Lessons from the best teachers, my patients – first international guest writer!!

A quick plug for our colleagues over at the RCGP First 5 committee. Jodie does a great interview for a podcast on general practice for GP’s early in their training with some great reading recommendations!

This week, I’m very excited to announce that we have an international guest writer from Pakistan, Dr Sanam Shah. We met when she visited the UK last year in October for the conference exchange and she has kindly offered to write a piece for the blog.  As GPs, we are privileged to see a cross-section of society and, having spoken to Sanam, I realise that the challenges faced by family doctors worldwide are the same. We truly have far more in common that that which divides us.

Thank you for this insightful piece!

Lessons from the best teachers, my patients

The glint and glimmer in her eyes reflected the 75 years or so of her life. Since the first time I had met her, I always sensed the ambience spring alive in her presence; she was very regular to see me despite the 500 km and more she had to traverse on several stretches of unpaved roads and horrendous public buses to reach me from a village in the periphery of Sindh, not far from where I originally come from. I realised the vagaries of her journey all too well or so I thought; she used to leave her ailing husband behind every time, accompanied by her son, who worked to gather enough sustenance for each long journey to Karachi and back. I last saw her in February 2018, her visage unchanged and her speech as gushing as ever.


I believe it is vital to know where people come from as belongingness comes from understanding those precise physical, social and environmental factors that mould us. So let me describe her circumstances. Sindh is the land of the Indus Valley Civilisation, dubbed an ‘Ocean’ in ancient history. It has survived invasions dating from Alexander the Great to Ashoka, to multitude of dynasties shaping the fate of this region. However, invasions and occupations are also fraught with implications that trickle down to present day. She knew that better through her years of course. The ‘Ocean’ of prosperity is tainted with images of children in rags who have not known childhood, they don’t go to school for lack of institutions and safety; plight of the hungry who head to the cities and inhabit squatter settlements with their own civil problems; lack of electricity and gas, inequalities of water supply and awful shortages; struggles of women in a patriarchal setup and cues for help that largely go unheard and unnoticed. Eventually, parents who never went to school struggle hard to send their children to one so they have a shot at a better future. Then there is the struggle with natural disasters like flooding and rural inhabitants are the worst hit as the infra structure is unable to sustain the ruthless onslaught. However, I feel that this precise history and culture has imparted a sense of unending stoicism to the inhabitants, indeed it appears any circumstance beyond this ordinary would be strange.

There is more where she comes from. I admired her veracity and always looked forward to see her radiant demeanour. Yet that day in February was different; I felt very uncomfortable as I found it extremely difficult to break that her organs her succumbed to liver cancer; the unabating hepatitis C infection was left undetected over the greater course of her life and the turn of events had taken a toll on her physical self but remarkably failed to dampen her spirits. As I put her hand in mine, her son continued to look down; that 500 km journey back home to her loved ones was really not going to be an easy one this time.

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In medical school we were taught about an intricate network of health systems in Pakistan comprising of primary, secondary and tertiary levels. Alongside a sizeable proportion of GPs, there is a strong workforce of Lady Health Workers (LHWs) who provide primary healthcare to the rural masses. Their services are supplanted by Basic Health Units and Rural Health Centers forming the core of the primary healthcare structure, supported by secondary care provided at Tehsil Headquarter Hospitals and District Headquarter Hospitals and ultimately the tertiary care teaching hospitals. A very enlightening relay of service delivery indeed, but soon after this realisation, I fell into a cycle of learn and relearn. I had not received an accurate dose of reality; the sort of stark realities that struck after medical school had me abound with questions. Health status in rural areas is worse than urban areas and we continue to see people traveling far and wide to access private health services in urban cities that cater up to 80% of healthcare delivery. There are exorbitant financial strains liable to rural income inequalities and I often find myself juggling the indispensability of prescribing drugs and missing a days meal or two for entire families. It is extremely easy to stress boiling drinking water until I am taken aback by a person’s plea of unaffordability or absence of natural gas resources; people still access water from bore wells, open wells, tube wells and hand pumps in several locales,  though it has been difficult to assess the extent of contamination from modern agrarian and industrial practices. Beyond the trials of daily living, unknowingly, I stumbled across a different kind of attachment one day when a lady I’d been seeing for well over a year declared this was her one final visit while she handed me a hand-crocheted pouch in semblance of her appreciation. She was all alone and her circumstances did not allow her to see me anymore. She always carried a bag of photo memories of the loved ones she had lost and spoke of them without exception at length every time. She didn’t need medical care, she just needed to talk. I understood I had to let go, unwantingly.

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Primary care and primary healthcare is inadequate as in many parts of the world today, and communities often don’t understand its underlying concepts. Given the poverty and lack of awareness, it is commonplace to find a pharmacist dispensing healthcare for all kinds of problems, a quick source of unrestricted and unsolicited advice and drugs and a threat to public health in eventuality. It is no wonder to witness the rising trend of diseases like Hepatitis B and C and medication errors due to wrong practices. Yes primary care is indispensable but also is access to other basic needs. The RCGP Exchange in Liverpool last year has certainly raised my reflections on the delivery of healthcare at the two extremes of the healthcare spectrum; the underlying principles engender consideration of cultural background, social class and social factors as well as awareness and experiences of marginalisation and inequity. Perhaps, no amount of medical knowledge and degrees will guarantee a better future; there is copious data to prove the association of health with economic development and the availability of clean water, nutrition, housing, sanitation and safety as well as income and gender equalities. Health issues cannot be addressed without understanding these precise underlying social and economic circumstances unique for every person. Thereafter, health needs to be thrust to the top of political agendas, involve multi-sector partnerships and horizontal programming to reach bigger goals.

As I sit contemplating, it seems imperative to understand problems before really fixing them, understand our people and patients, their circumstances and challenges. Conversations with patients are vital to extract such information and their health seeking behaviours. Over time I have greatly appreciated the importance of conversing with patients rather than medicalising their lives given any chance. The hurdles are immense, this however does not stop them from shaping a future they most desire.

Sanam was part of the 2017 conference exchange to the UK (second from left)

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