The other side of the story

Last Saturday, while grilling the chief secretary of Punjab over salaries being paid to managements companies formed by the Punjab government, the Supreme Court also took notice of salaries in the range of Rs1.2 million being paid to doctors employed by the Punjab Kidney and Liver Institute (when doctors in public hospitals are paid around Rs0.2 million). Led by Dr Saeed Akhtar and including folks like Dr Faisal Dar of Shifa International in the board, the PKLI is primarily meant to be a state-of-the-art kidney and liver transplant centre set up by public funds.

This conversation isn’t about legalese or the SC’s jurisdiction to interfere in policy matters or the sustainability of a no-holds-barred, do-good approach driven by a suo-motu happy apex court, but about the incidental consequences of even the best-intentioned judicial forays into policy. We love zero-sum myopic conversations. Should we invest in research or higher education when 2.8 million kids are out of school? Should we set up new schools when the existing ones don’t teach much? Should we set up transplant centres when people are dying of dirty water?

We don’t have a tradition of organisations voluntarily filing amicus briefs in cases involving public interest to make courts wiser while deciding questions affecting all of us. And in the SC’s inquisitorial suo-motu proceedings there is no one to present the alterative viewpoint. This creates a danger of judicial outcomes being shaped by the personal experiences and worldview of judges comprising the bench. So here are a few personal stories the court might wish to consider as it ponders over standardising doctors’ salaries.

Nighat Tariq, mother of three, was 55 years old. She had been treated three times for Hepatitis C in various public and private hospitals in Faisalabad. Seeing that she wasn’t eating well, Nida, her youngest daughter and medical student, got an ultrasound done to discover on January 26 that her mother had a liver tumour. To get better healthcare and advanced labs done, the family came over to Shifa Islamabad and got workups done. Dr Faisal Dar, Pakistan’s leading liver transplant surgeon, oversaw the process.

Dr Dar advised, in consultation with other specialists, that given the cancerous tumour’s size, it would need to be removed through a radiotherapy procedure called TARE to enable the patient to then undergo liver transplant. No hospital in Pakistan has the expertise to administer the procedure. India was the next best option. The family applied for a medical visa and saw the patient’s health deteriorate as it waited for India to make up its mind whether it would issue the visa or not. The wait lasted some five weeks.

Even under international humanitarian law it is a settled principle that the wounded and the sick have a right to be cared for no matter whose side they are on. And here we are, two nuclear-armed neighbours, not at war but frozen in petty mindsets eager to do the meanest things to each other. One of India’s ‘visionary’ decisions under the Modi regime has been to sit on or refuse medical visas to really sick Pakistanis. That hurts us because our own visionaries have refused to invest in advanced medical treatments at home.

Anyhow, with much prodding by the Indian High Commission in Islamabad, the visa finally turned up. Nighat reached Delhi along with her husband and daughter on March 9 to be treated by Dr Subash Gupta (who has been an angel to Pakistanis in need of liver transplants, including my mother) and his colleagues. Turned out that the disease had progressed and it was too late for TARE (and a subsequent transplant). The family got back to Pakistan on March 23. Nighat passed away early morning March 27. At the moment all this mourning family has is what ifs.

Back in 2010 my mother was suffering from Liver failure due to Hep C. At the time Dr Dar was finishing his fellowship in liver transplantation at Kings College London School of Medicine. He got us an appointment with his professor. But due to her fast deteriorating condition my mother couldn’t travel to the UK. Pakistan and India weren’t best friends back then either but the Indian High Commission stamped our visas over a weekend in December 2010. We reached India in time and with Dr Gupta’s excellent medical treatment, my mother got a second life.

In 2012 she suffered liver rejection and had to be hospitalised due to her critical condition. Dr Gupta advised that moving her out of hospital in such condition could be fatal. By then Dr Dar had returned home and set up a liver transplant unit at Shifa. He along with the polite and skilful (but understated) Dr Atif Rana treated my mother for over a month and she finally came out of the woods. Initially due to Dr Gupta in Delhi and subsequently due to Dr Dar’s expertise and care in Islamabad, my mother has been able to live a full life post-transplant.

What if Dr Dar had chosen to continue to work in London? What if he had joined a hospital that didn’t have the resources to set up a liver transplant centre? What if the 0.2 million salary on offer at public hospitals and the work ethic had been excruciating for a trained and skilled surgeon and he had chosen to return to UK after a few years of ‘public service’ in Pakistan? We didn’t have to deal with such ‘what-ifs’ in 2012. But these what-ifs torture thousands of Pakistanis, like Nida. She must wonder whether her mom would be alive if a facility could administer TARE in Pakistan.

Dr Dar is a one-man army. He has performed over 600 living-donor transplant surgeries since 2012 at the only sustainable and properly staffed liver transplant unit in Pakistan. Last year, he performed over 202 liver transplants. But he shakes his head if you tell him it’s a big achievement. He says that, given Pakistan’s Hepatitis and liver disease statistics, we need at least 5000 transplant surgeries each year. It was thus that he chose to assist PKLI in setting up a transplant unit in Lahore, subsidized by the state, to also treat those who can’t otherwise afford the expensive treatment.

I don’t know Dr Saeed Athar. He might have a similar story in the area of kidney transplants. I do know Dr Abdul Nadir who also treated my mother for Hep C (with Sovaldi) when it mounted its return post-transplant. The treatment was new around the world and Dr Nadir had experience with administering it and being involved in related research in the US. We were lucky that he shuttled to Pakistan every few months to see patients and was hands-on in providing oversight even from the US. Dr Nadir has since moved back and now works at the PKLI.

These are profiles of only two doctors one knows personally. There must be others. It was thus painful to read reporting of the SC’s proceedings last week that created a perception that public funds were being pilfered without care, with the case of 1.2 million salaries for PKLI doctors flagged as an example. Is a million-plus salary excessive for the likes of Dr Dar or Dr. Nadir, who with their training, skill and expertise can make a lot more anywhere in Pakistan and even more around the world?

This isn’t an argument for paying doctors in public hospitals less. Incentives in public employment must be linked to skill, training and performance of employees. But why paint prospective centres of excellence in black? Can Shaukat Khanum Hospital (SKMCH) run on the same budget as a public hospital? Will it attract top talent if its salary structure is the same as that of a public hospital? Wouldn’t Pakistan be better off with more SKMCHs created by the state? Can professionals (doctors, lawyers, architects) be paid uniform compensation?

We are making it impossible for the best amongst us to associate with and assist the state in any way. Let’s hope the SC, driven by an urge to do-good by us, doesn’t inadvertently quell excellence by misconceived policy interventions.

The writer is a lawyer based in Islamabad.

Email: sattar@post.harvard.edu