Karachi is undoubtedly the height of urban chaos Pakistan has to offer. This city offers sustenance to more than 16 million people but its broken and inept systems deny a fair chance of survival to many.
It has been 30 months since we buried our beautiful 10-year-old daughter Amal Umer (who was sitting in the back seat of our car) as an aftermath of a run-of-the mill mobile snatching/mugging, an unnecessary and unwarranted police shooting (not a crossfire) with an AK47, a hospital that denied immediate medical care and an ambulance which never showed up on time. All this only 100 yards from a police station, at a spot which, to this day, remains as unlit and dark as it was on that unfortunate night of August 13, 2018.
What happened that night was a series of unfortunate events, one after the other, but all that followed has been another struggle altogether.
As a measure for reform in lieu of the suo moto action that was taken on this case, the Sindh Government passed the Sindh Injured Persons Compulsory Medical Treatment Act (Amal Umer Act) in 2019. As affected and aggrieved parents who have suffered a tragic episode on the streets of this city, we believe this act is a step in the right direction — but the lack of its implementation is still affecting the injured on an everyday basis.
The mother of Amal Umer, after whom the 2019 Amal Umer Act is named, writes on an eye-opening study on trauma care in Karachi hospitals, which could offer a starting point for an integrated trauma system in the province
In our effort to continue pushing for the implementation of the Amal Umer Act, we founded Rah-e-Amal, a not-for-profit organisation, with a group of like-minded individuals from civil society. Rah-e-Amal aims to work towards the improvement of emergency trauma care in Karachi in particular, but also in the rest of Sindh.
It has been a catalyst in carrying out a survey to assess trauma care capacity in public and private hospitals of Karachi, under the authority of the Sindh Health Department, as part of the reforms suggested during the compilation of the Amal Umer Act. The survey should be an eye-opener for the citizens of Karachi.
The city of Karachi is no stranger to interpersonal violence or road traffic accidents. Over the last 10 months alone, Karachi has witnessed 154 deaths due to road traffic accidents, while street crime has also been on the rise. This despite the pandemic lockdowns and reduced traffic on the streets.
According to the Road Traffic Injury Surveillance programme in Karachi, five major facilities recorded 1,022 deaths during the year 2015, of which 28 percent were of the ages between 21 and 30. Yet, the city remains unequipped to deal with them. There are a wide variety of reasons for the high mortality, which include poor road safety measures, an absence of emergency medical services (EMS) and the lack of a trauma care system.
In Pakistan, the emergence of Rescue 1122 in the provinces of Punjab and Khyber Pakhtunkhwa seems to be a step in the right direction. The network has grown stronger over the years, with the incorporation of trauma centres along with EMS. On the other hand, Sindh completely lacks any such system. A 2015 survey of hospitals in Sindh identified inadequacies with regards to skills and equipment, and highlighted the absence of pre-hospital or hospital-based systems for the care of an injured patient.
The Amal Umer Act 2019 has, therefore, been a welcome step towards better trauma care in Sindh. The legislation places responsibility upon existing hospitals to provide skilled and equipped emergency medical transport and in-hospital treatment services regardless of medico-legal or financial limitations of the patients. It also places responsibility on the government to reimburse trauma-related costs for patients.
However, the fulfilment of these promises feels far-fetched as not only does the Department of Health already owe millions in reimbursement costs to the private health sector, it also lacks thorough implementation of other regulations as well.
Nevertheless, the Act accentuated the need to document trauma-preparedness in the existing facilities. The Indus Hospital and Health Network and Aga Khan University, therefore, undertook this task and conducted a baseline assessment of 22 hospitals, using the World Health Organization (WHO) Guidelines for Essential Trauma Care.
AKU’s Dr Salman Khalil, who was a research associate on the study, shared with us the findings of this survey, which was conducted in coordination with various leading doctors. I would like to quote his words verbatim.
“Our assessment showed that most facilities fall short of the recommended targets for trauma care set by WHO and even capacity for resuscitation — a basic and most essential component of care — was lacking,” Dr Khalil informed us. “We found that private hospitals demonstrated better capacity to handle trauma care and the government could collaborate with these facilities to capitalise on their trauma care strengths.
“Twelve of the 22 hospitals had an overall capacity score of less than 60 percent of the recommended standards. A written plan for trauma was absent in 73 percent of the hospitals, and staff in 12 of the surveyed hospitals had not attended any formal training courses in trauma care.
“For the acutely injured patient, basic resuscitation and assessment is imperative. However, our study showed that nine hospitals scored less than 60 percent with regards to resuscitative measures, such as airway, breathing and circulation. This signifies that these nine hospitals were not prepared to deal with acutely injured patients or even stabilise them for transfer to a more capable facility. Resuscitation is an aspect of trauma care that should be present in all facilities providing urgent care, regardless of a facility’s size and capacity. Thus it is an area that needs to be further strengthened.
“None of the public facilities assessed in the study had adequate availability of medicines as all consistently scored less than 60 percent. They seemed to rely heavily on privately owned pharmacies for medicines, thus making affordability a concern, even at public free-of-cost facilities.
“Public secondary-care hospitals were least equipped to handle trauma care, with an average score of 38 percent. Neurotrauma and availability of medicines were the lowest-scoring categories and basic resuscitative measures were also poorly available at these facilities, signifying that patients cannot be provided initial care at these facilities.
“The private sector plays an important role in the provision of trauma care at both the tertiary and secondary levels. In contrast to comparable public sector hospitals, we found that private sector tertiary (88 percent) and secondary hospitals (73 percent) had better overall scores.
“For the most part, even though there is a higher cost associated with them, private hospitals are a strength for Karachi’s trauma care capacity and need to be bound to actively participate in the treatment of the injured, which they often choose to refuse due to medico-legal and financial implications.”
The Amal Umer Act and the data gathered from this study can provide a starting point for an integrated trauma system. The deficiencies identified in trauma care need to be addressed at both a hospital level and city-wide level.
What Karachi desperately needs is a regulatory framework under which a trauma system can be founded. This would ensure designation and accreditation of major and minor trauma centres throughout the city, which will provide equitable coverage to the victims of trauma. Many institutions throughout the city are below par, whether it be in terms of training of healthcare staff or availability of equipment.
This regulatory framework needs to be looked into immediately by the Government of Sindh, the Sindh Health Department as well as by the Sindh Health Care Commission (SHCC). The province of Sindh deserves improved trauma and emergency care services for its people — a basic right that has been denied for too long.
An increasingly important aspect of an efficient trauma system is the EMS. Basically, creating a one-number integrated emergency service (1122, or a 911 of sorts) that will immediately attend to the emergency at hand. Karachi needs major commitment in this sector to ensure that patients are assessed immediately, on-site, by capable and equipped paramedical staff and then transported to the nearest designated centre for management.
A referral network, linked with the EMS between these centres, needs to be set up for the easy transfer of patients, should the need arise. Smaller institutes need to strengthen their trauma response to assess and stabilise any incoming patients, so that they can be referred to larger, more specialised facilities, once they are stable.
Karachi still has a long way to go in terms of developing a trauma care network.
Rah-e-Amal aims to continue its advocacy for the provision of capable emergency and trauma care services. It is hoped that the urgency instilled by the civil society will bring the stakeholders and the Government of Sindh together in working towards the establishment of an EMS that can promise a fair chance of survival in emergencies for the citizens of Karachi and the province of Sindh.
The writer is Amal Umer’s mother.
She is a filmmaker by profession
Published in Dawn, EOS, March 14th, 2021