H.I.V.疫情成為巴基斯坦醫療保健系統的焦點

 

H.I.V.疫情成為巴基斯坦醫療保健系統的焦點

資料來源:Maria Abi-Habib and Salman Masood/ 紐約時報/ 20191030

當重複使用注射器感染了一個小城市的數百名兒童後,衛生工作者說,整個系統需要進行改造。

 

 

巴基斯坦政府暫停了對一名兒科醫生的指控,他被指控重複使用注射器並讓數十名的兒童感染了愛滋病毒。在發現他已被重新分配到一家政府開辦的醫院後,此事在全國引起了軒然大波。

就在《紐約時報》發表有關兒科醫生的故事及其在H.I.V. 感染事件中的角色後的隔天,在星期三,發生疫情的信德省政府表示已暫停Muzaffar Ghanghro醫師的工作。,到目前為止,在1200多個病例當中,有近900例是兒童。

 

健康危機

孩子們的H.I.V.爆發流行令巴基斯坦感到恐慌。

Ghanghro醫師是H.I.V.在小城拉托德羅爆發流行最初唯一被歸責的焦點。但是政府官員現在認為,他不是那裡的唯一原因,而且他被指控的不良做法(包括重複使用注射器和靜脈注射針頭)在巴基斯坦是如此普遍,以至整個衛生保健系統都需要更好的監管。

Ghanghro醫師上週在接受《泰晤士報》採訪時否認有關他重複使用注射器和針頭的指控。

當春季爆發疫情後,他的診所關閉了。但是他說,他最近已經更新了執照,並且正在一家政府醫院執業,有大批的病人等待他的看診,這也讓政府監管該系統的能力受到質疑。

衛生工作者說,政府需要修改國家醫療教學大綱,以優先控制感染管制,目前這只是醫生培訓的一小部分。他們說,醫院經常在工具的滅菌過程中做文章以撙節費用。

在卡拉奇的阿加汗大學(Aga Khan University)之兒科傳染病專家Fatima Mir博士說:「爆發流行的唯一好處是,它暴露了政府在聯合國機構的支持下其系統中多個需要解決的缺陷。她是最早協助拉托德羅(Ratodero)地區處理疫情爆發的醫務工作者之一。

「拉托德羅的爆發說明巴基斯坦醫療保健的問題是,感染管制不力或根本不存在。巴基斯坦的衛生保健系統現在正在嘗試將感染管制納入該系統的正式組成部分。」

她說,巴基斯坦的醫生通常缺乏預防和控制感染所需的後勤和物資。當她在Ratodero去提供協助時,Fatima Mir博士說,在看病人的同時要尋找乾淨的水來洗手是一個挑戰。

「由於缺乏感染控制,這種爆發並不意外。出乎意料的是,這一次,兒童是主要受害者,其中有很多是他們」。她說。

4月下旬以來在Ratodero的近36,000名居民中進行了測試,其中1,112人的H.I.V.呈陽性,其中889名幼兒。對Ratodero的人口來說甚至沒有達到四分之一的人口進行了測試,官員們擔心實際數字會更高。

負責此案的地區檢查官在接受採訪時說,警方正在繼續對Ghanghro醫師進行調查,僅排除了他故意傳播該病毒的指控。地區檢查官Irfan Ali Baloch表示,Ghanghro醫師的醫療事故訴訟仍在繼續。

Baloch先生說:「一支醫學專家團隊來了,並採訪了他。」 「醫學委員會確定他沒有故意傳播愛滋病毒,但他的診所是處於這樣一種狀況,亦即該有的準則沒有得到維持。」

Ghanghro醫師仍面臨刑事指控,但不清楚為什麼他最近會被派往Ratodero附近的政府經營的醫院。

 

 

執政的Tehreek-e-Insaf政黨的官員將疫情歸咎於信德省地方政府的治理不善和腐敗。

其他觀察家說,疫情更多是與系統失能有關。

開發專家Zaigham Khan為《新聞》(The News)撰寫專欄,指出巴基斯坦在衛生保健方面的支出不到其G.D.P.1%。每6,000人中只有一名醫生,且主要集中在城市地區。

Khan說:「巴基斯坦正面臨全面的公共衛生危機,主要是由於治理不力和特殊利益居於主導地位。」

 

 

他補充說:「巴基斯坦是世界上仍存在脊髓灰質炎(小兒麻痺症)的兩個國家之一,另一個是阿富汗。」狂犬病和登革熱等可治療的疾病每年導致數十人死亡。 「在農村地區,大多數人受到庸醫的治療。除此之外似乎還不夠,甚至於醫生也經常開具過期藥。在法律體系中,醫生幾乎從未對這些做法負責。」

中央政府管理的國家愛滋病控制計劃的項目經理Baseer Khan Achakzai博士說,拉托德羅的狀況並不獨特,巴基斯坦的大部分地區都在努力遏制引起愛滋病的愛滋病毒之傳播。不受管制的診所仍在繼續營業,他說,經常將舊注射器重新包裝並出售為新注射器,儘管這些都應該在使用後將其焚化。

根據專門研究愛滋病毒/愛滋病的聯合國愛滋規劃署工作團隊的估計,從2010年到2018年,巴基斯坦的愛滋病毒陽性人數幾乎倍增,達到約16萬人。在此期間,1524歲年齡層其新感染者的數量猛增了38%,且大約只有10%被認為是H.I.V.陽性的人得到了治療。

 Achakzai博士說:「在聯合國機構的幫助下,正在建立一個最先進的愛滋病控制中心。」「這將確保受污染的注射器不會再被使用,並將所有的醫療廢棄物放入焚化爐。」

Achakzai博士說,除首都伊斯蘭堡外,巴基斯坦各地的醫學實驗室均不受任何監管框架約束。

他說:「沒有制衡措施。」

Maria Abi-Habib是駐德里的南亞記者。在2017年加入《泰晤士報》之前,她是《華爾街日報》在中東的巡迴記者。本文的另一個版本於20191031日在紐約版的第12A版印刷,標題為:H.I.V醜聞成為巴基斯坦的衛生保健系統的焦點。

An H.I.V. Outbreak Puts Spotlight on Pakistan’s Health Care System

After the reuse of syringes infected hundreds of children in a small city, health workers say the entire system needs to be revamped.

 

 

Imtiaz Jalbani, a father of four who lost two children to H.I.V. this year, points to an injection mark on his son’s hand. He claims the mark is from a syringe taken from the trash during a visit with the pediatrician Muzaffar Ghanghro. Credit...Mustafa Hussain for The New York Times

By Maria Abi-Habib and Salman Masood/ Oct. 30, 2019

Pakistan’s government suspended a pediatrician accused of reusing syringes and infecting scores of children with H.I.V. after it was discovered that he had been reassigned to a government-run hospital, in a case that raised fury across the country.

On Wednesday, the provincial government of Sindh, where the outbreak occurred, said it had suspended Dr. Muzaffar Ghanghro, just days after The New York Times published a story about the pediatrician and his role in an H.I.V. outbreak in which nearly 900 of the more than 1,200 cases so far have been children.

 

HEALTH CRISIS

The children’s H.I.V. outbreak that panicked Pakistan.

Dr. Ghanghro was initially the sole focus of blame in the H.I.V. outbreak, in the small city of Ratodero. But government officials now believe that he is not the only cause there, and that the bad practices he is accused of, including reusing syringes and IV needles, are so widespread across Pakistan that the entire health care system needs better regulation.

Dr. Ghanghro, in an interview with the Times last week, denied accusations that he reused syringes and needles.

His clinic was shut after news of the outbreak broke in the spring. But he said that he had recently renewed his license and was practicing in a government hospital with a stream of patients waiting to be seen by him, questioning the government’s ability to regulate the system.

Health workers say the government needs to revamp the national medical syllabus to prioritize infection control, currently a minor part of doctor training. And they say hospitals often scrimp on the sterilization process for tools.

“The only good thing about the outbreak has been that it laid bare the multiple flaws in the system that the government with support of U.N. agencies needs to address,” said Dr. Fatima Mir, a pediatric infectious disease expert working at the Aga Khan University in Karachi. She was one of the first medical workers to help with the outbreak in Ratodero.

“What the outbreak in Ratodero says about Pakistan’s health care is that infection control is poor or nonexistent. Pakistan’s health care system is now trying to integrate infection control as a formal part of the system,” Dr. Mir added.

She said that Pakistan’s medical practitioners often lack the logistics and supplies necessary to prevent and contain infections. When she was in Ratodero to help, Dr. Fatima said it was a challenge finding clean water to wash her hands with while seeing patients.

“With the lack of infection control, this outbreak is not unexpected. What is unexpected is that this time, children are the main victims, and there are a lot of them,” she said.

Of the nearly 36,000 residents in Ratodero tested since late April, 1,112have tested positive for H.I.V., 889 of them young children. With not even a quarter of Ratodero’s population tested, officials worry the real numbers are much higher.

The police investigation into Dr. Ghanghro is continuing, and he has been cleared only of the charge that he intentionally spread the virus, the district inspector general in charge of the case said in an interview. Dr. Ghanghro’s court case for medical malpractice is still continuing, said the district inspector general, Irfan Ali Baloch.

“A team of medical experts came and interviewed him,” Mr. Baloch said. “The medical board determined that he did not intentionally spread H.I.V., but his clinic was in such a condition that the protocols were not being maintained.”

Dr. Ghanghro still faces criminal charges, making it unclear why he was recently posted to a government-run hospital near Ratodero.

 

Image:Dr. Ghanghro is now practicing at a government-run hospital after his private practice was shuttered. He has denied he reused syringes, which is illegal.Credit...Mustafa Hussain for The New York Times

Officials from the governing Tehreek-e-Insaf party blamed the outbreak on the poor governance and corruption of the local government of Sindh Province.

Other observers said the outbreak is more about systemic failure.

Zaigham Khan, a development expert who writes a column for the newspaper The News, noted that Pakistan spends less than 1 percent of its G.D.P. on health care, and that only one doctor is available for every 6,000 people, mostly concentrated in urban areas.

“Pakistan is facing a full-blown public health crisis, mainly rooted in ineffective governance and dominance of special interests,” Mr. Khan said.

 

Image: Patients waited to see a pediatrician at a hospital in Ratodero, Pakistan, before H.I.V. testing.Credit...Mustafa Hussain for The New York Times

“Pakistan is one of the two countries in the world where polio persists, the other being Afghanistan,” and treatable conditions like rabies and dengue contribute to dozens of deaths annually, he added. “In rural areas, most people are treated by quack doctors. As if that was not enough, even doctors often administer expired medicine. Doctors are hardly ever made accountable for these practices in the legal system.”

Dr. Baseer Khan Achakzai, the program manager of the central government-run National AIDS Control Program, said that Ratodero’s conditions were not unique, and that much of Pakistan was struggling to combat the spread of H.I.V., which causes AIDS. Unregulated clinics were continuing to operate, he said, and used syringes are frequently repackaged to sell as new, although they are supposed to be incinerated after use.

From 2010 to 2018, the number of H.I.V.-positive people in Pakistan nearly doubled, to about 160,000, according to estimates by U.N.AIDS, the United Nations task force that specializes in H.I.V. and AIDS. During that time, the number of new infections jumped 38 percent in those 15 to 24. And only about 10 percent of people thought to be H.I.V.-positive are being treated.

 “With the help of U.N. agencies, a state-of-the-art AIDS control center is being established,” Dr. Achakzai said. “It will ensure that contaminated syringes will not be used and all medical waste would be put in the incinerator.”

With the exception of the capital, Islamabad, medical laboratories across Pakistan are not under any regulatory framework, Dr. Achakzai said.

“There is no check and balance,” he said.

Maria Abi-Habib is a South Asia correspondent, based in Delhi. Before joining The Times in 2017, she was a roving Middle East correspondent for The Wall Street Journal. @abihabib 

A version of this article appears in print on Oct. 31, 2019, Section A, Page 12 of the New York edition with the headline: H.I.V. Scandal Puts Focus on Pakistan’s Health Care SystemOrder Reprints | Today’s Paper | Subscribe