Tuesday, November 19, 2019

An HIV outbreak puts spotlight on Pakistan’s health care system

  • >>Maria Abi-Habib and Salman Masood, The New York Times
    Published: 2019-10-31 12:34:05 BdST

A paediatrician accused of reusing syringes and infecting scores of Pakistani children with HIV is now practicing in a government-run hospital after his private clinic was shuttered, in a case that is raising widespread questions about the integrity of Pakistan’s health care system.

The paediatrician, Muzaffar Ghanghro, was initially the sole focus of blame in an HIV outbreak that has hit more than 1,100 people — so far nearly 900 of them are children — in the small city of Ratodero.

But government officials believe he is not the only cause there, and that the bad practices he is accused of, including reusing syringes and IV needles, are so widespread across Pakistan that the entire health care system needs better regulation.

Health workers say the government needs to revamp the national medical syllabus to prioritise infection control, currently a minor part of doctor training. And they say hospitals often scrimp on the sterilisation process for tools.

“The only good thing about the outbreak has been that it laid bare the multiple flaws in the system that the government with support of UN agencies needs to address,” said Dr Fatima Mir, a pediatric infectious disease expert working at the Aga Khan University in Karachi. She was one of the first responders to help with the outbreak in Ratodero.

Dr Muzaffar Ghanghro, on Oct 24, 2019 in Ratodero, Pakistan, is now practicing at a government-run hospital after his private practice was shuttered. The paediatrician is accused of reusing syringes and infecting scores of Pakistani children with HIV. The New York Times

Dr Muzaffar Ghanghro, on Oct 24, 2019 in Ratodero, Pakistan, is now practicing at a government-run hospital after his private practice was shuttered. The paediatrician is accused of reusing syringes and infecting scores of Pakistani children with HIV. The New York Times

“What the outbreak in Ratodero says about Pakistan’s health care is that infection control is poor or nonexistent. Pakistan’s health care system is now trying to integrate infection control as a formal part of the system,” Mir added.

She said that Pakistan’s medical practitioners often lack the logistics and supplies necessary to prevent and contain infections. When she was in Ratodero to help, Fatima said it was a challenge finding clean water to wash her hands with while seeing patients.

“With the lack of infection control, this outbreak is not unexpected. What is unexpected is that this time, children are the main victims, and there are a lot of them,” she said.

Of the nearly 36,000 residents in Ratodero tested since late April, 1,112 of them have tested positive for HIV, 889 of them young children. With not even a quarter of Ratodero’s population tested, officials worry the real numbers are much higher.

The police investigation into Ghanghro is ongoing, and he has been cleared only of the charge that he intentionally spread the virus, the district inspector general in charge of the case said in an interview. Ghanghro’s court case for medical malpractice is still ongoing, said the district inspector general, Irfan Ali Baloch.

Ghanghro has denied that he reused syringes, which is illegal.

“A team of medical experts came and interviewed him,” Baloch said. “The medical board determined that he did not intentionally spread HIV, but his clinic was in such a condition that the protocols were not being maintained.”

Ghanghro still faces criminal charges, making it unclear how he is able to continue practicing, and why he was recently posted to a government-run hospital near Ratodero.

Provincial health care officials in Sindh province, who would be responsible for reassigning Ghanghro, said that he has not been given the permission to resume practicing medicine and that his medical license was not recently renewed.

But Ghanghro said in an interview with The New York Times last week that he recently renewed his license, and was practicing in a government hospital with a stream of patients waiting to be seen by him, questioning the government’s ability to regulate the system.

“He has applied to us to start practicing again,” said Abdul Sami, an official from the Sindh provincial health care commission. “But so far, we have not allowed it.

“If he has already started practicing, it is not to our knowledge,” added Sami, who is based in the district of Larkana, where Ratodero is.

Imtiaz Jalbani, a father of four who lost two children to HIV this year, points to an injection mark on his son’s hand in Ratodero, Pakistan, on Oct 24, 2019. He claims the mark is from a syringe taken from the trash during a visit with the paediatrician Muzaffar Ghanghro. The New York Times

Imtiaz Jalbani, a father of four who lost two children to HIV this year, points to an injection mark on his son’s hand in Ratodero, Pakistan, on Oct 24, 2019. He claims the mark is from a syringe taken from the trash during a visit with the paediatrician Muzaffar Ghanghro. The New York Times

Officials from the governing Tehreek-e-Insaf partly blamed the outbreak on the poor governance and corruption of the local government of Sindh province.

Other observers said the outbreak is more about systemic failure.

Zaigham Khan, a development expert who writes a column for The News newspaper, noted that Pakistan spends less than 1% of its gross domestic product on health care, and that only one doctor is available for every 6,000 people, mostly concentrated in urban areas.

“Pakistan is facing a full-blown public health crisis, mainly rooted in ineffective governance and dominance of special interests,” Khan said.

“Pakistan is one of the two countries in the world where polio persists, the other being Afghanistan” and treatable conditions like rabies and dengue contribute to dozens of deaths annually, he added. “In rural areas, most people are treated by quack doctors. As if that was not enough, even doctors often administer expired medicine. Doctors are hardly ever made accountable for these practices in the legal system.”

Dr Baseer Khan Achakzai, the program manager of the central government-run National AIDS Control Program, said that Ratodero’s conditions were not unique, and that much of Pakistan was struggling to combat the spread of HIV, which causes AIDS. Unregulated clinics were continuing to operate, he said, and used syringes are frequently repackaged to sell as new, although they are supposed to be incinerated after use.

From 2010 to 2018, the number of HIV-positive people in Pakistan nearly doubled, to about 160,000, according to estimates by UNAIDS, the United Nations task force that specialises in HIV and AIDS. During that time, the number of new infections jumped 38% in those 15 to 24. And only about 10% of people thought to be HIV-positive are being treated.

“With the help of UN agencies, a state of the art AIDS control centre is being established,” Achakzai said. “It will ensure that contaminated syringes will not be used and all medical waste would be put in the incinerator.”

With the exception of the capital, Islamabad, medical laboratories across Pakistan are not under any regulatory framework, Achakzai said.

“There is no check and balance,” he said.

© 2019 New York Times News Service