As the battle against Covid-19 rages on, young doctors continue to fight on the frontlines, often without basic protection and even timely payment of their salaries. Disillusioned, many feel that they are expendable and want to leave the country. But this is only the latest aspect of the many issues doctors have to face all across Pakistan

On April 14, 2021, like many Muslims across Pakistan, 26-year-old Dr Qadir Nawaz Jakhrani woke up an hour before dawn. He had sehri and then recited the Quran and said his fajr prayers.

After the namaz, he went to his bedroom and asked his wife to go to another room as he wanted to rest alone. “It’s the first of Ramazan,” he said. “I won’t be going on duty to the hospital.”A couple of hours later, when Jakhrani didn’t come out of the room, the family got worried and banged on the door. It was locked and they couldn’t hear anything inside. The family then broke the door down, unprepared for what was on the other side. Jakhrani had hanged himself from the ceiling fan.

Upon reaching the house around nine in the morning, colleagues from Jakhrani’s hospital, Taluqa Headquarter Hospital, Kashmore, found his wife, three children, father and brother in a state of utter devastation given what they had just witnessed.

In the hospital where he worked, nine medical officers were hired in total, but only four would come to duty. The other five got away by paying larger kharchis (bribes).

Just two days earlier, as Jakhrani was about to leave the hospital for home, he had hugged a colleague while humming the tune of ‘lag ja galay ke phir ye haseen raat ho na ho [embrace me for we don’t know if we’ll get the chance again].’ The next day, his co-workers noticed that he was spending a lot of time on his phone, reciting Quranic verses and posting them on Facebook.

“God knows what was going on in his mind all this time,” says one of his colleagues, who insists on remaining unidentified fearing action against him at the workplace. “It sometimes makes me angry that I didn’t understand the meaning of all this when it was happening.”

But all this has been happening to young doctors across Pakistan. After Jakhrani’s death, his family said that he was under a lot of pressure because of financial hardships — a reality young doctors, especially ones working in the public sector in Pakistan, are all too familiar with.

Jakhrani was among 1,100 doctors and 1,350 nurses hired by the Sindh government on 89-day contract arrangements to respond to the rising Covid-19 emergency. (2,300 nurses were hired originally, but later 950 were made permanent).

In the hospital where he worked, nine medical officers were hired in total, but only four would come to duty. The other five got away by paying larger kharchis (bribes) to the district health office. Colleagues and close friends of Jakhrani share that while kharchis are a norm in government offices, the district health office would demand five to 10 percent of the sum to release their salaries. Those who didn’t come on duty would give up to 40 percent, they share.

But having to share kharchis is still far from the biggest concern of the doctors putting their lives at risk during the pandemic.

In the days leading up to Jakhrani’s death, the staff had not been paid since December 2020. A sole breadwinner in the family, who had an older wheelchair-bound brother suffering from lymphoma, Jakhrani didn’t even have 500 rupees to pay to get his salary released. Helpless, he requested his colleagues to pitch in for him.

Jakhrani would regularly follow up with his co-workers about his pay. His manner kind yet desperate in voice notes, he would urge his friends to take care of their health during the pandemic.

Weeks later, a friend gathered 6,000 rupees while Jakhrani’s father borrowed 15,000 from a local grocer on a promise that the money would be returned very soon as Jakhrani’s pay would be cleared in the same week. A few days later, when the salary cheques were issued, Jakhrani was no longer around to receive them.

THE PERSONAL COST OF SAVING LIVES

Jakhrani’s suicide had doctors from Taluqa Headquarter Hospital boycotting their duties, and protests spread to other hospitals in the province. An enquiry committee, set up to investigate the matter, suspended the presiding assistant district health officer, Kashmore, Dr Ahsan Ahmed Dahani. After the episode, while the situation of salary clearance improved for a couple of months, doctors across rural Sindh share they haven’t been paid since May.

“The salary comes every third or fourth month, when the 89 days are completed,” says Rabail Abro, a nurse in Larkana. “They neither make us permanent nor pay us on time. It is embarrassing to keep holding out our hands in front of our friends and relatives for rent and food.”

At present, Abro and other nurses are dealing with people flooding the district health office for Covid-19 vaccine jabs. Close to 500 people are lining up each day, with Abro and team not even getting a moment to take a break and drink water.

Abro would do all this while listening to accusations from grieving family members who were suspicious of the coronavirus and were regularly seeing conspiracy theories on WhatsApp. Still, when local clerics would be called in to perform the last rites, it was healthcare workers such as Abro who would help them get into personal protective equipment (PPE).

In the mornings, Abro attends online classes as part of his training as a Post-Registered Nurse Bachelor of Science in Nursing (Post-RN BscN). And from afternoon to night, he’s a Covid-19 responder in the community.

For Abro, the starting six months were the toughest. He was working non-stop and there was no pay. In May-June 2020, when the country was hit by the first surge of infections and fear enveloped populations, people refused to even stand in close proximity to their loved ones. But social distancing was not a luxury medical workers such as Abro could afford.

“I was everywhere,” he says. “Attending patients in the isolation room, running between intensive care and high dependency units, and then taking the dead bodies to the graveyard for burial.”

Abro would do all this while listening to accusations from grieving family members who were suspicious of the coronavirus and were regularly seeing conspiracy theories on WhatsApp. Still, when local clerics would be called in to perform the last rites, it was healthcare workers such as Abro who would help them get into personal protective equipment (PPE). Then, with the help of men from Edhi Welfare, Abro and his colleagues would go down into the graves to lower the bodies and cover them with dirt.

Things for young doctors and healthcare workers have never been easy in Pakistan, but the virus made things worse. “At times I would wish all that was happening around us could switch off,” Abro says.

RISK ALLOWANCE

Despite working so closely in contact with the infections, Abro claims he has never received a risk allowance, which was promised by the government to healthcare workers in all provinces.

In the past 16 months, since the coronavirus came to Pakistan, doctors across the country have held several protests demanding the promised salaries and risk allowances by the government.

During summer last year, the Sindh government had announced that the allowance would include house job officers, postgraduate professionals, nursing students and staff employed at the government hospitals and health centres across the province. A few months later, the health department issued a notification that, with Covid-19 cases going down in the province, the health risk allowance was to be discontinued. Doctors and paramedical staff responded by suspending out-patient services in government-run hospitals across the province. While the decision was taken back the next day, on ground little changed.

“We know of permanent employees, who are not necessarily on the frontline Covid-19 response, receiving the allowance while we, who are being exposed every day, have not received any allowance,” says Dr Asif Abbasi, who is working in a rural health centre in Shahdadkot.

“At present, all doctors, paramedical staff and the ancillary staff are among the frontliners and deserving of health risk allowance,” says Dr Malik Adil, the casualty medical officer at the Institute of Kidney Diseases (IKD) in Peshawar. “The morale of doctors is down to the extent that I have colleagues who are taking antidepressants to cope and continue responding to the Covid-19 surges,” he says.

In June this year, the speaker in the National Assembly session took up the issue and directed the Ministry of National Health Services (NHS) to address it by noon the next day. As yet, no progress has been reported across all provinces. In the capital alone, healthcare workers boycotted hospitals and took to the streets when the government rejected a summary seeking allowance.

According to a recent newspaper article, the country’s leading auditors reportedly indicated irregularities, wasteful expenditures, loss and misuse of funds, fabricated purchases and negligence of Covid-19 public funds of worth three billion rupees in Khyber Pakhtunkhwa. Finance and Health Minister KP, Taimur Jhagra, in a series of tweets, refuted the leaked information calling it “confusing, misleading and irresponsible based on an ongoing audit process in the province.”

HIGH EXPOSURE IN THE CITY

While health workers such as Abro are struggling in smaller cities and rural areas, the conditions in bigger cities, with higher infection rates and low morale, are even worse.

Dr Kashif Jakhrani moved to Karachi last year to respond to the city’s Covid-19 crisis. Even though Kashif had high marks, he was not nominated for a position in his hometown Kashmore. After an interview at the Sindh Secretariat, he was offered a position in Karachi, because cases were rising in the city and they needed healthcare workers to step in. “We were told cases were peaking in Karachi, so many of us came from rural Sindh on these hirings,” Kashif says.

At first, Kashif was posted at the Arts Council for vaccination and, most recently, to Expo Centre in intensive care.

Coming from rural Sindh, the reality of living in Karachi was a rude awakening for Kashif. He was not prepared for the city’s high rents, unreliable transport (especially during initial lockdowns) and the hurriedness that comes with city life. The experience was made worse by the irregular salary schedule.

With the salary coming every second month, Kashif says he would have been better off with a daily wage private job in his hometown. “At least I would have sustained better with food provided from home,” he says. “We can’t help but worry that we’ll be laid off as soon as Covid-19 ends. I’m trying to get posted back home, but it’s not happening any time soon.”

The issues doctors such as Kashif face are widespread throughout the country. Doctors across the country are endangering their lives with little protection for themselves.

On any regular day, that often stretches to 48 working hours, Dr Romana Wazir, a Peshawar-based postgraduate student training in obstetrics and gynaecology, is found running between labour rooms, operation theatres, wards, emergency rooms and outpatient services — constantly exposed to the virus.

In the past 16 months, since the coronavirus came to Pakistan, doctors across the country have held several protests demanding the promised salaries and risk allowances by the government.

In August 2020, the first time Wazir got infected with Covid-19, a 28-year-old pregnant woman had left the hospital facility through an out-pass before she could be screened for the virus. The next morning at seven, the patient returned to the hospital with irregular breathing. She was moved to the intensive care unit (ICU) and put on a ventilator. Finally, a C-section was performed on her. While the baby was born premature and survived, the mother couldn’t make it past the third day of giving birth.

Wazir also tested positive soon after. She then completed a 20-day isolation at home. During this time, her sister caught the virus too. More recently, in July this year, six postgraduate trainees, including Wazir and a nurse from her ward, got infected. All were vaccinated and couldn’t track the root of the exposure.

Something similar happened with Dr Adil from the Institute of Kidney Diseases (IKD). In June 2020, he got infected and brought the virus home. He and his wife, also a doctor, self-treated and remained in isolation. Six months later, his wife got infected again and Dr Adil got exposed too. “There is zero compensation for all that is happening to me and my family,” says the doctor, adding that the government should consult them to know what they need.

NO PROTECTION

A year into the pandemic, there is still no regular supply of personal protective equipment (PPE) at hospitals around the country. “The mask I’m wearing, I bought it on my own,” says Dr Adil. “During the second wave, when the PPEs [mainly the gowns and masks] supply was started, we were told to wash them after use, as there weren’t enough.”

The shortage expands to healthcare centres in Quetta and Panjgur. Patients frequenting the facilities cough about in out-patient service areas, while the healthcare workers have the bare minimum protection and are often just wearing gowns and masks.

Coming from rural Sindh, the reality of living in Karachi was a rude awakening for Kashif. He was not prepared for the city’s high rents, unreliable transport (especially during initial lockdowns) and the hurriedness that comes with city life. The experience was made worse by the irregular salary schedule.

“They stretch the lifelines of the kit to as many hours as they can, until it is only worth throwing away,” says Dr Hanif Luni, general secretary of the Young Doctors Association (YDA) in Balochistan. “How do you expect people who haven’t been paid their due monthly salaries to buy anything on their own?” he asks. “We have been operating on donations from businesses and charities.”

In April last year, a month into the virus spreading like wildfire, around 150 doctors were arrested from Quetta city for protesting the lack of PPEs and appropriate equipment across the province. At that time, the province was at the centre of an outbreak in the country, with thousands of pilgrims crossing the border from Iran, triggering community transmission on Pakistani soil.

The healthcare workers boycotted services and the protests spread to cities in Punjab.

A couple of days later, President Arif Alvi was noticed chairing a Covid-19 briefing by the Punjab government wearing an N-95 mask, infuriating the medical community across the country. The Balochistan government said that they were agreeing to the health workers demands and also extending ad hoc contracts of about 500 doctors.

NO JOB SECURITY

These reactive measures are often temporary and taken without proper planning. And it is the doctors who pay the price for this lack of planning too.

The doctors who were appointed on ad hoc basis for the pandemic response — which also included 250 doctors and nurses as announced by the Balochistan health department — aren’t regularly receiving salaries. “I would say 15 to 20 percent have been paid salaries from time to time,” claims Dr Luni. “When the infection surges would dial down, the health workers would be laid off and, a few months later, when the cases would rise again, they would reappoint them with no backlog clearance.”

The appointed medical officers — men and women — are now among scores of postgraduate trainees who haven’t been paid in the past 10 months. Health workers report that, with hospitals facing a dearth of professionals, medical equipment and medicines, patients resort to violence. There are also limited slots for further training. (Balochistan has only two tertiary care facilities which also serve as training centres).

In such a scenario, it is only natural that young doctors are disillusioned. A big chunk of female students pick family life, while men go for private services. In Balochistan, trainees wanting to specialise in areas such orthopaedic surgery, endocrinology and general patient surgery look outside their hometowns and provinces or, those with means, outside the country.

Postgraduate training slots in Punjab were also reduced by at least two-thirds between 2020 and 2021. More than 10,000 doctors across the province are unemployed, unable to continue beyond their one-year internships.

Dr Sadia, a resident of Gujranwala, applied for an ad hoc medical officer position at two different places and has been waiting on results for the past eight months. “Less than 10 percent of people are selected from thousands of applicants and, each year, we hear how candidates pay lakhs to secure the seat,” she says.

The handful who make it are not guaranteed a full year of employment, because they are required to give up the seat if a public service commission candidate is available to secure it permanently.

On any given day, Zeeshan Noor, a member of YDA Punjab, who is also struggling to enrol in postgraduate training in dermatology, receives calls from medical graduates needing a job. “A few days ago, I heard from a desperate recent graduate wanting to meet as soon as possible,” he says. “She came to us saying her mother passed away, father has Covid-19 and she needs a job. Any job, private or public, would do, she told me.”

EXIT PAKISTAN

While doctors are often portrayed as miracle workers who can give people a second lease on life, Pakistan’s young doctors appear to be waiting for a miracle themselves. Understandably, many are done waiting.

Dr Rohit Keswani completed his MBBS from Chandka Medical College two years ago, ended his one-year housejob in surgery and then joined as a frontline worker against Covid-19 last year. On any given day, Keswani collects Covid-19 samples and manages patients inside the health facility. Holidays come and pass by, and families such as Keswani’s continue waiting to get salary clearance and spend time together.

As time passes by, and his hope to get a permanent contract staggers, he knows he needs to look elsewhere. Currently, he’s preparing for his Occupational English Test (OET) exam — a language test for medical practitioners to be eligible to be considered for residency programmes and, eventually, licences in the UK and the US. “I’m trying to secure a seat in Karachi for the exam,” he says. “Currently, seats are booked for at least three months.”

Pakistan produces an estimated 14,000 doctors each year. The Pakistan Medical Association (PMA) states that around 60 percent of the students, majority of whom are women, don’t pursue postgraduate training or any service. “Around 15 percent of the remaining have interest and actively look for postgraduate training opportunities,” says Dr Qaiser Sajjad, the organisation’s secretary general.

Owing to the scarcity of training positions in the public sector, while some go for private positions, those with additional means and ambitions appear for foreign training and subsequent licences. As per a conservative estimate, the US and the UK currently house at least 30,000 Pakistani doctors in all. A few thousands, as per unofficial figures, include those opting for Saudi Arabia and other Gulf states.

The country at present houses a little over 200,000 doctors and 116,659 nurses. In the past two years alone, over 2,000 healthcare workers across categories of physicians, nurses and pharmacists have registered with the government’s Bureau of Emigration and Overseas Employment, for placements abroad.

In a recently post-Brexit world, and a month before Covid-19 was declared a global pandemic, a memorandum of understanding was signed between Pakistan’s employment bureau, AFCO Private Limited (a private recruiting agency in Pakistan) and the UK’s MMC recruitment group, in which it was agreed that Pakistan would provide 150,000 medical professionals, including doctors, nurses and pharmacists to the UK.

Later, during the same year, Kuwait’s government and Pakistan signed agreements stating that Pakistan would send 600 medical professionals, in different batches, to combat the coronavirus. By June 2021, as many as 1,134 healthcare professionals, including doctors, staff nurses and technicians have made it to the Gulf state, as tweeted by the Ministry of Overseas Pakistanis and Human Resource Development.

This year, the inflow of remittances witnessed a spike by 17 percent, a milestone for the Pakistan Tehreek-i-Insaf (PTI) government, whose manifesto has been to facilitate investment of overseas Pakistanis in the economy. At home, however, brain drain continues with young professionals leaving the country.

Doctors leaving Pakistan is nothing new. But with the pandemic making more and more young doctors feel like they are expendable, it is no surprise that young doctors are looking elsewhere for greener pastures.

TESTING TIMES

While the situation for young doctors continues to remain uncertain, the current graduating medical students have another conundrum at their hands.

Maham Arooj is a Peshawar-based fresh medical graduate, completing her internship in medicine and surgery this year. If nothing had changed in the year of her graduation, a year of training would have made her eligible to be a certified doctor in Pakistan, and free to pursue another job or postgraduate training. But receiving a licence is no longer that straightforward a process.

In 2019, the Pakistan Medical and Dental Council (PMDC), the official body for regulating medical, dental education and practice in the country was dissolved. The body was replaced by the Pakistan Medical Commission (PMC), a nine-member body headed by the president, initiated on the promise of establishing standardised reforms in the training and education of healthcare workers.

The formation of the body was widely criticised and protested against for being illegal, with organisations such as the YDA ‘rejecting’ the body because no elections were conducted to appoint members. But a few months down the road, a Pakistan Medical Commission Act, 2020 was introduced, gathering the ire of students, trainees and medical institutions.

Under the new ruling, a National Licensing Exam (NLE) has been introduced, directing all medical graduates from September 2020 to pass the exam to attain a full licence of practice, previously undertaken only by foreign graduates and practitioners. In the past several months, doctors from Dera Ismail Khan to Islamabad to Peshawar have held various demonstrations against the new directive, applicable retrospectively on candidates originally registered with the now-defunct PMDC.

Medical representative bodies and educational institutes have argued that the new exam, which is comparable to the US licensing exam in its nature, if executed, poses a question on the credibility of students and schools that conduct five years’ worth of professional exams, getting a candidate ready to enter the market. A petition filed in the Lahore High Court by the students was also ruled in favour of the PMC.

“It’s an additional financial burden on the parents and the student to get registered,” says Dr Qaiser Sajjad of the PMA. Sajjad asks that, if a candidate fails this new exam after having already qualified from a medical college, who is to stop him or her from opening a private practice somewhere?

“I and all my batchmates are boycotting this exam,” says medical graduate Maham Arooj. “The date of the exam registration has already passed and I’m hopeful that the students who enrolled when the PMDC was functional, will be exempted.”

The PMC website, however, states that exams will be conducted in the last week of August.

This bureaucratic chaos has been created while other parts of the world witnessed final year students collecting their graduation degrees early to join the Covid-19 response and share the burden of overworked and understaffed medical facilities in their countries. In April 2020, at least 13 medical schools in the US fast-tracked their timelines and allowed students to graduate early and join hospitals.

In an environment riddled with issues of non-payment of salaries and ill-fitting contracts rooted in corruption, lack of postgraduate training opportunities leading to growing unemployment and brain drain from the country, what is a 25-year-old, fresh out of medical school thinking?

One young doctor provides great insight with just one sentence. “Getting by is one thing and living is another thing altogether,” he says. The disappointment in his voice, the lethargy caused by running around Covid-infected patients and fighting a battle with no recognition, protection and even basic benefits, says more than words ever could.

Header: A file photo of Young Doctors Association activists staging a protest in Peshawar | Shahbaz Butt/White Star

The writer reports on labour and the environment. She can be reached at haniyajaved1@gmail.com

Published in Dawn, EOS, August 22nd, 2021