Health Sector in Pakistan - 2

PROFESSIONAL PERSPECTIVE:

AILING MEDICAL EDUCATION:

Medical students all over the world grumble about unceasing pressure, torrents of material, lack of time to think much less for relaxation. They are, let us say, only one of the party who so complain. The aggrieved party of patients gripe that the products of the present system, the current crop of doctor have no compassion, run their practice like assembly line and are more fascinated by tests and procedure and gadgetry display than the needs of the human being they treat. The third complaining party, the Medical School teachers as a whole are worried about turning out sub-standard, narrow minded, unenthusiastic graduates impatient to attain name fame and fortune without going through the process of tedious time factor hard labor and without suffering painful process or trial of wits, loosing sweat and tasting pangs and pain for reaching expected heights. This may be partly due to irresponsibility, aggressiveness, poor discipline, absence of mutual respect, give and take of teachers and taught, and most dishonest and vicarious assessment of merit and examination system prevalent. Under-standibily, it has many roots and is out come of the break down of moral structure, selfish attitude and undesirable social order. On all counts without any doubt Medical education is in bad shape and in chronic bad health. As usual there is no consensus on diagnosis and treatment and all concerned have their own prescription of fixing what is wrong and provide suggestion of some way out of it. At least in Pakistan, medical education as a means of providing an end to workable, meaningful, indigenous and economic health care system has definite morbid pathology, which surely needs medical surgery.


BASIC CAUSES:


The most crucial need is to orient the system to serve the needs of the overwhelming rural majority. This must involve a reduction in manpower and influence of the foreign trained specialists and consultants who have so far dominated both medical policy making and medical practice in Pakistan. The Health services in developing countries have been largely designed by doctors modeling them on experience gained while being trained or working in developed countries. Without exception, these medically qualified health planners have chosen as a high priority the training of doctors in large teaching hospitals, and with exception of a few small countries have invested large sums in building of this disease palaces (hospitals).

The running cost of tertiary care hospitals usually amounts to at least quarter, sometimes a third and in some countries absorb haft of the total national health expenditure. Tying up such recurrent expenditure has crippled attempts to provide a more enlightened health service. Tertiary care hospitals produce skilled personnel that they act as referral center, and that they will mostly take care of complex conditional teaching hospitals are (like a national air lines) also built as a matter of national prestige.

The doctors are produced on Curriculum as prevalent in Europe or America, which too is fast deteriorating in quality in our country. Recently this was pointed out by Federal Minister of Education while briefing a visiting group of American educationists by admitting that "Our education system is falling apart." Medical education has to its credit highest rating country wise and is socially prestigious and economically safe investment at cheaper cost and absorbs high proportion of best science students from schools. Once qualified these doctors see a more promising career if they specialize and the majority spend many years chasing higher qualification either in the country or overseas and only take up general practice by force of circumstances with frustration or apathy.

NEED OF THE HOUR:

Clearly, the developing countries need large number of general duty medical officers and not large number of specialists for practical health care system. It is necessary to identify the most common of population ailments and modify with importance the teaching in out colleges and arrange training in out hospitals.

Most of our prevalent diseases are Water and Food borne and due to lack of sanitation and result of malnutrition. According to an official survey 64% of disease are due to infection and parasitic disease. 11%due to Malaria, 8% due to congenital abnormality, birth injuries and peri natal mortality, 6% due to other causes including heart, diabetes and surgical problems. The association of American Medical Colleges representing 27 institutions in USA and all 16 in Canada (same number as in Pakistan) after conducting a 3 years survey and spending one million dollar have agreed as to" what is the education that all physicians need and how to make the process less brutal." At least on one point there is a general consensus that after World War II the curriculum is bursting at the seams and there is simply too much for young doctors to learn. Memorization, that's what it is all about in a densly packed education, Ironically much of the information pushes on medical students will be of limited use when they become practitioners.

This is due to very fast changes in scientific discoveries and that there is no point in trying to teach every little fact. Steven Mullar, Chariman of Johns Hopkins University and its hospitals wants to pare down the curriculum so that students can concentrate on the fundamentals of medical sciences and practice. Similarly Dr. Thomas I. Leaman, President of "Society of Teachers of Family Medicine" symbolizes the teaching and training in medicine for the people and community to an amateur farmer in the early spring who, with great enthusiasm and anticipation plants, lettuce, parsley, okra, artichokes, oregano, radish and guords, but neglects to leave room for staples; beans and potatoes, Leaman feels that" we need to recognize in ourselves and in our teaching that first and foremost we must be superb clinicians and we must continually have our own clinical sills. These are our basics," Our beans and potatoes" (Dal roti)

CONCEPTUAL SHORTCOMINGS:

In Pakistan, Pakistan Medical and Dental council has been assigned at its first responsibility as listed in its publication" Code of Medical Ethics", to" public interest by maintaining medical and dental standard". But as it is, so far it has not yet touched on the subject, which is understandably, the health care needs of the community. Neither it has made any beginning to prepare doctors to tackle 80% of the disease of the people, which is only possible through teaching, and training is Family medicine. By all imaginations, arguments, sense of proportion and fairness to the people this basic duty and responsibility of such supreme and august body as P.M.D.C., has remained neglected and Council has failed to assign itself to offer instructions, teaching training and continuing education in family medicine which besides health care, embraces how to foster sympathy, how to communicate better with those being treated, how to deal with patient and his families with compassion and his whole life rather than the fragmented pieces of content of sub specialties ignoring" Whole person medicine" and community needs.

WHAT IS FAMILY MEDICINE:

Family medicine in the past, called general practice has now in the age of specialization and explosion of technology and piling of by products of scientific research after Second World War and greater demand by the community for quality and content of modern age health care needs has acquired specialty status all over the world. It is an academic discipline and a clinical entity. It embraces a wide range of diagnostic and therapeutic skill while leaving to the various specialties more complex technical problems and procedures.

It is concerned with the earliest alterations from normal health and factors that influence or provoke such alteration. A properly trained family physician should have a firm grounding in basics, behavioral and social sciences, a broad knowledge of medicine, extensive training in internal medicine, and selective training in each of the specialty and special training in psychological medicine. Family medicine as a whole is the provision of primary, personal, comprehensive, preventive and continuing total health care to individual of either sex, of all ages, their families and the community. It is a discipline in breadth in contradiction to other specialties, which are disciplines in depth.

INEVITABLE CURRICULUM CHANGES:

In many countries these changes are occurring in medical education and particularly in Pakistan it is inevitable and overdue. Increasing emphasis should be given to restructure undergraduate curricula to community practice, family medicine and social sciences. The students need more orientation to patient and his needs rather than disease process and drug culture. The doctor in making, through out his career, is burdened by the threat of examination by specialist teachers and is denied of chances to be taught and trained in community and Family medicine and thus remains ignorant and unaware of the burden of his future responsibility to the national health care delivery. Essentially for such responsibility he is unprepared. Basically he has to be a good clinician, health educator, community leader and able to continuously educate himself and his subordinates. Learning experience should be relevant to clinical, family and community practice. It should be problem oriented with motivation for regular assessment and auditing and compulsive continuing education and vocational training. In summary, one feels most despondingly that such needs as given above have not yet realized by authorities or any attempt made for changes in the colonial system or medical education.

THE STATE OF THE CHILDREN:

The political and economic changes of recent years have made it clear that a new world order is evolving. UNICEF submitted ten propositions for the agenda of that new order - from the point of view of a world wide organization, which comes into daily contact with some of humanity's most acute problems. Excerpts from it, which are relevant to us in Pakistan are reproduced below. The ten propositions are as follows:

1] That the promise of the World summit for children should be kept and that a new world order should bring an end to malnutrition, preventable disease, and illiteracy among so may millions of the world's children.

Fact:

A quarter of a million young children die every week; millions more live on with malnutrition and almost permanent ill health. Approximately half of all cases of malnutrition, disease and early death are caused by five, or six specific illnesses which can now be prevented or treated at very low cost. This is not a threatened tragedy or an impending crisis. It happened today. It will happen again tomorrow. And by any objective standard of scale or severity, this issue would rank in importance with any on the human agenda. But in practice, such problems have had little purchase on priority because they are primarily the problems of the poor and the powerless.

2] That the principle of first 'call for children' - meaning that protection for the growing bodies and minds of the young ought to have a first call on societies 'resources' - should become an accepted ethic of a new world order.

Fact:

In many nations of the developing world, the lacke of this principle has meant that the debt crisis of the 1980s has been translated into rising levels of child malnutrition and falling levels of school environment.

In many nations of the industrialized world, the lack of this same principle has meant that the rising affluence of the 1980s has been accompanied by a sharp increase in the proportion of children living in poverty. Some nations have shown, in recent years, that it is possible to begin putting this principle into practice. The Republic of Korea has ensured, in each of the temporary economic reversals of the 1970s and 1980s that specific policies were in place to prevent rising oil prices or falling agricultural output from being translated in to worsening level of health, nutrition, or education among its children. The government of Indonesia, under economic pressure from the slump in oil prices in the early 1980s took a conscious decision to cut back spending on industrial projects and on hospital building in order to maintain expenditures on rural health clinics, immunization programmes, and primary schools.


3] That if the issue of malnutrition, preventable disease, and widespread illiteracy are not confronted as a new world order evolves, then it will be much more difficult to reduce the rate of population and make the transition to environmentally sustainable development.

Fact:

Reducing child deaths gives parents more confidence in family planning. Most of the developing nations are now entering or approaching the stage at which further declines in child deaths are associated with much steeper declines in birth-rates. Doing what can now be done to protect the health and save the lives of millions of children will therefore help, not hinder, efforts to slow population growth.

4] That the growing consensus around the importance of market economic policies should be accompanied by a corresponding consensus on the responsibility of governments to guarantee basic investments in people.

Fact:

On average, only about 12% of government spending in the developing world is devoted to basic investments such as primary health care and j primary education for the poor majority. World Bank studies have shown that raising the average educational level I of the labor force by one year can raise GDP by as much as 9%. Better adult I and child health has been shown to save millions of lost workdays. Correcting child malnutrition and iron deficiency anaemia have been shown to reduce absenteeism, increase attention spans, and improve schools results.

But for the present purpose, such studies are like striking matches in laylight. The evidence that investing in people lays the foundations for conomic growth looms large before us in the shape of those countries which lave succeeded in achieving rapid and sustained progress in the postwar vorld. Liberating people's potential via land reforms and universal health and education services has been fundamental to that success in countries md region such as Japan, South Korea and Taiwan. All of these have shown hat basic education and health for all are not just social expenditures but xonomic investments, not just indulgences which can only be afforded after countries have become prosperous but the foundations without which widespread prosperity will not be achieved.

All for some:

Of the resources which are allocated directly to health and education, more that half is allocated to relatively high cost services for the few, and less than half is allocated to low-cost services for the many. It is estimated, for example, that 80% of the $12 billion allocated each year o water supply systems is spent on putting private taps in the homes of the elatively well-off, at a cost of approximately $600 per person served, and lat only 20% goes to the public wells and stand-pipes which can bring clean water to the poor majority at a cost of $30 to $50 per person served, deallocating even a proportion of total expenditures in favor of the poor x>vld therefore liberate enough resources to achieve the goal of safe water upply for almost every community in almost every country by the 2000.

Education:

Such distortions of public spending in favor of the better-off are also vident in national education systems. Despite decades of research findings which regularly demonstrate that investment in primary education yields significantly higher returns in both ocial progress and economic growth , government spending in almost all eveloping countries is heavily biased toward higher education for the few ather than basic education for the many.

The necessity of importing primary education is vital. In both Japan and outh Korea, for example, universal primary education preceded economic ake-off. And in both, this basic investment in people was made at a stage when their per capita incomes, in real terms, were lower than in most leveloping countries today.

Japan moved rapidly towards universal prima education at the end of the last century. South Korea ensured that almost all its children were in primary school at a stage when its per capita GNP] was little more that $100 per year. Emphasis on secondary and higher education came later and was not made at the expense of primary education] for the great majority.

Many other countries have taken the opposite course, financing higher! education dis-proportionately with the result that up to half of all children I fail to complete four years in primary school while secondary and tertiaryj education absorbs an exaggerated share of the budget in order to produce many more graduates that the economy can usefully absorb.

If aid to secondary education, as opposed to primary, is excluded, then that proportion drops to below 5%. Only about 1% of international aid goes! to the primary health care systems which could prevent or treat 80% of the disease, malnutrition, and early deaths in the developing world. Only about I 1% goes to the family planning services which could do so much to improve the lives of millions of women and children. And considerably less than 1% I goes to primary education which as we have seen, is both basic human need I and one of the best possible investments that any country can make in its] own future.

The principal difficulty in shifting social expenditures in favor of the poor I majority is usually a political one; increasing the proportion of the budget! spent on primary health care or primary education represents, in effect, a I transfer of resources from the better-off and the politically influential to the poor and the powerless. Where affluence is inseparable from influence, that J transition will be very difficult indeed.


6] The international action on debt, and trade should create an environ-1 ment in which economic reform in the developing world can succeed in j allowing its people to earn a decent living.


Fact:

The continuing debt crisis means that the poor world is now transferring $50 billion a year to the rich nations. Protectionism in the rich world costs the poor world a further $50 billion a year in lost exports.


7] That a process od demilitarization should begin in the developing world and that, in step with that process, falling military expenditures in the] industrialized nations should be linked to significant increases in international tional aid for developing and for the resolution of common global problems,

Fact:

The amount now spent on the world's military exceeds the combined inual incomes of the poorest half of humanity. The goals of the world tmmit for children - including drastic reductions in malnutrition and kease and a basic education for all children could be met by reallocating D% of military expenditure in the developing world and 1% in the in-strialized world.

8] That the chains of Africa's debt be struck off and that the continent be en sufficient external support to allow internal reform to succeed in generation the momentum of development.

Fact:

Africa today is only managing to pay about one third of the interest [due on its debts. Even this is absorbing a quarter of all its export earning and osting the continent, each year, more than its total spending on health and ducation of its people.

9] That a new world order should oppose the apartheid of gender as [rigorously as the apartheid of race.

Fact:

More than a million girls die each year simply because they are born female; the cause of death is the disease of discrimination. It is commonplace that the developing world's women bear and care for its children, fetch and carry its fuel and water, cooks its meals and shop for its homes, and look after its old and its ill. It is less widely known that women ) grow and market most of the developing world's food, earn and increas-; proportion of its income, and work, on average, twice as many hours a day as men. In return for this disproportionate contribution, the women the develop-ling world are generally rewarded with less food, less health care, less education, less training, less leisure, less income, less rights and less protection. The practical costs of this bias are the reduced effectiveness sof almost jvery other aspect of the development process.But to discriminate against girls in the matter of educational opportunity I is perhaps the biggest practical mistake of all.

Over many years and in many I countries, the education of women has been shown to be associated with the [confidence to adopt new ways, the propensity to make greater use of social I service, the ability to earn higher incomes, the improvement of child care I and nutrition, the reduction of child deaths, the acceptance of family planning, the reduction of average family size, and the literacy od the succeeding generation.

10] That the responsible planning of births in one of the most effective and least expensive ways of improving the quality of life on earth - both now and in the future - and that one of the greatest mistakes of our times is the failure to realise that potential.

Fact:


Over 50,000 illegal abortions are performed each day. Several million children die each year because they were born too soon after a previous birth or because they were born to mothers who were too young to give birth safely. Over 100,000 young women die every year because they do not have the knowledge or the means or the right to plan the number and spacing of their pregnancies of all women could exercise that right, the rate of population growth would fall by approximately 30%.

ENVIRONMENT AND HEALTH:

Human beings require a healthy environment to flourish and to enjoy optimal health. Durability to live longer, and healthier, human body and the environment in which we live. The essential factors and variables that determine our increased life expectancy include;




1) what we eat,




2) what we breathe,



3) what we drink,



4) where we live- our environment,



5) what work we do,



6) our genetic make up,


7) our life styles, and many other factors that can affect our health and longevity.


Since the 16th century Renaissance to the modern industrialized, urbanized, technologically advanced and commercialized world today, Humankind had strived for more comfort, more health, more money, more knowledge, more control of his or her life, and environment. However, in this process of "advancement" we have created ( and are exposed to horrendous environmental hazards and threats to ourselves.

Examples of our Environmental Destruction include:



1) Air pollution,


2) Ozone depletion,


3) Acid rain,


4) Water contamination,


5) Urban smog,


6) Deforestation,


7) Soil erosion,


8) Disappearing species,


9) Concentration of carbon and


10) Hazardous waste, to name a few.


Three quarter of the 49 million people whose deaths are registered each year, are killed by illnesses related to &poor environment, and an unhealthy life style according to a WHO Director-General Report in March 1992.

Increased pollution levels in the environment may lead to poor health and also decreased life expectancy. The intensity of exposure depends mostly on the extent of the emission, the location of the source, the duration of the emission, and the transport and transformation processes that occur between the source and the exposed individual or segment of the population. The dose of the pollutant that individuals with in a community receive, depends not only on the general levels of pollution in the food, air and water they drink, but also on a whole range of other personal variables- the time spent in the working and home environment, the time spent to and from the work place, the individuals eating and drinking preferences, social habits, cultural norms and personal life styles. The total exposure of an individual is therefore affected by age, gender, culture, occupation, location, environmental hazards, the route, the duration, the concentration of pollutants, and a whole range of personal activities within his or her environment.

Risk assessment of human, exposure requires detailed studies of individuals and their life styles; to complement the environmental levels at point locations- in soil, air and water. The exposure of an individual to a pollutant, and its intake, can be measured by direct monitoring, or estimated by indirect monitoring. Biological indicators of exposure can be obtained by analysis of breath, body fluids and tissues such as- blood, human milk, serum, plasma, hair finger nails, teeth, stool, urine and sweat, for pollutants and their concentration.

A Working Definition of "Hazardous Waste"-RCR Act 1976 It is defmed as a waste, or combination of wastes, which because of its quantity, concentration, physical or
chemical, or infectious characteristics may;

1) cause, or significantly contribute to, an increase in morbidity or mortality or an increase in serious irreversible or incapacitating reversible illness or

2) pose a substantial present or potential hazard to human health or, the environment - when improperly treated, stored, transported or disposed of or otherwise managed.

Note: - By-products of ths treatment of any hazardous waste are also to be considered hazardous, unless they are specifically excluded.

Hazardous wastes have four characteristics:

1) Ignitability

2) Corrosivity

3) Reactivity

4) Toxicity.

Any one or a combination is enough to label any waste" hazardous."

Chemicals, Lifestyles and the Environment

For the past 50 years, there has been a tremendous increase in the production of organic chemicals to satisfy our demand for consumer goods, as well as an increased demand for valuable heavy metals, for both personal and industrial use. As we enjoy the benefits of consumer goods, we must also learn to deal with the challenges that go along with them. The chemical industry has produced a side variety of products that have much improved our standard of living and generally increased human life expectancy . However, associated with these benefits are the risks of accidents, contamination, pollution, spills and more hazardous wastes all of which could endanger human health, leave harmful residues in our environment, which can or may affect fish and wild life, viruses and bacteria or impair the fragile balance and harmony of nature and the very precious environment that we live in.

Examples of Environmental Hazards affecting Health Occupational Causes of Cancer

Etiology Site of Malignancy

Arsenic Lung, Skin and Liver.

Asbestos Mesothelioma, Lung.

Benzene Leukemia.

Benzidine Bladder.

Chromium Lung.

Radiation Numerous Location.

UV Light Skin, Eyes.

Vinyl Chloride Liver Angiosarcoma.

Coal tar Scrotal Cancer.

Environmental Lung Disease

Inorganic Dusts Organic Dusts

Asbestos exposure Cotton dust, flax

Silicosis Grain dust-farmers,

Ship crew member,

Barge.

Coal worker’s pneumoconiosis Mouldy hay-Farmers Shepherds-animal handlers.

Siderosis

Lead exposure

Mica.marble dust.

Toxic Chemical affecting Lungs

Acid Fumes; (Nitric, Sulfuric, Hydrochloric acid) All of these can cause Ammonia mucous membrane Cyanide irritation. Violent Formaldehyde coughing. Dyspnea Halide (C1, Br, F) Pulmonary chronic Hydrogen sulfide bronchitis. COPD. Nitrogen dioxide

Ozone

Phosgene

Sulfur dioxide

Toxic to eyes

Lead

Arsenic

Thallium

Tobacco

Methanol

Quinine

Carbon disulfide

Formaldehyde

Ozone

Heat, x-rays

Ultra violet rays

Neutrons

Drugs

Kidney Nephrotoxic Substances

Mercury

Gold

Cadmium

Lead

Lithium

Bismuth

analgesics

carbon Tetra Chloride

Cyclosporine

Snake venoms

Heroin, Amphetamin-Antibiotics (some) -Radiation

Liver Hepato Toxic Substances

Carbon Tetra Chloride

Trichloroethylene

Yellow Phosphorous

Mushroom (Amanita, Galerina)

hydrocarbons

solvents

Steroids

oral Contraceptives

Anesthetics

Analgesics

Radiation

Tranquilizers

Neuro Toxins Nerve Damage

Snake venom (cobra, viper etc.)

Snails

Lizards

spiders

shellfish (dinoflagellates)

Fish (Stingray, Toad fish etc.)

Insects (Ticks, Centipede etc.)

Cis-Platinum

Isoniazid

Acrylamide

Buckthorn (Toxic berry)

Carbon Dioxide

Diketone Hexacarbon

Lead

Thallium

Organophosphate

Sunlight- UV rays

Skin Dermato Toxins

Temperature change

Phenols

Germicides

Heavy metals

Solvents

insects

Chemotherapy agent

Antibiotics (many)

Steroids

Gold

Pesticides

Fumigants

Toxic gases

Acids- Alkalies

Most medications could

Arsenic

Mercury

Radiation

Bone Marrow Toxins

Benzene

Radiation

Anti-metabolites

Arsenic

Gold

Insecticides

Mitotic inhibitors

Anthracyclines

Sulfa drugs

venoms

Nitrosoureas

Alkylating agents

Chloramphenicol

Heavy metals

Besides toxic and industrial waste, we have may other environmental hazards tike:

• Automobile Accidents.

• Noise Pollution

• Radiation Injury

• Gun Shot Injury

• War Injury

• Physical ViolencE- Domestic and others

• Infectious Diseases

• Natural Disasters- like floods, earthquakes etc.

• Sports Injuries

• A.I.D.S.

• Occupational Injuries and Hazards

• Psycho-Social Problems- Drugs, depression, suicide etc.

Note :

There are 5 million known chemicals, 60,000 of which are used commercially, it is a few hundred chemicals that are very hazardous and can cause significant harm.

Some Concluding Thoughts:

This earth that we live on is the only planet that we human beings have. Let the laws of nature rule, not the laws of greed. Let us keep our planet free from unwanted pollutants, sow the seeds for our future generations. As scientists and physicians we can measure how clean is clean, how green is green. After all, it has been said that" A healthy body has a healthy mind". How can we have healthy bodies if out environment is not as clean as it used to be?

Its time we all asked...

1. How clean is the air we breathe ?

2. How pure is the water we drink ?

3. How wholesome is the food we eat'?

4. What are the pollutants and environmental hazards where we live or work ?

5. How much radiation are our bodies getting ?

6. What other hazards will be introduced in our world in the future and for what reason ?


Remember:


The flip side of industrialization, urbanization and modernization is always pollution, pollution and pollution. Today, we cannot afford to pollute, pollute and pollute any more. It’s our responsibility to prevent our precious planet earth from all hazardous wastes and hazardous thoughts that are endangering our lives and also the lives of other living things.



Cont/P-3