Critical care services & life expectancy
I READ with great interest the article in the Dawn entitled ‘Valuable lives and invaluable ventilators’. I commend the paper on bringing this important topic to light. However, this issue concerning ventilators is merely the tip of the iceberg. The greater problem is the delivery of critical care services and the finances, equipment and personnel associated with this branch of medicine.
I recently immigrated to Pakistan after having practised critical care medicine at a major Quaternary care teaching hospital in New York City for 20 years. The process of returning to Pakistan provided me the opportunity to see several ICUs in Karachi. Overall, I would have to say that there has been a systematic underdevelopment of critical care services in Pakistan. The reasons for this are many, but the greatest drivers would be a lack of clear-cut financial return to hospitals on investing in the capital equipment, space and necessary expertise, as well as a presumed lack of improvement in public health through investing in critical care. This is unfortunately an extremely myopic view of critical care services.
The impending global need for critical care services has been receiving increasing press and engendering an active debate concerning critical care in the world. In the US critical care services account for 0.5-1 per cent of the GDP. For any hospital in the US, critical care services accounts for anywhere between 15 and 21 per cent of a hospital’s operating budget. Whereas from 1985-2000 the number of acute inpatient beds has declined in the US by 31 per cent, the number of ICU beds has increased by 26 per cent.
This shift in increasing ICU beds is a reaction to the greater need for this discipline, especially in view of the so-called ‘silver tsunami’ (an ever-aging world population with greater comorbid diseases and, therefore, critical care needs).
The US epidemiological data would suggest that acute lung injury will increase by 50 per cent by 2030. Simultaneous increases in severe infection (sepsis) and mechanical ventilation can be expected.
In Pakistan the situation is no different. The predication for increased global need for critical care applies to Pakistan as well. Without appropriate critical care services we cannot increase the use of advanced therapies (both surgical and non-surgical) for cancer, heart disease, neurological disease or organ transplantation beyond kidney transplant. Factors driving global critical care demand such as increasing urbanisation, war, terrorism, natural disasters and infection outbreaks are all present here in Pakistan. Investment in preventive medicine can only go so far and for those diseases that preventive medicine cannot impact upon, critical care is necessary.
Recently, the monumental WHO Global Burden of Disease Project 2012 published its findings and Pakistan has gratefully seen an increase in both male and female life expectancies.
However, without proper planning and development of critical care services in Pakistan, the gains in life expectancies for our sickest citizens can be expected to plateau or, perhaps, even drop in the coming decades.