States. Issues can include wrong administration of drugs (or
dosages), ignoring patients’ drug allergies and continually administering them
those same medicines, wrong site surgery, wrong patient surgery, unnecessary
procedures, and so on.
If it’s such a grave concern abroad, where they have highly
regularised and efficient health systems, then what we are hearing about or
seeing in countries such as Pakistan is likely just the tip of the iceberg.
There’s no denying that
something has to be done and fast, at various strata, to improve the situation
in Pakistan. In reality, though, it may not always be that simple. You have to
realise that most medical errors aren’t traceable to one individual’s overt
mistake, but are more likely due to a failure of monitoring systems at
different levels; referred to as the model of accident causation, details
of which are beyond the scope of the current blog.
Biomedicine is complex; hospitals, due to their human factor, are
even more so. As the complexity of a system increases, chances go up of something
going wrong that will bring the entire system crashing down. However,
acknowledging that we have a complex system is perhaps the entry point towards
solving the burgeoning crisis.
There are ways around it. One approach may be to have a robust and
transparent patient safety and clinical quality culture (represented through an
autonomous department) that provides oversight into the day-to-day-clinical
care functionality of the hospital. Such a department should encourage patients
or their attendants (the parents, if the patients are children) to share any
clinical care related grievances, be they real or perceived. Equally important
would be for the said department to responsibly and transparently investigate
and share final deliberations with the aggrieved.
Although creating a new system
to deal with a pre-existing one may seem counterintuitive, some affordable
version of an Electronic Medical Record (EMR) may be highly useful with
redundancies built into it; subsequent alerts for incorrect drugs or dosages is
just one example among many of the utility of EMRs that have been shown to
improve patient safety.
This
is the time to mention the benefits and potential of artificial intelligence based
machine-learning algorithms that will likely become more cost effective in the
future and will be extremely useful for ensuring better and safer patient care
globally.
A
handful of hospitals in Pakistan have officially been credentialed to deal with
medico-legal cases, but these tend to be for supposed criminal cases. Majority
of alleged medical errors, negligence or malpractice, need not be categorised
as ‘criminal’ from the get go, before due diligence has been exercised by the
investigating authorities. Over-labelling all such cases as criminal widens the
chasm between health professionals and their patients. Print and social media
may then add fuel to the fire, much prior to the completion
of root cause analyses.
What we need to focus on instead is a positive
culture in the hospital that encourages a system of reporting ‘near
misses’ – mistakes that get caught just in time before becoming bigger
problems. Moving away from a punitive approach will likely improve reporting of
such issues; it will also lead to more accountable physicians and nurses with a
higher morale, creating a robust health system. After all, there is no denying
that we do need these highly skilled professionals amongst us providing a
crucial function for the betterment of society; we just need to get better at
managing them.
[from Health & Disease]
DISCLAIMER: Copyright belongs to the author. This blog cannot be held responsible for events bearing overt resemblance to any actual occurrences.
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