In 2000 Dr Young Hong Traveled to:
The Shaukat Khanum Memorial Cancer Hospital
Lahore, Pakistan

Dr Douglas Bridge Palliative Care Physician Royal Perth Hospital, Perth, Western Australia

Highlights

After Dr Bridge had attended a clinic the physician announced: I cannot practice good palliative care with so many patients. The solution is to concentrate on education, training others so that the workforce is multiplied.

Pakistani Physician

The visit provided an opportunity to facilitate the formation of a national association of palliative care.

Dr Douglas Bridge

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Read excerpts from his report

Read full report

 

Excerpts from his report

This Travelling Fellowship was very successful due to good planning and the combination of people, places and times. The visit was initiated by Jan Phillips, an Australian oncology/palliative care nurse working at the Shaukat Khanum Memorial Cancer Hospital. Famous cricketer Imran Khan founded this hospital in memory of his mother, who died from bowel cancer in 1985.

Activities

Major teaching presentations were delivered in Lahore, Islamabad and Peshawar. In addition there were numerous informal teaching opportunities in clinics, ward rounds, at meals and in strategic planning discussions.

Illustrative experiences

Referring to a patient whose facial expression indicated obvious pain, a nurse reported:

" The patient does not complain of pain". This statement was strictly correct. The patient had not complained of pain. This illustrates two features of hospital care in Pakistan. Firstly, public patients expect to be treated like objects, and are reluctant to complain about anything, including pain. Secondly, the educational system encourages students to memorize textbooks and follow rules, not to show initiative or think creatively.

A father of five returned to SKMCH from beyond Multan for a palliative care outpatient review. Because of his painful rectal tumor he had lie for 12 hours on the floor of the train. Regional centers are planned to avoid such needless suffering.

Achievements

The visit provided an opportunity to:

Full Report

Report of the IAHPC Travelling Fellow to Pakistan

Dr Doug Bridge, palliative care physician, Royal Perth Hospital, Western Australia

March 4-18, 2000.

Background

This Travelling Fellowship was very well planned and seemed to bring together the right people in the right place at the right time. The visit was initiated by Jan Phillips, an Australian oncology/palliative care nurse, who commenced work in Pakistan in November 1998. Jan saw the need for further external input, and sought the assistance of IAHPC early in 1999. This allowed adequate time for good preparation. She expended enormous energy and skill to ensure that thorough preparation had been made, not only in her own institution, but throughout Pakistan.

The Shaukat Khanum Memorial Cancer Hospital was a particularly suitable host institution. It was the brainchild of Imran Khan, who achieved international fame as the captain of the Pakistan cricket team, which won the World Cup in 1992. His mother died from bowel cancer in 1985, after three months of severe suffering. This motivated him to found a charitable hospital named in her memory. Because of his high profile, it is well funded, with staff and equipment of international standing. Most patients are treated free of charge. Although this makes it quite atypical, it serves as a role model, and its Board of Governors has considerable political clout.

Dr Doug Bridge was well suited for this travelling fellowship. In addition to his palliative care clinical skills and teaching experience he worked in rural Bangladesh from 1977-1979, and speaks fluent Bengali. Bangladesh was originally East Pakistan, and shares Pakistan's Moslem religion and culture. This provided an immediate advantage in adapting to the local culture.

En route from Perth to Pakistan, Doug met with Dr Rosalie Shaw in Singapore. She is the Executive Director of the recently formed Asia Pacific Hospice Network. She supplied him with valuable contacts and teaching materials, plus helpful advice about the approach to take.

She placed education as the top priority, including professionals and the public. Regarding the

challenge of persuading governments to legalize morphine for medical purposes she stated "you must have friends in high places"

The timing of this visit coincided with several independent initiatives within Pakistan, which meant that there was a receptive atmosphere for the formation of a national association.

Activities

Five major teaching presentations were delivered: two in SKMCH, one at the King Edward Medical College in Lahore, one at the Marriott Hotel in Islamabad and one at the Lady Reading Hospital in Peshawar. The average attendance was 50. Three were mainly to doctors, one to final year medical students and their professors, and one to a nursing seminar. In addition there were numerous informal teaching opportunities in clinics, ward rounds, at meals and in strategic planning discussions.

The highlight of the social program was being taken on a tour through the Khyber Pass right to the border of Afghanistan, escorted by a truckload of soldiers from the Khyber Rifles regiment. The awesome scenery, the sense of history, and the sense of being afforded privileged access to a "forbidden" place made this an unforgettable experience.

 

Illustrative experiences

1. Referring to a patient whose facial expression indicated obvious pain, a nurse reported:

" The patient does not complain of pain". This statement was strictly correct. The patient had not complained of pain. This illustrates two features of hospital care in Pakistan. Firstly, public patients expect to be treated like objects, and are reluctant to complain about anything, including pain. Secondly, the educational system encourages students to memorize textbooks and follow rules, not to show initiative or think creatively.

2. The physician on the palliative care team used to see 20 outpatients in one afternoon clinic. After Dr Bridge had attended a clinic he announced: "I cannot practice good palliative care with so many patients. In future I will limit the clinic to ten patients". This will indeed enable better care to be given to those who attend. But what about the patients who miss out? This dilemma typifies the problem facing Shaukat Khanum Memorial Cancer Hospital. Although precise national health statistics are unavailable, some rough estimates can be made. With a population of 135 million and an average survival of 60 years, the annual death rate would be approaching two million. There may be as many as 400,000 cancer deaths annually. SKMCH can treat less than one per cent of these patients. The solution is to concentrate on education, training others so that the workforce is multiplied.

3. A father of five returned to SKMCH from beyond Multan for a palliative care outpatient review. A colostomy had been performed to treat his incurable cancer of the rectum. Because of his large, painful tumor he could not sit, so he traveled for 12 hours lying on the floor of the train. At the clinic he was given a further supply of morphine tablets. Although they were supplied free, their value was less than his train fare. But much worse than the financial cost was his unimaginable suffering during the journey.

Such instances have strengthened the hospital’s determination to develop formal links with regional hospitals. These will serve for both follow-up care and as a screening center to avoid a fruitless journey to Lahore for patients who would not meet the criteria for acceptance.

Achievements

The visit provided an opportunity to:

• Encourage the present palliative care team in their challenging work

• Educate hundreds of health professionals in the principles of palliative care

• Raise the profile or palliative care in the media and amongst influential persons

• Facilitate the formation of a national association of palliative care

The future

On March 15, 2000, a highly significant meeting was held between Dr Saira Khan, founder of the RahatKada ("Home of Peace") hospice in Karachi and three senior staff of SKMCH, Dr Moeen ul Haq, Medical Director, Mrs Della Anverali, Nursing Director, and Jan Phillips. Doug Bridge was present as an observer and catalyst.

Enthusiastic agreement was reached about the formation of a Palliative Care Association of Pakistan. After a short planning phase a national meeting will be held at which the Association will be formally constituted.

The following issues were identified for further action:

• A council of management requires individuals who are committed, vigorous and politically powerful

• Government registration is required

• The association must be indigenous, "Made in Pakistan"

• International links will be sought, in particular membership of the Asia Pacific Hospice Network

• The association will be apolitical in the sense that links with neighboring programs in India will be encouraged

• The association will be independent of its members, including SKMCH

• Comprehensive geographical and institutional representation will be sought (private, charitable, government and academic).

• The motto is co-operation, not competition

• Funding will be sought from private donors, government matching grants and international sources

• Education will be a primary focus

• The legalization of morphine for medical purposes is an urgent priority

 

Submitted by: Dr Douglas Bridge