Death of a little girl:

Death of a little girl

Precisely three days from today it will be a year since 3-year old IMANAE MALIK died at the Doctor’s Hospital Lahore .The case , pursued actively by Imanae’s  father  , Aqeel Malik , received ,initially at least , a blaze of publicity with the newspaper stories , TV talk shows and internet discussion forums dominated by the story .Candle-light vigils were held , imanae’s face  stared down  from billboards.The child ,who had suffered a superficial scald-burn on her left hand died after receiving an injection of Pavulon. Pavulon a muscle –relaxant which mimics curare is used with general anaesthesia in surgery as an aid to intubation or ventilation .

It does not have sedative or analgesic effects and is used in some US states as one of the three components making up a lethal injection at the time of execution .It is used in Belgium and the Netherland to carry out euthanasia , after first inducing coma. The substance which has a paralytic effect on all muscle groups, kills by stopping breathing .Its use , as in the case of Imanae, represents a truly awful way to die.

The question of how a child with a minor injury received the substance so inappropriately raises issues about the methods involved in licensing  doctors in the country , the education they receive and the standard of care they are able to offer. The case of Imanae Malik’s death continues to be heared by the Supreme Court of Pakistan  .The out come is awaited .But sadly as the media intersest has faded, crucial issues have not been taken up.Till they are , other people remain at risk of suffering a fate similar to Imanae’s.

Perhaps the most central of these maters pertains to the competence of  Dr Sandeep Kumar , the young physician who administered the injection , and has since fled , presumably back to sindh to evade arrest .Mercifully he is thought no longer to be practicing as a doctor .The story goes back to the village of Obharo in the Hyderabad district till recently . They have since shifted to Ghotki .

Like many others unable to gain admission at a public-sector medical college at home or afford the fees charged by the private colleges that have sprung up across the country , Kumar’s family had arranged for him to pursue  his medical  education in china .Five thousand Pakistani  students are currently enrolled at Chinese universities ,though for the last two or three years Kyrgyzstan has emerged as a more popular  destination for medical students –perhaps Chiefly because the annual fee of the around Rs400,000 is three times lower too than that of Chinese Institutes and lower too than that charged by many Pakistani private institutions.The quality of the training Kumar received is uncertain .While Pakistani students with Chinese qualifications ,like others studying in non-English speaking countries , are required to pass the National Equivalence Board examination to get permission to practise in Pakistan ,all those who sat the test had been declared successful in the past by the Pakistan Medical and Dental Council. The exam was outsourced last year to the University of Health Sciences with just ten per cent or 52 out of 526 candidates from 15 countries ,reportedly clearing it since this happened.

The glaring discrepancy is just one among the many in the maze which constitutes the medical educational system in Pakistan .There is worse to come .Days ago ,the PMDC withdrew  the conduct of the NEB test from the UHS,leaving the university shocked and handed it over to the Dow University of Medical Sciences.The PMDC say the purpose is to rotate the exam between four provinces.Insiders say the low UHS pass percentage has angered PMDC high ups as it means fewer regristrations and less revenue.

There are currently at least 92 PMDC recognised  colleges in the public and private sector.Till 2010 the PMDC had granted recognition to almost every institute that applied for a regristration .This year it has balked at Federal Health Ministry recommendations that 25 new institutes be recogniseds.Weak monitoring of existing institutions ,allegations of corruption in the grant of regristration to institutes and doctors and a failure to maintain standards by withdrawing recognition add to the charges against the PMDC .its registrar has consistently denied these allegations and said colleges can be penalised for the poor standards.This has rarely ,if ever happened.

In june this year reports surfaced in the press of large scale registration granted to doctors who had attended dubious institutions in Afghanistan or Central Asia , by top PMDC officials in exchange for large sums of money.Today these doctors practise at hospitals and private clinics across the country .Their number is unknown and files containing records have vanished from PMDC offices.

The affiliation of those involved in the scam to top political leadership has prevented an impartial investigation .Others engaged in the practice of medicine have been  known in some cases to affix false certificates , produced off a  computer printer on their  walls. Some possess  a year  or two  of medical training ,some not even that.Mechanisms to check such malpractices are poorly enforced and the result is that people seeking medical care have no assurance of its quality.

A number of private medical colleges run in complexes comprising no more than a few rooms , with laboratories that would not be acceptable at the better high schools. Even at public institutions in Lahore, students say they receive only limited  practical training and in the past have been able to bribe staff to carry out dissections or other practical work.Curriculums used at most  medical schools have been criticized by the WHO for failing to direct sufficient attention to community medicine , in a setting where it is badly needed. The failure to incorporate practical and clinical skills has been identified by the experts as a week link at many colleges.

Also , medical ethical is taught only at a  few institutions and medicine is frequently seen by those who take up the professions as means to rake in profits .Emphasis on  research , essential to modern day practice of medicine is not built into teaching and apart from a few select institution Continued Medical Education in any form is not a requirement unlike the situation in the US where it is a requirement for licence renewal.A great deal though depends on individual interest , diligence and ethics- something which again goes in part with good teaching .

The case of Imanae Malik underscores some of this. The fact that a child could be administered a lethal injection at an institute rated the best in Lahore , is disturbing . It is unclear if others present in the emergency room objected to the administering of Pavulon ,though one nurse at least is believed to have done so.Though he has remained on the run since the incident ,Dr Sandeep Kumar is understood to have told associates he was trying only to somehow ease the child’s pain especially as her parents were vehemently demanding more be done. He has also reportedly cited sleep deprivation a condition familiar to every doctor and not that should result in a child being killed.

The case has already resulted in the some measures meant to safeguard patients .The Punjab and Balochistan assemblies have passed healthcare bills ,laying down mechanisms for the monitoring of health services.Whether the provisions are enforced is for now difficult  to forecast .There is also greater awareness among people of their right to care though it is also a fact that  many complaints from patients or their families are frivolous , intended to defame or based around their rage and grief rather than on logic .We have yet to see if the tragic death of a small girl results in meaningful measures set to make medical care safer and plug the many loopholes in our medical education system.