Civil Hospital
Written by Hafsa Hanif - Dow University of Health Sciences, Karachi
In the first of a series of articles on perspectives of medical students around the world, Hafsa Hanif, a student at the Dow University of Health Sciences in Karachi, discusses the serious challenges facing medical students and women in a Gynaecology department which he believes is a microcosm of public healthcare in Pakistan.
Dilapidated ancient structures inhabiting a rowdy and polluted land, grumbling of decades of neglect and scarcity of resources - Civil Hospital, Karachi is a meek testimony of the plight of its visitors and inhabitants, besides the organizational and administrative anarchy that has plagued it and public hospitals of its like in Pakistan. Catering to the provinces of Sindh and the neighbouring areas of Balochistan, 2 of 4 provinces in the country, it is among the largest public sector hospitals in the country.
The Gynecology Department is divided into three independent functioning units crammed on the same floor of an obsolete edifice. The visitor entrance to the inpatient departments at the hospital is through a rusted black gate timidly positioned in the midst of a rowdy downtown area in the earsplitting noise of rickshaws, motorcycles and public buses besides the hustle and bustle of the marketplace. The filthy and garbage laden hospital ground is the unqualified complement to the polluted air from the combustion of low quality fuel by automobiles. A site too typical for a Karachite is dull maroon spots on the ground as if remnants of dried drops of paint splashed on the ground. A witness to the socioeconomic class that the hospital caters to, these are spitout products of ‘pan’, a local substance of abuse. The dirty walls bear ugly graffiti, posters, and political banners.
The uneven ground and broken pavements harbor vendors offering a variety of packed and unpacked cooked food in amazingly unhygienic conditions, that are sure to astound infectious disease control personnel. Their businesses, ironically, are inside a hospital. Flocks of people can be seen occupying the pavements of the hospital ground and passageways to sit and relax, because of the scarcity of waiting areas. There are no sign boards to guide visitors to the gynaecology department; they have to feel fortunate if they locate the department in ease, inquiring from doctors walking by on the way. The better and less congested of the two ways that lead to the department is through a narrow, ill-lit staircase that leads to a somewhat better lit, but nevertheless dirty and narrow passage way. The passageway is part of the third Unit of the department. It leads to the Emergency section and Labour Room, besides the other 2 Units. The other route has a lift next to the staircase, a scarce entity in the hospital, allowing patients on wheel chairs and stretchers to be transported.
“Privacy is a luxury that the hospital does not provide even in the labour room, where women lay on beds next to each other watching each other as they bear labour pains.”
Illventilated and ill-lit as it is, as many as 16 beds can be crammed in a single room, besides a nursing counter and bathroom. Other rooms can be relatively spacious, albeit dirty and lacking the very basic facilities a ward room requires. There is no outlet for oxygen gas with each bed, nor a monitor, nor any other technical apparatus. The beds, positioned next to each other, with a bench intervening for attendants, have no curtain or other means of separation to allow for privacy. Nor do doctors possess the ethics to endow patients the blessing of confidentiality of their case, during ward rounds and otherwise. Alas! Privacy is a luxury that the hospital does not provide even in the labour room, where women lay on beds next to each other watching each other as they bear labour pains and deliver.
“These women have been living in horrible socioeconomic circumstances where even running water is a blessing to be valued.”
The slow moving fans in the ward rooms are a test in patience for doctors and patients alike;; air conditioning in the ward rooms is out of the question. Cats wandering about the beds is a routine;; at times they are seen impinging on remnants of food in the metallic dishes patients are served lunch in. These dishes are washed and reused. The beds are not the kinds that would be comfortable to lie on. The mattresses are routinely contaminated with filthy discharges of women and the excreta of their newborns, not a surprise, considering the literacy and health awareness of the patients. The bed sheets similarly contaminated cannot be changed daily because of the scarcity of resources. The bathrooms too bear witness to the deplorable sanitary conditions at the ward and the hygiene consciousness of the women who use them. And these women could not have been cleaner having lived in horrible socioeconomic circumstances where even running water is a blessing to be valued. The vast majority of women who visit the hospital can not afford pads for their menstrual flow;; they use pieces of cloth, wash them, and reuse them. Hence, as medical students, we are trained to take histories of menstrual flow in terms of the material of the cloth used and how much it gets soaked!
“Medical students... also find an opportunity to practice... per vaginal examinations... the unfortunate patients do not have the right to object.”
Medical students (third year on-wards) posted at the ward view it as an opportunity to gain a hands-on practice of giving injections, inserting IV cannulae and catheters, and drawing blood. There are no protocols for having been formally trained on the procedures or performing a specified number under observation before doing them oneself. Students, however, prefer doing the first one or few procedures under supervision for fear of causing harm. Busy as they are, doctors may at times casually drop the responsibility on students to draw blood or administer an injection, which they would themselves have to do otherwise, because of the shortage of nursing staff. Medical students on posting, also find an opportunity to practice per abdominal and per vaginal examinations, the latter, especially in the labour room, even on patients on whom they are not indicated. The unfortunate patients do not have the right to object.
“The doctors... scream at and humiliate patients, which at times is a very sorry sight to witness.”
The hospital cannot afford packed alcohol swabs. So pieces of cotton, somewhat soaked in an antiseptic are kept in a jar. Hence, each time it is required, the jar has to be opened and piece of cotton taken out. As for tourniquets, which are also an expense the hospital can not bear, they are made by cutting used tubing of IV drips, at times after they have been disposed off. Lubricant for urinary catheterization is also unavailable; patients have no option but to bear the pain.
A major issue the department faces is the offensive and brusquely mannerisms of its doctors and other staff. In their arrogant and conceited attitude they literally scream at and humiliate patients, which at times is a very sorry sight to witness especially in the labour room when patients are in pain. The patients well know this is something they will have to bear with, for they will not be heard, and the doctors are confident they will not be questioned. Doctors do not even have the etiquettes to talk to medical students; I remember breaking down in tears once when one of them uncouthly reproached me for a fault that was not mine.
Patients’ female attendants staying at the department are lodged in a single room where they all sleep and spend the day together. The room, which can be packed with as many as 50 women at the same time, is a real ordeal for attendants in the summer heat and humidity.
The Labour Room, ER, and Operation Theatre, though ‘renovated’, face many of the same problems as the inpatient department. Civil Hospital is not one of its kind. Other public hospitals in Karachi and other parts of the country may be functioning in even more grave circumstances. However, in view of the crises that have loomed over the country in the past decade, the future of health services in the country seems very gloomy.
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