| Free TB treatment: Murree's best-kept secret |
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Naseem, a mother of three, had been consistently coughing for about a month before she was diagnosed with tuberculosis (TB) in December 2006. Her husband Rashid runs a rented grocery store near Hasan Abdal and earns Rs 5,000 per month for the family of five. He mentioned his wife’s coughing to a customer, who suggested it might be TB and told Rashid about a sanatorium in Murree that provides free treatment.
Naseem had been under treatment as an outpatient for four months when Daily Times met her and her husband at the Syed Muhammad Hussain Government TB Sanatorium in Simli, Murree, 35 kilometres from Islamabad. “The treatment here has been very good. I can go about my work normally now, I barely feel ill any more. But the doctor said I should continue the medicines for some time, otherwise I may get sick again,” Naseem said. Rashid was trained by the sanatorium staff to oversee his wife’s medication, and he “takes this job as seriously as he takes his five-times-a-day daily prayers,” Naseem claimed. The couple leave their children behind and travel to the sanatorium once a month to get her medicines.
Located 4,500 feet above sea level in the midst of nature in all its glory, the 360-bed sanatorium caters to around 300 to 400 outpatients every day. An overwhelming majority of the TB patients at the hospital belong to lower Punjab or upper Sindh (the Seraiki belt). The remaining belonged to Azad Jammu and Kashmir (AJK), and areas surrounding Murree.
Equipped with an outpatients department (OPD), an indoor department, a laboratory, an X-ray department, an operation theatre, private rooms, a mosque, a kitchen, a post office and a rest house, the sanatorium has catered to 387,839 outpatients, and has admitted 14,188 TB patients between 1999 and 2004 alone. The number of patients coming to the hospital, however, has shown a decline from 2004 onwards. One reason for this would be the fact that efforts have never been made to actually publicise the sanatorium – people hear about it through word-of-mouth, the sanatorium’s medical superintendent (MS), Dr Ishtiaq Shah, said.
He maintains that the publicity of the sanatorium is the responsibility of the State because the sanatorium is not provided with funds for advertising. Unfortunately, state-run TB awareness programmes focus on the symptoms of the disease and the need to continue treatment.
A number of shopkeepers in the area around the sanatorium were asked about the hospital. While most of them gave ready answers about the location of the place, they stared in disbelief when told that almost all the facilities there were free – except for the private wards, which cost around Rs 120 per day. Apart from this, there is an admission fee of Rs 10, and a ‘parchee fee’ of Rs 2. Erythrocyte Redimentation Rate tests (ESR, a blood screening test useful in detecting and monitoring TB, tissue necrosis, rheumatologic disorders, and other diseases where symptoms are vague or physical findings minimal) costs Rs 10, an X-ray Rs 15, sputum analysis Rs 10, and urine tests cost Rs 16.
“Except for special vitamin supplements, etc, which we cannot provide here due to limited funds, all other medicines, even those for Multi-Drug Resistant (MDR) TB are free,” said DMS Dr Zohra Jabeen.
Treatment for regular TB lasts around eight months, and costs approximately Rs 2,000 per patient. MDR-TB, however, takes longer to cure (two years), and medication costs around Rs 200,000 per patient. “Even then, the chances of complete cure are very negligible,” Dr Shah said. “One of the causes of MDR-TB is the fact that people drop out of treatment prematurely when they first get TB. They start taking the medicines, and when the symptoms alleviate (usually within two to three months), they decide they don’t need the treatment any more.”
Once this happens, the bacteria mutate, become resistant to the drugs that the patient had initially taken for TB, and the disease comes back with a vengeance in the form of MDR-TB. Drop outs in mid-treatment and the subsequent conversion of the disease to MDR-TB is also one of the major challenges in TB treatment in Pakistan.
“The dropout rate at the sanatorium is negligible, however,” Dr Shah said. “We keep follow-up checks on OPDs, and have a system where they are provided with the required medication once a month. ‘Parchees’ are made, and patients collect medication according to the schedule mentioned in them. Moreover, members of their families are trained to make sure that the drugs are taken on time.”
The sanatorium provides treatment for MDR-TB as well, the MS said. “There are, however, very few instances of success. By the time patients come to us, the disease has usually progressed into the extreme drug resistant (XDR) phase. We can’t treat that, and the patient dies.”
Most of the MDR and XDR patients at the sanatorium are referred there from lower Punjab and upper Sindh. “Even though we get more patients with regular TB (70 percent) than MDR/XDR-TB, treatment for the latter costs us more on the whole,” Dr Shah said.
The sanatorium administration also has apprehensions about how long they can continue to provide medication to MDR patients. “We have to justify our expenses to the federal government, which is our major source of funding,” the MS explained. “All they see is that something in the vicinity of Rs 200,000 is being spent on [MDR] patients, and the results are not very encouraging. We might be forced to stop treating them, if we can’t find alternate means to support the funding.”
The discontinuation of financial support for treating MDR TB isn’t the only threat to the TB sanatorium, however. The facility is short on medical staff. It is currently manned by three doctors and is supported by a crew of nurses and other staff. “We need more people,” Dr Jabeen told Daily Times. “Fresh medical graduates should come here and spend some time working at the sanatorium. We could give them experience certificates, and the training they receive here will be helpful for them in their careers.”
The sanatorium also needs an endowment fund. The staff is not provided with a risk allowance against exposure to tuberculosis, and as per the rules of state-run hospitals, the doctors need to be provided with a hard area allowance and a rural compensatory allowance. “We work here around the clock, seven days a week,” Dr Jabeen said. “That is to say, we do have specified duty timings, but since we live nearby, we are available on call all the time.”
Some of the equipment at the sanatorium needs to be repaired, the administration said. Last year’s request for a grant to repair faulty equipment was not sanctioned by the government.
Moreover, the revenue department of the Punjab Government intends to sell some land at Company Bagh. The natural springs that supply water to the sanatorium are located on this land. If the sale goes through, it may curtail or suspend the water supply to the sanatorium, and will also hinder future expansion and remodelling of the facility.
“An important factor of TB treatment that we lack here currently is psychological counselling,” Dr Shah said. “We’re looking to expand into that area as well, in the future.”
History
In 1928, Dr Syed Muhammad Hussain purchased a piece of land in Samli Tajal (Murree), and started up a facility to treat Muslim TB patients free of cost. Six years later, the almost epidemical growth of the disease caused the Rawalpindi branch of the Red Cross Society to sit up and take notice. At the time, the society was headed by Mrs Kethbert King, the wife of the then-Rawalpindi Division Commissioner. The plan to set up a sanatorium in Murree was finalized on May 8, 1935. Dr Hussain was approached, and he donated his buildings for the purpose. On August 14, 1947, the management of the sanatorium was transferred to the Punjab government, and the institution was provincialised the next day. It was expanded and developed during subsequent years. The sanatorium is now spread over 365 kanals. The financial and administrative controls of the sanatorium lie with the Punjab health services director general. The day-to-day functions are, however, managed by a 12-member board of governors, including seven active members. Apart from this, the Samli Sanatorium Trust also looks after the improvement of the sanatorium. The eight-member trust is chaired by Lt Gen (Retd) Muhammad Iqbal, who is also the chairman of the Pakistan Red Crescent Society (Punjab branch).
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