ALAF KHAN
Now and then I have been randomly jotting down my “Silent Musings” without any chronological order or any sequence of subject matters. Medical issues are rather a small part of the whole effort. Here is an excerpt from that unpublished collection: —
We the Messiahs.
Those with high scores in their 12th grade (F.Sc.) examinations in Pakistan are usually interviewed by the media about their ambitions for the future. ‹I want to be a doctor and serve the ailing humanity› is the usual reply. This noble ideal, alas, has a short life in many cases. Some of these young idealists, sooner or later, succumb to the urge for mundane glory and life comforts like those enjoyed by some of their seniors. More time is given to private patients than to those in the general wards. Juniors often dispose of the bulk of outpatients before Sir or Madam peeps in briefly to see how things are going. Specialists give stipends to their juniors and paramedics for doing most of the routine work in their private clinics. Private Consultation is a misnomer when you call in 2-3 patients and as many of their relatives at a time in the presence of your own assistants. Neighboring drug stores, clinical labs, X-ray plants, ultrasound clinics, and ECG facilities share with us the money they receive from the patients that we refer to them. Lab tests are often advised in the absence of legitimate needs. Touts roaming in the surrounding streets entice patients who want to consult some specialist. The specialist pays the tout an agreed sum per patient that he brings. There is no end to the misdeeds of those who forget the oath they took at graduation. But, then, you have to find a President, a General, a Minister, a Senator, a Member of the legislature, or a bureaucrat who has honored his or her oath of office. One becomes a lump of salt once one enters a salt mine:
ہر کہ در کان نمک رفت نمک خواہد شد is an old Persian line that still stands valid.
Here are three cases that are not too rare:
A. I purchased a small portable ultrasound machine for the late Dr. Murad Ali. He started his private ultrasound service in a small apartment next door to my clinic. Murad’s service to the patient was efficient, reliable, and ethical. Genuinely poor patients were scanned free of charge. Doctors and their immediate family members were also examined gratis.
He, on 8th April 1987, came to me for advice about a patient referred to him by a consultant gynecologist for a pelvic scan. The gynecologist ran a private maternity home in our University Town in Peshawar. Her referral note addressed to Murad was short and brutally blunt. It said:
Dear Dr. Murad Ali, Season’s greetings to you. In the future, you will charge all my patients coming to you for investigations half the amount, the other half I shall take in agreement with you. Please send a reply through the bearer of this chit. Thanks.
Mrs. J. A. MBBS, DGO, MRCOG Consultant Gynecologist.
Patient: Johar. Primary amenorrhoea 18 years. O/E PR. Negative. Referred to the ultrasound unit, Dabgari, Dr. Murad Ali.
I told Murad to scan the patient free of charge and give the referral note to me. I stopped at the gynecologist’s maternity home on my way home that evening. This being our first encounter, she did not recognize me by face.
What do you want? she blurted out as she came out to see me. I showed her the referral note she had written to Murad. What about it? she asked. “Please don’t refer any patient to Murad in the future”, I told her gently. “Murad does not split fees and does not pay commissions”. Why should I send patients to you bloody fools if you do not pay commission, was her parting message. This was the first time — and the last — that I heard the words bloody fools from a woman’s lips. Years later, I showed this letter to my friend, Shaukat Ali Jawaid of Karachi, who is an internationally known medical journalist and author. I also showed him the following two specimens of professional ethics verging on criminality. He published all three of them in his fortnightly Pulse International, Karachi.
B. Seventy-seven-year-old Raza Khan had been my close friend since 1972. His cardiologist son, Ovais Raza, had come home from the USA to get married to Prof. Sirajuddin Ahmed’s daughter in August 1998. Invitations to the wedding ceremony had already been sent out. Raza Khan’s responsibilities had understandably made him feel tense. His elder son, Asif, took him on 28 July 1998 to a psychiatrist in our inglorious Dabgari Gardens of Peshawar. The Messiah with MBBS, DPM, (London & England) prescribed the following array of nine powerful brain-affecting drugs for simultaneous intake:
1. Inj. Clopixol IM 3 times daily. 2. Mellaril tabs 100 mg twice daily. 3. Kemadrin tabs ½ +1 daily. 4. Rekotnil tabs 3 mg 1+1 daily. 5. Tabs Prothiaden 75 mg 1+1 daily. 6. Restoril tabs 15 mg 1+1 daily. 7. Epilepsin tabs 200 mg 1+1 tabs daily. 8. Inj. Valium 10 mg I.V. slowly 0+1 daily. 9. Serenace drops 50+50+50 daily. He mercifully did not specify the volume of each drop. Counting fifty drops is quite a job by itself. Stamped on the three edges of the prescription sheet was the advice that all medicines must be continued without interruption
(دوایی کا استعمال مسلسل جاری رکھیں)
Raza Khan received the first dose of dose of all nine drugs at the doctor’s clinic. He was doped so heavily before reaching home that his son had to carry him on his back from the car to the bedroom. Later in the evening, he was partially awakened with much effort to take his second dose of each drug. Efforts the next morning to wake him up for his breakfast were futile. He had been effectively drugged to death. His funeral preceded his son’s wedding by a few days. The Messiah, in the meanwhile, continued his profitable healing art unhindered.
C. Thirty-eight-year-old Saidan Gul was a linesman employed in the electricity department in Quetta, Balochistan. He, on 29 May 2000, suffered sudden paralysis of his right limbs with a total loss of speech. His paramedic brother, Muhammad Ayub, took him on 3 June 2000 to the Professor of Anesthesia at Bolan Medical College. The Professor administered the following concoction:
- Acupuncture and electrification on all Chinese traditional points on collaterals and related channels, far and local points.
- One combined shot of Western medications for relieving neuronal edema and superadded infection.
The one combined shot of Western medications, administered by the professor in his clinic, consisted of the following 10 drugs in one go:
Inj. Akatinol + Inj Cavinton + Inj. Galamate + Inj. ACTHAR + Inj. Rocephin 1G + Inj. Solu Medrol 160 mg + Inj. Furosemide / KCl tabs + Tabs Duxil (45) 1+1+1 daily for 15 days + Tabs Persantin (45) 1+1+1 daily for 15 days + Tab Disprin one daily + Tabs ??? (unreadable) (45) 1+1+1 daily for 15 days.
There was no mention of Saidan Gul’s Blood Pressure, Blood Sugar, heart rhythm, or any diseased heart valve that could have resulted in brain damage. The neuronal edema and superadded infection were myths concocted to justify the culpable array of drugs. There was no note of the patient’s history nor any clinical findings on the professor’s prescription sheet.
One sunny day I read the news that the worthy professor of anesthesia had been elected a Member of our (dysfunctional) Medical & Dental Council of Pakistan.
Rabies – Polio – Tuberculosis – AIDS – Thalassemias – Tetanus
Rabies
The Daily Jang of 02 Nov 2019 reported the following tragic story:
Forty-five-year-old Saleem was the sole breadwinner of six children and a pregnant wife. Today Saleem is going through the agonizing last day of his life in the ICU of JPMC, Karachi. He had tried to save his four-year-old daughter from a stray dog that had attacked her. The dog bit Saleem’s thumb. Two major hospitals in Karachi had no anti-rabies vaccine. He was told to get the vaccine from some drugstore. He received the first dose and was advised to get subsequent doses from a local doctor. He ultimately landed in the ICU of JPMC with established rabies.
According to statistics for Karachi, more than 9,000 persons were bitten by stray dogs during the year ending 31 October 2019. Statistics from the Sindh Health Department reported 19 deaths and more than 200,000 cases of dog bites in the province during that year.
According to the Economics Times of 03 September 2019, Pakistan had imported from India anti-rabies vaccine (Indirab) in large quantities at a cost of 36 million US dollars. Incidentally, Indirab has been in use in many countries for a while but the FDA of the USA has not approved this brand.
Statistics for stray dog bites in the rest of the country are also staggering.
I encountered the first-ever case of rabies in Bannu (N.W.Frontier Province of Pakistan) in 1970. Abdul Ghafoor, the 12-year-old son of Ahmad Jan, was brought to my outpatient clinic in Bannu District Headquarters Hospital on 16 September 1970. A dog had bitten him on 24 July 1970. Now he could not drink liquids and was intolerant of any electric fan. Standing face-to-face with him, I asked him to close his eyes. At that moment I gently blew my breath over his face. The boy staggered back in utter terror with his mouth wide open. Fear of wind (aerophobia) and of liquids (hydrophobia) are the hallmarks of established rabies. Death is then a cast-iron certainty in the ensuing 24 to 96 hours.
Rabies is endemic in Pakistan.
We shoot humans with scant remorse but won’t shoot a dog. Aseefa Zardari, daughter of Benazir and Asif Ali Zardari, was extremely angry at the killing of many stray dogs by municipal authorities in two areas of Karachi South (News International, 07 August 2016). Perhaps she would be less compassionate to the canines if a member of her own family had been the victim like the 196 persons who had died of rabies in KP Province alone during the year 2010 (Daily Aaj, December 25, 2010).
I had, during the 1980s, written four memoranda to Governor Fazle Haq on the gravity of the problem and the non-availability of a potent vaccine. The fourth memorandum was sent to him after the death in our ward on 26 August 1984 of the eleven-year-old Fazli Azim of village Balogram near Shangla in Swat. It was impossible to console the boy’s devastated father, Mr. Shahzada.
Quacks freely promote their lethal anti-rabies recipes, potions, talismans (تعویذ), charms, and incantations (دم،درود) . One such advertisement claimed powdered red pepper to be a dependable cure for rabies (Daily Aaj, 5 February 2019). The same newspaper of 28 February 2019 published a Health Tip that recommended 10 -12 grams of turmeric (curcumin) in water by mouth twice daily, plus its poultice on the bite site as a cure for rabies. An advertisement, including a mobile number, guaranteed a cure for rabies with an amulet (تعویذ). It was painted on the roadside wall along Abdara Road in Peshawar’s University Town. The municipality presumably charges advertisers handsomely for using urban walls as advertising boards. Many claim to have been empowered by their spiritual mentors (پیر) to cure rabies through incantations or specially formulated prayers. All such claimants are killers of humans. Our newspapers, municipalities, and health ministries are partners in these lethal practices through their indifference. Anyone claiming a cure for established rabies ought to be punished for homicide.
Immunization of pet animals has largely eradicated rabies from the developed world. Its incidence in Pakistan is probably higher now than it was during British rule when municipalities employed dog killers and budgetary provisions were made for the purchase of strychnine and minced meat for killing stray dogs.
Sporadic reports of dubious authenticity have recently appeared in some medical journals claiming recovery from rabies after long periods in coma. The published protocols, however, have been questioned by experts. Established rabies remains a death sentence that no court, monarch, or parliament can commute.
After seeing the first case of rabies in Bannu in 1970, I wrote to the Deputy Commissioner of Bannu, Capt. Ashraf Hussain, requesting him to order the elimination of stray dogs that roamed the streets in every town. He wrote to the Municipal Administrator, Laeeq Khan, in a typically bureaucratic style asking him to take appropriate measures in this regard. Laeeq Khan’s Press Release was a specimen of even greater bureautic excellence. He had offered a reward of 0.25 rupee per dog to anyone who brought stray dogs to his office for destruction. One had to take sixty or so dogs to Laeeq Khan’s office to get a reward of one US dollar at the 1970 exchange rate. He probably meant twenty-five rupees per dog but, like any good bureaucrat, he had signed the typed script without reading it.
The rules established by the British for controlling the population of stray dogs still exist in our municipalities. But none would say what happens to the budgetary provisions for the purchase of minced beef and strychnine and the salaries of the municipal dog killers.
Laeeq Khan was later promoted to Provincial Secretary in salary grade #18. One day — or night— he slipped out of the country to avoid imminent arrest for corruption.
The UNO, WHO, Bill Gates, and some NGOs have been running sustained vaccination campaigns for the eradication of poliomyelitis. Their goal is noble but the overall perspective is flawed. Polio can inflict grave disability but it kills rarely. Rabies never disables; it always kills. Hundreds perish through rabies in Pakistan alone every year.
A columnist of Daily Mashriq (Peshawar) reported at least ten thousand cases of dog bites in the country in one year. It means at least one hundred potential deaths even if only one percent of the dogs were infected and the victims not vaccinated promptly with a potent vaccine. The Jinnah Postgraduate Medical Center in Karachi treated 6,500 dog bite cases in 2015 and 3700 cases in the first eight months of 2016 (Dawn, 4 August 2016). Rabies is a preventable killer for which the UNO, WHO, NGOs, and our municipalities show scant concern. During the one-half century of my medical career, I have seen scores of persons die of rabies, tuberculosis, and tetanus but not a single one dying of polio. On the contrary, scores of polio workers and their police escorts have been murdered by zealots in Pakistan’s KP province alone.
Polio, in the meantime, hasn’t killed a single person. Our Governor, General Fazle Haq, elevated our Lady Reading Hospital in 1984 to the status of a Postgraduate Medical Institute. Each medical unit could have one Registrar as a Trainee Medical Officer. These TMOs were doctors who had passed Part I of their FCPS examination in general medicine and then had to undergo clinical training for two years in an approved unit before sitting their Final FCPS examination in their chosen specialty. A TMO also had to carry out a research project and write a Dissertation detailing all aspects of his research. Approval of the Dissertation by two Assessors was a prerequisite for sitting the final FCPS examination. I took Dr. Abdullah Shah — our hemodialysis pioneer — as my first TMO. He chose rabies for his research project. An epidemiologist in Tehran sent us a published study of his. It shattered our long-held erroneous notion about rabies. It had been believed for ages that the saliva of an infected dog contains the virus only during the last ten days of its life. It was assumed that a dog-bitten person was safe if the animal survived for more than ten days after biting the person. It was standard advice by doctors to the public to quarantine the animal for at least ten days instead of killing it sooner. The researcher in Tehran had kept a dog in a cage for several years and had isolated the rabies virus from its saliva thirteen times. This information shook us to the core.
Casualty Medical Officers in all the district hospitals in the province were asked to refer all cases of dog bites to us immediately. The yield rose steadily. An anti-rabies vaccine of the sheep brain suspension type was the only one stored in our public sector hospitals. It was prepared by our National Health Laboratory in Islamabad and was invariably useless. We made arrangements with Mr. Akhtar Malik, proprietor of Medicos in Peshawar Saddar, to import and store anti-rabies gamma-globulin and the Human Diploid Cell vaccine made by Merieux of Pasteur Institute in France. Patients were referred to Medicos for a course of six injections on days 0, 3, 7, 14, 30, and 90. Patients were not allowed to take the injections home for fear of poor storage facilities or even wilful default. They all reported faithfully to Medicos for the doses on their scheduled dates.
Anti-rabies gamma globulin directly fights the virus but also blunts the patient’s own immune response to the virus. Its use, however, is considered justified in high-risk cases such as those bitten on the head or upper part of the body close to the brain.
Those who could pay for their vaccine did so. The poor ones had their cost paid from our Medical-A Welfare Fund in a Bank Account. Either Sadiq Shah or I could sign the withdrawal cheques. We never asked even our affluent patients in private rooms for donations. People like Haji Fazli Mabood of Rose Hotel, Dr. Adnan Fazle Haq, and many others brought us their own zakat and sadaqat (charity) as well as those of their family members.
A group of eight persons from Kohi Hassan Khel (کوہی حسن خیل) in the nearby Frontier Region came to us one forenoon. They had all been badly mauled by a wolf when the rabid beast leisurely paced the village streets after the dawn prayers. It attacked everyone who came its way. Each victim had been bitten on the upper half of the body. They all received gamma globulin and full courses of the Human Diploid Cell vaccine. Someone in that village had killed and buried the wolf. One of the victims phoned his brother at our request to immediately bring us the animal’s head. My secretary, Zahoor, was dispatched with the wolf’s head to the National Health Laboratory for examination of the brain for Negri Bodies. It was reported as ‘full of Negri Bodies’. A year later, all those eight patients came to our ward to confirm and celebrate their survival.
A friend of General Fazle Haq had received a full course of the Islamabad-made vaccine from day one of a dog bite. He came to us with established rabies and died two days later. Fazle Haq asked our Administrator why the patient died so soon after admission when he had been promptly vaccinated in Charsadda and was alert and walking unaided on admission to our ward. The query was sent to me for comment. The gist of my reply was that all patients with established rabies die regardless of their condition on admission and despite having received the Islamabad-made vaccine. No one asked why they died so soon after admission.
I dwelt on the permanent budgetary provision from the days of the British Raj for the elimination of stray dogs. This blunt reply had a striking but fleeting effect. Fazle Haq took the whip to the municipal officials in the province. For a couple of weeks, we saw bloated bodies of dead dogs and the dying ones twitching in the last moments of their lives. That is how strychnine kills a dog or a cat. It did at least prove that the municipalities still stocked strychnine but they never used it. And the dog killers? They continued to work perhaps as domestic servants of their bosses.
Our abiding adherence to the notions of the Middle Ages causes many avoidable tragedies. Belief in the preventive and curative powers of talismans (taweez ) and incantations (Dum-Darood) has fatal consequences. Someone in every village or two claims to have been authorized by his mentor to cure epilepsy, exorcize ghosts, and cure rabies. These ghosts are well known to physicians as hysteria, attention seeking, or conversion of emotional problems into physical symptoms. Tombs of persons with saintly reputations are visited in the belief that the holy souls inside the graves can cure a long list of maladies. The Hakeem, homeopaths, quacks, clerics, and paramedics practicing as doctors make a sizable contribution to these avoidable tragedies. The branding of joints with hot iron pokers for arthritis has been mentioned earlier. Ghastly scars of branding around the knees can still be seen in our villages in Pakistan.
Saints and shrines were similarly linked with diseases and cures in Europe until not that long ago. Rheumatic chorea was Saint Vitus’s Dance for ages. Ergot poisoning caused pain, burning, and blistering of hands and feet. For centuries it remained Saint Anthony’s fire in Europe before its cause was identified. We are keeping alive the old Western non-wisdom long after its demise in its homeland.
Pakistan’s import of huge quantities of anti-rabies vaccine (Indirab) from India has already been mentioned. The vaccine is made available in many of our secondary and tertiary-level hospitals. The Internet’s list of FDA-approved drugs, as of November 30, 2024, does not include Indirab. Its manufacturers say the page is still under construction.
(To be Continued)
