The Lady Doctors Of Larkana - Fatima Bhutto

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The lady doctors of Larkana
A hundred beats
Sunday, October 28, 2007
Fatima Bhutto
Last week I visited a government hospital for women in Larkana.
Established in the 1970s, the hospital offers a gynecology ward, a
general health ward, a menopause and infertility clinic and a quaint
but small women's mosque on their premises. The hospital's gynecology
unit treats approximately 150 out patients every day, delivers up to
20 children by cesarean section and another 15 by natural birth per
day, and cares for up to 50 expectant mothers. Somewhat miraculously,
all this pre and postnatal care comes at the hands of only thirty
doctors. Thirty women, that is.
These thirty women doctors work around the clock, understaffed and ill
equipped, to uphold the Hippocratic oath they swore to when they first
became physicians. The oath -- first, do no harm -- is not one these
phenomenal doctors take lightly.
There are only five beds in the natural delivery ward, sometimes they
are all occupied and the women must give birth in unison with no
luxury such as privacy awarded to them. Waste management in the
natural delivery room consists of a black trashcan placed at the edge
of the bed where afterbirth, blood, and fluids are disposed of. Rubber
sheets, which are quickly washed down after each delivery, cover the
beds. The hospital cannot afford to buy and clean cotton sheets for
the patients. Similarly, there are no hospital gowns for the women to
wear; they deliver in the clothes they came in. There are a sparing
amount of beds available and no unit for the newborn infants, they are
handed to their mothers after birth and sleep with them on their
narrow, steel-rimmed beds. Though lacking in sufficient equipment and
medication, the hospital, a government run one, equitably treats women
from Larkana and the rural areas surrounding upper Sindh. They charge
Rs. 800 for cesarean deliveries -- with free post-operative medical
care -- and approximately Rs. 350 for natural deliveries.
The lady doctors of Larkana are true heroes. They work for meager
salaries, between Rs. 6,000 to 17,000 -- a pittance for their superior
skills. They work day and night, weekends, and holidays and though
exhausted, their bedside manner is impeccable (they were very gracious
when I fainted in the middle of a cesarean section, from the halothane
mind you. Not because I was frightened or anything, no sir). The
problem here is not the doctors or the health care provided in the
interior of Sindh, the problem is, as usual, the state and their
fundamental incompetence in caring for the most basic needs of the
The government has not offered the prerequisite test that determines
positions in their hospitals since 2005. The last time the government
held the test they awarded 110 doctors, out of a possible 30,000
qualified candidates, commissions in government hospitals. Why? When
so many people are denied access to health care why would the
government scale back the number of doctors in its hospitals? The
answer, the explanation to why government hospitals in Sindh are
finding it increasingly difficult to provide adequate care for women,
especially expectant mothers and infants, is wholly inadequate,
especially given Pakistan's dismal health statistics.
According to the Red Crescent, Pakistan ranks far behind other
developing countries in the reproductive health risk index. We have
one of the lowest records of female health and education, combined
with the poverty and low social status that affects most Pakistani
women, these factors ultimately result in women being systemically
disadvantaged when it comes to asserting their rights to health care.
As it stands, according to the United Nations Population Fund (UNFP)
Pakistan boasts one of the highest rates of maternal mortality in the
world. Five to six women die every hour during childbirth due to
completely preventable causes. During the nine months of pregnancy one
in 38 Pakistani women dies from not receiving any prenatal care
whatsoever, compared to one in 230 women in our neighbouring state Sri
Lanka. Almost half of the total number of pregnant women in Pakistan
are anemic throughout their pregnancies due to improper nutrition and
in time they give birth to disproportionately malnourished children.
Our infant mortality rate -- 82 infant deaths for every 1,000 -- is
also a record holder. These deaths are seen as inevitable due to the
fact that out of the approximate six million women that bear children
in Pakistan every year, two thirds of them receive absolutely no
prenatal care, factor that in with the reality that 80% of infants are
delivered at home without the aid of a trained physician.
With statistics as grim as these, why the rollback on doctors in
government hospitals? The immediate concern is money, it's always
money. Government hospitals pay their staff salaries that private
hospitals in the interior of Sindh, comfortably relaxed in the glory
of privatization, would never dish out. On average, a doctor working
in a government hospital in Sindh receives a stipend of Rs. 12,000. An
equally qualified doctor working in a private hospital in the interior
has to make do with Rs. 3,000 a month. With salaries so low, it's
financially no different to work as a traveling midwife than it is to
hold a private position. One might also argue that it's not exactly
worthwhile for government hospitals to be handing out so much money
from their annual budget to their employees, especially not since
corruption is such a celebrated (and now safe, thanks to the NRO)
component of the Pakistani work ethic.
The second reason, as far as I can tell, is that the National Program
for Family Planning and Primary Health Care is prioritizing a new
initiative. They are training, paying, and supervising Lady Health
Workers (LHWs) from regional communities -- who are not qualified
physicians, only trained in first aid-- to deal with local health
issues and provide basic care. While the idea of LHWs is theoretically
commendable, it is certainly curious that the government would
undertake such a program for largely superficial medical ailments when
there are thousands of women and infants dying from severe and
complicated health factors. Maternal mortality is a serious killer in
Pakistan. The fact that the government pays the LHWs a salary of Rs.
2,600 a month, far less than they would have to pay government
hospital staff, is also telling. The UNFPA wrote in a 2003 report that
'there is no evidence that the training programs in Pakistan have
worked to reduce maternal mortality' further concluding that at most
it had improved the performance of local midwives.
Most, if not all, of these women's and infants deaths could be avoided
and easily so. With access to trained physicians, medical care and
prenatal treatment Pakistan's women would survive their pregnancies.
We are not talking of life threatening illnesses, not of AIDS or
Cancer; we are talking of a nation with an appalling low maternal
health index that is cutting back on the number of positions in their
more affordable hospitals. The Sindh Health Department's website,
(navigating it is an exercise in futility, I don't advise it) is
crammed full of data, and yet it doesn't address the most serious
problem facing Pakistan's government hospitals -- the fact that there
are no doctors in them.

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