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, 1,112 have 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 number is 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.
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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 Husain 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.