Glimpses of Pakistan

Pakistan has much to teach us about medicine, and about people. Community clinics in Karachi range from a very "high-end" clinic to a "free clinic." The high end clinic is run by the Aga Khan University and is where Cindy Haq, MD established the Department of Family Medicine. This clinic has an impressive physical plant which includes in-house laboratory and X-ray facilities to support several family physicians and consultants. The charge for a visit is about $8.00. At the other end, is a free clinic in an urban slum where there are goats walking in excrement in the streets. The medical students in this clinic are seeing patients with multiple problems including a very heavy load of psycho-social problems (many displaced from the area near the Afghanistan border or the earthquake area). The students take up collections so they can buy some medicine and get needed tests for the patients.

The refugee camp in Pakistan is enormous. If you remember the scene from Raiders of the Lost Ark where at the end, the Ark is put in a huge warehouse that goes on endlessly, you have some notion of size of the refugee camp in Rawalpindi for earthquake victims. There is housing about 22,000 people, all in tents. The camp has a communal cookhouse and bathroom and washing facilities. Individuals or families are living in tents perhaps 12 feet to a side about 5 feet apart. Utensils and food have been donated.

At the end of the visit, again having the requisite tea, the administrative leader, Mr. Khursheed Rizvi, begins to talk. We're sitting at a small table outside his tiny office surrounded by people who live in the camp. The table has bottles of water and cups of tea. He talks with radiant good humor and laughter and with stories and allegories of computer programming. He is smiling and laughing and full of life and joy. He talks of the equality of all people, of how we are each important and how we must each be most thankful for what we have. He relates that when he went away to school his father told him to look at a flower and consider its beauty, all for free, the same for poor as for rich.

Later, at the very posh Pearl Continent-Rawalpindi hotel, we meet for lunch with the Oxford-trained Dr. Usmani who is the very dedicated Chair of the Department of Obstetrics and Gynecology at Rawalpindi General Hospital. We discuss the possible application of the Advanced Life Support in Obstetrics (ALSO) Course to her institution and to the delivery of maternity care services in Pakistan. She is enthusiastic about developing training for the Traditional Birth Attendants who, although untrained and often illiterate, perform 80% of the deliveries in Pakistan.

Dr. Manzoor Butt has an excellent practice in a rather poor area of Rawalpindi. Not "excellent by US standards" but excellent in its context. There is a small waiting room with a partition between the two areas for men and women (a rare amenity) but no toilet and no medical records. He does have a small room for doing gynecological examinations, again a rarity. He has a computer in his practice with high-speed internet access. He scrupulously avoids the incentives so available to less ethical physicians (kick-backs from laboratories as an example). He is very careful about sterility. He sees about 60 to 100 patients a day and the average charge is about $1.30, and many pay nothing. He gives free medicine to his non-paying patients.

Dr. Mansoor's practice is exemplary in terms of what he is doing in his community. He organizes the following:

• Community walks for traffic safety
• Formal teaching sessions for "lady health visitors"
• Community groups and teams of volunteers (some from well-to-do families) address issues of clean water, sanitation, mosquito control, medical care for the poor and education for women.

Because of the lack of ambulance services, he has organized a Rapid Response Team to deal with accidents and injuries in the community. He has sponsored art contests to provide some income for women. "I have strong faith in our women and youth. ...If someone wants to do any good to ordinary and deprived people he should simply start respecting and giving importance to them."

Another physician, Dr. Majeed in Karachi, works under similar restraints while striving to provide the best possible care, for about $1.30 per patient. He rents out three small stores so that he can afford to see patients for approximately 15 minutes each. His rentals finance his medical practice!

There is much more to tell - at another time, perhaps.