It’s been some time since I wrote a blog post.

So much has been happening that it’s a little hard to wrap my head around it all.

Perhaps most significantly, my grandfather passed away about two weeks ago. He had been in the hospital for surgery, and though the surgery went well, I think his body was too weak to cope with it. He was 95 years old.

On the day that he passed I sat down and wrote two pages worth of memories I had of him. Some good, some not so pleasant. I was fortunate to have him in my life. He was a wise man. He had seen the world. He had fought in World War II. And he had always been a presence in my life. Losing him was not easy. I wish I had spent more time with him. I wish I had asked him more about all the stories he had to tell.

It has now been a couple of weeks and it’s a little easier to remember all the fond memories. Perhaps in a later post.

In the mean time, I will follow his life-long advice to me, and will not leave anything half done. I had stopped blogging because I felt there was just not enough time. But I have lots to say. And I am going to do a better job of being consistent.

So here . . . . .we. . . . .go!

A new year is upon us, and new year’s resolutions are the order of the day. I too have made a long list of such resolutions, and I’m fairly certain many of them will be forgotten by next week.

Personal goals aside, I have come up with a wish list for Pakistan for this New Year. These are some things I that desperately want for our country. I must warn you that this wish list is full of naïve hope, but it’s a new year, and I thought what the heck! Doesn’t hurt to dream. So here it is, my wish list for Pakistan for 2012:

5. PIA soars again.

For those readers younger than me, there was once a time when PIA was a real airline. Don’t worry if you can’t imagine this; it was a long, long time ago. These days the national ‘airline’ has a rather casual relationship with its flight schedule. On top of that PIA seems to be losing ground in that all-important ratio of keeping the number of take offs equal to the number of landings. You would think that’s basic math, but for some reason PIA tends to lean toward having more take offs than landings. Just to be clear, crash landings don’t count as landings.

But what was reality once could become reality again. An airline that has such a proud tradition could somehow deep within its soul find a small glimpse of professionalism. Should that happen, who knows; maybe half the fleet won’t be grounded indefinitely.

4. Trains go Choo Choo again!

Contrary to popular belief in some government circles, trains are indeed essential to the economy. Pakistan Railways was never known for punctuality, and it certainly doesn’t have the proud (albeit remote) traditions of PIA, but at least in the past the trains used to run. You could go to the train station and expect to hear the familiar horns of the train engines. No more. Now the train stations might as well be graveyards for a national institution rotting away at its core due to political interference.

Here’s hoping that the next Minister of Railways sees some need for Pakistan Railways to not only survive but also thrive. Before that, I hope there is a new Minister of Railways. The current man in charge doesn’t give me much hope.

3. Will someone please come up with an Energy Policy!

A whole generation of Pakistanis has never known a world without load shedding. It is as normal for us to have the lights go out as it is for us to have the sun go down every night. Way back in early 1980’s, I remember a summer when the power would be out for 2 hours every evening. You would think we would’ve figured out the power shortage problem in the 30 years since. Unfortunately we seem to have made matters infinitely worse. Electricity is no more a necessity but a luxury of life. It’s the same with natural gas. Sometimes there is enough pressure to cook; sometimes we just make do.

A few years ago somebody had the bright idea to introduce CNG as an alternative energy source. Seemed like a great idea. It was cheaper than petrol and we seemed to have plenty of it. And now that 7 out of 10 cars in Pakistan are running on CNG, we seem to have run out of it. What a sad joke this is.

Just like our foreign policy, our energy policy is not a policy at all, but a series of tactical moves. We go from one short-term move to the next, like a drunken fool trying to walk down a dark narrow alley and hitting the walls after every step. There is no vision of what we need to do over the next year, much less next several years, to get out of this perpetual energy shortage.

2. Imran Khan comes to power.

I know, I know. Many people like him a lot, but some are suspicious of his sudden ascent. Does the ever-powerful ‘establishment’ support him? And what is up with all the corrupt people joining his party.

Let me tell you this. I hope the ‘establishment’ is supporting Imran Khan. If that means a better chance of his coming to power, I am all for it. Imran Khan on his worst day is better than the current government on its best. As for the diverse collection of ‘lotas’ and thieves who are lining up to join his party, I think people like us can’t have it both ways. A few years ago we used to say that Imran Khan would make a great Prime Minister but he will never come to power because he is too idealistic and he has no team. Now that Khan Sb has developed a little political acumen, we can’t complain that he is letting people of questionable pasts join his party. There are a thousand election tickets to be given out. I challenge you to go find me one thousand honest Pakistanis.

1. We Learn to Speak

You might wonder what I could possibly wish for more than Imran Khan somehow coming to power. There is one thing. You see, Imran Khan is an honest man, but he is no miracle worker. He can’t fix everything, and he certainly can’t do it overnight. And who is to say that he will come to power anyway.

What I want more than anything else in this coming year is for Pakistanis like you and me to grow a spine. I want us to not be ok with PIA’s canceled flights and Railways’ parked trains. I want us to not be ok with load shedding and gas shortages. I want us to not be ok with political parties talking up democracy while acting like monarchies. I want us to stop giving in to demands of kickbacks and bribes. And I want us to stop worrying about all the political favors we will lose out on if we speak our minds. If there is one lesson to be learnt from Cairo and Tripoli, it is this:  the voice of the people is the voice of God. But history doesn’t change by itself; you have to speak up and be counted.

 We get the leaders we deserve.

The last week of the year is always an interesting mix of emotions for me. There is a sense of some satisfaction at the goals that were achieved during the year, but this satisfaction is often tempered by a sense of disappointment at lost opportunities and missed objectives. And then of course there is the hope that the new year will be different. It will be a fresh start. A new beginning.

But before we begin the new year, let’s look back at the year that was.

This last year was one of mixed results for me. A few achievements, and a few failures. I feel like I fulfilled my teaching responsibilities reasonably well. I think I did a decent job as lab director and as a pathologist. We started some new tests. We upgraded certain instruments. We brought new technology to Lahore. We debuted a new website for the lab. On a personal level, I started writing this blog, which was something I had been putting off for years. But of all the things I did this year, perhaps the most important was my lab’s contribution in the fight against Dengue Fever.

But there were quite a few failures as well. I failed to study as much as I had wanted. I failed to conduct meaningful research at my lab. I failed to develop certain team members like I had hoped. On a personal front, I failed to stick to my exercise routine. And this blog which I finally started was not regular enough or good enough to propel me to international fame and glory .  Most importantly, I failed to make more time for my personal relationships. Fourteen hour work days are not fair to the family.

So how was 2011 for you? Massive hit or Epic miss? Or perhaps something in between?

AIDS is taboo in Pakistan. Every time the topic comes up, the general attitude is one of denial. People say that AIDS does not exist in Pakistan. How could it! This is an Islamic country, and the ‘illegal, immoral’ activities generally associated with HIV/AIDS are just not a part of our social fabric.

According to the National AIDS Control Program, about 100,000 Pakistanis are living with AIDS.  This number is most likely an under-estimate as most patients with HIV don’t even know they are infected. One is compelled to wonder where all these cases are coming from.

Like many other countries, the most important reason for the spread of HIV in Pakistan is sexual promiscuity. We may not like to admit this, but prostitution has been a part of our society for a long time. The ‘diamond market’ in Lahore was a thriving enterprise long before the Badshahi Masjid was built.  In addition, a growing number of young adults are engaging in sexual activity before marriage. Don’t believe me? Just visit my office the next time I have an unmarried teenager in my office waiting anxiously for a pregnancy test result.

There are of course several other reasons for the spread of HIV. Pakistan has a major IV drug abuse problem. By some estimates more than a million Pakistanis are addicted to drugs. These people often do drugs in the company of their peers, and they are very likely to share needles. Injecting drugs into your veins is bad enough; worse yet to do so with a previously used needle.

Another important and under-recognized manner for the spread of HIV is through transfusion of infected blood. While the screening of blood donors for HIV has been mandatory for several years, many health care facilities still use outdated disk methods to test for HIV and Hepatitis. These methods have high false negative rates. Consequently HIV positive blood donors are often not detected in time, and an unsuspecting patient gets HIV through no fault of his own. These are some of the saddest cases of HIV, but sadder still are the babies who are born with HIV because their mothers have the disease.

In the end it doesn’t matter much how a patient got infected. What is more important is what to do about it. We must educate patients and the general public about HIV and AIDS, about how this disease spreads, and also how it doesn’t spread. The last thing an HIV patient needs is to be treated like toxic waste; shaking hands with a patient will not kill you. World AIDS Day is a great opportunity to talk about this illness, read about it and discuss it with friends and family. A hundred thousand patients is a small number in a country of many millions. But this number will continue to rise unchecked unless we do away with our collective hang-ups and start talking about it.

The Dengue fever outbreak of 2011 has been worse than anyone expected. It arrived sooner than anticipated, and is far more widespread than anyone could have prepared for. Starting in early August, Dengue fever has in two months affected many thousands of people. Almost 200 have perished. Every day it seems there are a few more lives lost to this public health disaster. The relentless media reminds us every day that no one is safe, and people everywhere are in anguish over this ever-present mosquito and the virus it bears.  

On the 10th of August I wrote that a Dengue outbreak was imminent. I am no Nostradamus; I was merely reporting what I was seeing in my lab. Today, at the risk of sounding silly, I want to tell you that I think the Dengue outbreak is finally coming to an end. At the least it seems the worst is behind us. There has been a steady decline in the number of new cases diagnosed over the last week or so.

While this outbreak may be coming to an end, we all know that Dengue will be back. There are many lessons to be learned from the crisis and our collective response to it. I thought this might be a good time to discuss some. So here are a few things that I have learnt:

- Cleanliness is half the faith for a reason. Perhaps it was going to take a disaster such as this to remind us of the sheer importance of hygiene and cleanliness. Dengue seems to be on the decline. I hope the lessons in cleanliness we have had to learn in a hurry will stay with us for some time to come.

- Mosquitoes love water! If we have gathered one thing from the unending footage of the bold chief minister draining water coolers, it is that water sits and collects in more places than we might imagine. And every such small puddle of water could be a breeding ground for a new generation of mosquitoes.

- Dengue can kill in more ways than one. As doctors, our understanding of Dengue fever and its management has taken a quantum leap in the last 6 weeks or so. Patient management has grown from simply the prevention of bleeding to the management of third compartment fluid loss as well. And we know that 80-90% of Dengue fever patients are asymptomatic; they never even know they had the illness! I myself was not sure how useful the Sri Lankan and Indonesian experts would be in this time of crisis. I have to admit that the knowledge they imparted and the endless seminars and lectures based on their experience and insight have raised the general level of expertise in the local medical community.

- Perhaps most importantly, we now know that no one can do this alone. Two months ago, it was Shahbaz Sharif Vs Dengue Fever. Today, it is Us Vs Dengue Fever. The most successful initiative of the Punjab government in the face of this crisis has been to get the public involved in public health. There is a limit to how much fumigation the government can do. There is a limit to how many water coolers Shahbaz Sharif can drain for the benefit of TV crews. This is a public health issue, and unless everyone gets involved, we don’t stand a chance.

If experts are to be believed, Dengue fever will be back in the spring. And it is going to be with us a few more times after that as well. I hope and pray that it is never as bad as it has been this year. Hopefully we will remember the lessons of 2011, and they will better equip us to deal with this menace in the future.

I saw a patient yesterday. She was a 40 year old mother of three, her youngest daughter only 6. The patient had gone to a general surgeon because of a breast mass, and she had been referred to me for diagnostic work up.

The lady told me that she had had the mass for over a year. I asked her why she hadn’t seen a doctor earlier, and she said that she hadn’t wanted to draw attention to herself. The family had limited resources, and she had not wanted to become an additional burden.

My patient has cancer. I suspected as much the moment I saw the mass. And when I saw the slides, my suspicions were confirmed.                                                                                                                                                       

The year was 1999. I was a final year medical student. We were attending the Out Patient clinic at Mayo Hospital in Lahore. With our professor we saw patient after patient who had ignored a breast mass for a long time before finally giving in to the pain or weakness. I remember one patient in particular who had come from a village near Peshawar. She had ignored her breast mass for a few months. Then she had sought the blessings of her local ‘Pir Sb.’ When that didn’t work, she had gone to a ‘hakeem,’ who had given her a potion which had obviously not helped. More than a year after first noticing her breast mass, she had finally gone to see a local doctor, who had referred her to Mayo Hospital. By the time she made it to Lahore, the cancer had replaced all of her breast and spread to her axilla and beyond. A mass which could have been removed completely a year earlier had now become incurable.

These are sad stories. And these stories are not at all uncommon. Cancer of the breast is one of the three most cancers among women. One in nine women will develop breast cancer in her lifetime. But breast cancer does not develop overnight. It usually begins as a small mass in the breast, which grows ever so slowly for a long time. It is at this stage that a woman should go to a doctor and have the mass examined and biopsied. Most breast masses are benign, but the cost of ignoring a mass that might be malignant is very high. Every day women die of breast cancer which could have been treated if detected in time.

In my experience, most women who don’t see a doctor for a breast mass are reluctant because they are shy to talk about the issue. In other cases, women simply don’t want to ‘waste’ limited resources on their own health. These are terrible reasons to risk the life of a mother, a sister or a daughter.

 Unless we start to get over our hang ups and actually talk about this issue, we will never be able to educate women and their families about the risks of breast cancer. We must change our collective attitude towards women’s health and breast cancer. Only then will these sad stories become less frequent.

There is a major Dengue fever outbreak in the city of Lahore. Several thousand patients have been documented, and many more have gone undiagnosed. In addition, there is a general sense of paranoia about this illness.

One of the important aspects in the care of Dengue fever patients is the establishment of the diagnosis. Since a large number of patients are non-affording, it is important to make arrangements to make these diagnostic facilities accessible to all. However, it must also be ensured that the diagnostic facilities and resources are not wasted.

One of the recent measures was the notification that set the rate for CBC at Rs 90. In spirit this is a good move as it allows all segments of society to get tested, but there has been an unexpected consequence. A large number of people have started getting their CBC test done simply because it is so cheap! Diagnostic facilities which were already working at full capacity are now faced with another tidal wave of blood samples. As a result, the following things are happening or are bound to happen:

1. Because of the rush of ‘normal’ patients seeking to get their test done, the actual Dengue patients are being overlooked.
2. As the workload increases beyond the capacity of the diagnostic facilities, the reporting time for the crucial CBC test is rising. Already the reporting time at most facilities has grown to more than 12 hours.
3. In the rush to test these thousands of CBC samples, patients who do not have Dengue fever but other illnesses such as malaria or leukemia are likely to be overlooked or ignored.
4. There is a finite supply of reagent needed to perform the CBC test. At current rates we are consuming the reagent far quicker than it can be imported. Heaven forbid if labs start to run out of the reagents needed to perform the CBC test. Then we will have taken a crisis and made it worse.

In this time of crisis, it is very important that collaborative and streamlined efforts are made by all those involved in caring for Dengue fever patients. We must focus our attention on actual Dengue fever patients instead of trying to cater to everyone who desires a CBC test. We must remember that not every patient with fever has Dengue fever. And we must all work together to educate the public about this illness.

A month ago I wrote about a storm that was headed our way. Well, in case you haven’t noticed, it’s here. And it is worse than any of us expected. Dengue fever has hit Lahore with even more ferocity than last year. There are hundreds of cases all over the city. Hospitals are filled to capacity. At our lab, we are reporting dozens of new cases every day. And I don’t think the outbreak has peaked yet.

There will be time later to look back upon who failed who. What public health measures were not taken. There will be ample time to make committees to examine what went wrong.

Ten months ago Dengue fever hit our cities. The outbreak was unprecedented in severity. In the blink of an eye there were hundreds of cases all over Lahore. Doctors and hospitals were caught completely off guard. Many doctors, myself included, were unfamiliar with Dengue fever and how to manage it. As the ranks of patients swelled, the capacity of hospitals to care for them was quickly overwhelmed. Though no one will admit this today, many hospitals in Lahore stopped accepting patients because they simply did not have the capability to take care of any more.

Dengue fever gets its name from the Dengue virus which causes the disease. The virus cannot spread directly from one person to another. It relies on a certain species of mosquito to spread from one host to the next. Patients complain of fever, weakness, headaches, muscle pains and a skin rash. In a small numberof cases patients develop Dengue hemorrhagic fever, with very low platelet counts and risk of internal bleeding. Patients with this complication need to be transfused with a large number of platelets, and the most effective way to donate platelets is through platelet pheresis, a procedure which is unfortunately not widely available. Last year, desperate for platelet transfusion, patients and their relatives were left to scour the various hospitals and labs looking for the mercurial platelet ‘kits.’ The handful of places that had the facility for platelet pheresis were simply not equipped to handle such demand. In our lab we performed more than 700 platelet donation procedures during this episode. Eventually, we ran out of kits too and had to rely on older methods for platelet donation. This desperate situation lasted almost two months, and by the end Dengue had afflicted thousands of patients in Lahore alone.

There is a similar storm headed our way now.  It is supposed to be too hot for Dengue fever to be spreading. It is supposed to be too early in the summer. But apparently viruses don’t care when they are supposed to spread. My lab is diagnosing about ten new cases of Dengue fever every day. This is paltry compared to the hundred a day we were diagnosing last year, but the trend is upward. Like most other health care facilities, we have tried our best to be better prepared this time. We have ordered more platelet kits than last year. Most importantly our team is better prepared. I hope that all of our preparation will be enough to handle what seems imminent; even more, I pray that all of this preparation will in the end be unnecessary, and the outbreak will not come to pass.