Because of the Covid-19 pandemic, only a few hospitals are dealing with emergencies; hence there is increased pressure on government hospitals because of patients turning up who require immediate consultation and surgical intervention.

Recently, an incident took place at a teaching hospital that demonstrates what happens when there are no SOPs [standard operating procedures], protocols or guidelines for emergency situations such as the current pandemic.

 A few weeks ago, at around 10.30pm, a patient arrived at a teaching hospital in Karachi complaining of a severe abdominal pain and fever. After initial assessment and basic investigation, he was diagnosed with acute appendicitis and it was decided that the inflamed appendix would be removed through abdominal surgery. But, that night, there was no operation theatre available for this patient, so the surgery took place at 4am. A normal appendix was found but the doctors removed it anyway, on the basis of suspicion.

Post-operatively, hardly any improvement was seen in the patient, who then had an episode of diarrhoea. At this development, one of the resident doctors suspected that the patient might be suffering from Covid-19.

With the mere mention of the dreaded virus, everyone who had come in contact with the patient — right from the casualty department to the operation theatre — panicked. In the absence of a practical protocol and the non-availability of resources, nobody knew what to do with a post-operative patient who was suspected of having contracted the coronavirus.

While countries around the world are proactively helping their healthcare personnel deal with the Covid-19 pandemic, Pakistan’s apex healthcare body remains moribund

The patient was transferred to the so-called isolation ward, where doctors, nursing staff and other health providers do not have personal protective equipment (PPE), nor have any experience of dealing with this type of suspected-infected patients with the potential to spread the disease.

The swab specimen from the nose and throat of the patient and everyone who had come into contact with the patient was sent for a Covid-19 test. In a panic, a series of meetings involving the hospital administration, the in-charge isolation wards, the in-charge intensive care units, the department of infectious disease, and the professors of anaesthetics, surgery and medicine, took place. Some basic decisions were made and it was decided to perform tests for Covid-19 prior to any surgery.

It was decided that patients testing positive would be transferred to isolation wards that were to be created especially for Covid-19 patients. The doctors and health providers attending to these patients would be wearing PPE. It was also decided that a special 20-bed intensive care unit would be created exclusively for Covid-19 patients requiring a ventilator.

It has now been more than five weeks and up until now (April 26), except for the provision of PPE kits provided by a donor, none of the above decisions have been carried out, thanks to our inefficient healthcare system. Fortunately, the test results for the above-mentioned patient, and everyone who had come in contact with him, were found to be negative, which came as a great relief for all. 

The situation is not different in the other provinces of Pakistan. It seems that the provincial health ministries are in denial as far as the severity of the situation is concerned. The chief minister of Sindh tried to take prompt and appropriate action for public safety as the crisis unfolded and was right in implementing rules such as a lockdown in the province, the creation of isolation wards, a 1000-bed hospital for infected patients at the Expo Centre and for the testing of the coronavirus to be increased. The government of Balochistan also followed Sindh and began working along the same lines.

The National Institute of Health (NIH) issued the first advisory regarding the prevailing coronavirus situation on January 25 and the national plan against the spread of Covid-19 was issued on March 13. But both of these were ignored by the federal and provincial governments, the majority of the health authorities, the general public and religious leaders, despite warnings from the Pakistan Medical Association and the news from the dangerously changing situation around the world.

Meanwhile, the General Medical Council (GMC) in the UK and the Medical Council in Ireland were issuing SOPs for doctors and health workers. After a council meeting, the GMC allowed final-year medical students to join the National Health Service (NHS) as doctors in the war against Covid-19. The GMC also restored and renewed the registration of all overseas doctors registered with the GMC to return to the UK and work in the NHS. The Irish Medical Council immediately renewed the registration of Irish Fine Gael politician and physician Dr Leo Varadkar, who registered himself to work in the hospital once a week after 17 years of medical practice in Dublin. 

In our part of world, however, the Pakistan Medical and Dental Council (PMDC)/Pakistan Medical Commission remains dysfunctional because of continuing litigation and the government’s unwillingness to allow PMDC to work as an autonomous, independent body. The PMDC’s mandate is to regulate medical education and training in the country, to issue guidelines for emergency situations such as the Covid-19 pandemic and to register fresh medical graduates to work in the health sector. But because of the situation with the PMDC, more than 10,000 doctors (fresh graduates and already-registered ones) await their registration and renewals of expired registration, even after the submission of forms and renewal fees.

There are also hundreds of doctors who graduated from Pakistan who are waiting in the UK, US, Canada and Australia for their ‘good standing’ certificates to start their residency programmes in those countries. For their part, the GMC has exempted British national Pakistani graduates from ‘good standing’ certificates to work in the UK.

PMDC is dysfunctional because the owners of private medical colleges and vested interest groups in the public sector medical colleges and medical universities do not want to see regulation in medical education, training and clinical practice. As far as medical education is concerned, the government has no vision. In 2019, the government dissolved PMDC through an ordinance, paving the way for establishment of a new organisation called Pakistan Medical Commission (PMC) which recognised more than a dozen private medical colleges which lack basic facilities, qualified faculty and a proper attached hospital, all at the cost of patients and the medical profession. 

Medical councils and regulatory bodies all over the world are facilitating doctors to work in hospitals with valid registrations. They are making sure that medical education is available, without any gaps, on the internet, at every level in medical schools. They are also actively providing the latest information and guidelines to registered doctors and making sure that they have a safe working environment in hospitals to provide advanced scientific medical care to patients.

But Pakistan’s PMDC/PMC is least bothered about the continuation of medical education and training in private and public sector medical colleges, in either normal or emergency situations in the country. They were unable to produce any guidelines for doctors and owners of private hospitals in relation to safe practices within their institutes. The PMDC doesn’t even bother to look at the well-prepared and well-thought out recommendations of the NIH because of the lack of vision and absence of leadership at the PMDC.

In the recent disappointing Supreme Court decision, which allowed the government to take over the PMDC by nominating nine members, no timeline was given for the formation of the new medical council by the election and representation of professionals in the body. The court’s decision was unable to restore the autonomous position of the council. Therefore, with dependence on the government, the PMDC will continue working for vested interest groups and will not be able to bring a change in the status quo.

It is high time that the PMDC should give a timetable for the formation of the council as per the rules and regulation of the PMDC ordinance. Revolutionary actions are required for the creation of an autonomous, independent and powerful PMDC that can regulate medical education and protect the medical profession, so that the country is able to face challenges such as the Covid-19 pandemic.

In the meantime, the PMDC should act on an emergency basis, with extra staff, to process the more than 10,000 pending applications for the registration and renewal of PMDC certificates for doctors who are not currently working legally. The PMDC should also send the ‘good standing’ and no-objection certificates to all those desperate Pakistani doctors waiting for these documents in different countries.

The writer is ex-Secretary General Pakistan Medical Association & ex-Member PMDC

Published in Dawn, EOS, May 3rd, 2020