Negligence, apathy, stigma and repeat

The HIV outbreak at Nishtar Hospital highlights severe negligence and the need for fundamental healthcare reform.

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We do not have all the facts about the recent HIV outbreak at Nishtar Hospital in Multan. But we do know quite a few things already. For example, we know that the recent outbreak was seen among patients in the nephrology unit who come there for dialysis. We also know that there are dozens (perhaps more) who have been infected, who were previously not HIV positive. Early investigation has also highlighted serious negligence and disregard of well-established protocols that have been known to medical communities for decades.

But there are many more things that we also know, that go well beyond Multan, and have known for a while. For example, the HIV outbreak at Nishtar Hospital is not the first, or the only, outbreak of HIV due to criminal negligence. We have been here before. In April 2019, a devastating outbreak of HIV was reported in Ratodero, Sindh. It was a result of criminal negligence including unacceptable infection control practices, widespread reuse of needles and presence of illegal blood banks to name a few. Poor oversight continued until the outbreak became a major crisis that was reported both locally and in newspapers around the world. Of course, we saw then as we see now, a robust effort to blame the patient. For example, in the most recent case, the VC of Nishtar Hospital simply rejected the notion that the patients were infected by dialysis machines at the Nishtar Hospital and said that the patients "could have been infected at private clinics they visit for blood tests and scre¬ening". Years ago, a friend of mine, who is an infectious disease physician and has worked in many parts of the country, had told me that micro-epidemics in Pakistan are likely to happen regularly due to lack of seriousness in infection control and a fundamental disregard for rules, especially when it comes to the poor.

This takes me to my third point about what else we know already. We do know that majority of the people who rely on public hospitals are not well-connected, affluent or powerful. They are often poor and are completely dependent on the overstretched, poorly resourced and crumbling public system. The power dynamic in these public places of care is also acute. The medical practitioners, who make life or death decisions, are able to get away with a lot. Even if the poor patients see practices that seem suspicious, they are unable to argue or demand a change. The power dynamic silences all screams for justice and fairness. The consequences of speaking up are often the denial of the only avenue of care that exists for them.

Finally, HIV is also unique as care is further complicated by stigma associated with the disease. In our collective psyche it remains a disease associated with immorality and hence those who are HIV positive face an additional burden. In our society that is quick to judge, and judge harshly, many patients are unlikely to come forward, or seek the care they deserve.

The Nishtar HIV story is awful and absolutely heartbreaking. A thorough and a transparent investigation is needed. Those who have been affected also need to be cared for. But there is a bigger issue here that goes beyond a single hospital or a single disease (i.e. HIV). While oversight and SOPs are fundamentally important, they will not resolve the core problem. Policing every single behaviour of the care providers is not the solution. The solution lies in making sure that all of us, including the physicians, nurses, support staff and everyone else, cares about the lives of everyone, regardless of whether someone is watching over our shoulders or not. We ought to value the lives of everyone as we would for our own loved ones. This notion of responsibility and care is not going to come from oversight alone, but from recognising everyone as an equal human. The issue here is not just of oversight, it is of our most fundamental values of whose life matters and whose does not.