Dr Shafi Bhuiyan with colleagues. He and his colleagues argue that COVID-19 has exposed gaps in the Canadian healthcare system.

By Shafi Bhuiyan and team of ITMDs
Toronto, Canada, Sep 3 2021 (IPS)

Access to quality healthcare is a basic human right, but for many, especially those in vulnerable communities, the right is not fully realized.

The Covid-19 pandemic exposed this systemic inequality and gaps in the Canadian healthcare system.

While surgical backlogs and delayed appointments may be prominent features of the healthcare crisis, the indirect impacts of Covid-19 must be considered. These include a halt in preventive programs, such as cancer screenings, declining health among Indigenous and aging people and for those with chronic illnesses, as well as worsening mental health among health care workers, to name just a few.

Canada already possesses a significant number of educated, qualified, and experienced Internationally Trained Medical Doctors (ITMDs) who can help fill gaps in the healthcare system. For example, Immigration Refugee Citizenship has reported that over 5,000 physicians came to Canada between 2015 and 2021, and this number does not include ITMDs who immigrated via a different method.

Many ITMDs possess much-needed cultural diversity, linguistic skills, and cross-cultural patient care talents. These can be utilized in the long-term care sector, for chronic disease prevention, and with Indigenous peoples and ethnic-racial groups, especially those residing in remote and rural areas across the country. Although 20% of the Canadian population lives in rural areas, only 8 percent of physicians work cfin these areas. Many ITMDs are well suited to provide quality healthcare for some of these communities.

Canada’s annual immigration intake plan is to welcome more than 400 000 immigrants per year in 2021-23, in keeping with the national plan for population growth. Based on data trends from Immigration, Refugee, Citizenship Canada (IRCC), this will likely include at least 900-1000 physicians each year. The need for diversity among physicians will continue to rise to provide culturally sensitive and quality care for all Canadians. ITMDs can provide culturally sensitive care and in-demand language skills to Canada’s increasingly diverse population.

Although the Truth and Reconciliation Commission of Canada (TRCC) Calls to Action were created in 2014, most healthcare calls have yet to be addressed. ITMDs can help address the long-standing shortcomings for this communities’ access to equitable healthcare and could contribute to rebuilding trust in the healthcare system.

The underutilization of immigrants’ education and qualifications has been reported to cost Canada $3 billion per year. Supporting the incorporation of internationally educated health professionals into the healthcare system would benefit Canada’s healthcare system and positively impact the economy.

Integration of internationally educated health professionals / ITMDs into the healthcare system requires a national strategy with a multi-stakeholder approach that focuses on scalable solutions. This strategy needs the engagement of governmental policymakers, regulatory bodies, employers, educational and training entities, service delivery agencies, and ITMDs themselves.

Once ITMDs have proven their expertise, they still require a bridging program to integrate their skills and expertise into the healthcare labor force. A recent survey of selected ITMDs who had participated in a career bridging program showed one-third had passed their licensing exams. These exams assess candidate’s clinical knowledge and skills to ensure they are comparable to Canadian medical graduates. Despite this achievement, another hurdle remains, to secure licensure. This is the residency program, which ranges from 3 to 5 years depending on the field of specialty.

The residency application process is complicated, but to describe it simply, medical students apply – via the Canadian Resident Matching Service, or CaRMS – for residency positions at universities across the country in one or more specialties of their choice. Not only are the total number of residency slots limited, but there are caps on the number of slots reserved for internationally trained versus Canadian medical graduates. The available slots for ITMDs are considerably smaller.

With the 2021 residency match results, data clearly illustrates the inequity i.e. a total of 2,852 Canadian medical graduates were matched. On the other hand, 410 internationally trained medical doctors were matched to residency positions. Over 90% of ITMD’s who have passed their qualifying exams cannot secure a residency due to their limited number and inequitable distribution of the residency slots.

An immediate solution is developing and delivering bridging programs, including in-class training and practicum placements, to support ITMDs’ employment in work commensurate with their skills, training, and experience, such as clinical assistant, research associate, and healthcare manager. Incorporating ITMDs into the healthcare system as licensed physicians can be further achieved via Practice Ready Assessments, increased residency opportunities, and increased post-graduate public health education and training.

Developing a clear roadmap will facilitate ITMDs’ integration into the Canadian healthcare system and foster diversity and equity in health research, management, and patient care.
There is a worldwide health crisis. If we cannot save a life despite having a huge pool of foreign-trained physicians ready to serve any time, we are neglecting untapped human resources to the detriment of our health.

The inclusion of ITMDs in the health system will benefit the healthcare system, patients, and the community and have a positive impact on society by reducing wait times and ensuring a better quality of life.

ITMDs are here, ready, willing, and qualified to serve Canadians as we work together to strengthen our healthcare system. There is no better time than NOW! Let’s work together to make healthcare more available and accessible to all Canadians so that no one is left behind.

• The authors are from Asia, the Middle East, Africa, and South American countries.  
• The co-authors are Drs Bhuiyan S, Orin M, Krivova A, Fathima S, Walters J, Uzonwanne G, McGuire M, Mohammad A, Alamgir AKM, Radwan E, Tasnim N, Tazrin T, Parungao J, Saad W, Shalaby Y.

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Immigrant Health Professionals have lots to offer Canadian society, but often face barriers.

By Shafi Bhuiyan and team of ITMDs
Toronto, Canada, Aug 27 2021 (IPS)

Albert Einstein said, “In the midst of every crisis lies great opportunity.” The year 2020 was a year of crisis across many sectors in Canada, especially the health care sector. There was a severe strain on the health care system through long waiting lists for family physicians, specialists, and vaccination clinics, and Intensive Care Units were working at a high level of capacity.

People’s Charter for Health describes health as a reflection of a society’s commitment to equity and justice. Health equity is not complete without equity in opportunities for medical professionals from all backgrounds to practice medicine.

Canada’s healthcare system has faced many challenges, including but not limited to long waiting times, geographical disparities, an aging population, and limited access to personal doctors and specialists. The COVID-19 pandemic further brought to light the gaps in healthcare and how opening career pathways for internationally trained medical doctors on the front lines could only be beneficial.

The Canadian demographic pattern is changing through globalization and immigration policies – hence diversity matters. There are increasing numbers of internationally trained medical doctors (ITMDs) who can work in Canada’s health care system but struggle to pursue their careers after moving to Canada due to bureaucratic and other obstacles. The ITMDs can contribute to our health care system alongside Canadian graduates. They also bring culturally sensitive care and in-demand language skills to Canada’s increasingly diverse population. 

Systemic barriers exist in Canadian healthcare for immigrants; hence, inequity in the system needs to be addressed by providing culturally respectful services. ITMDs can ensure equal opportunities to contribute to health services (i.e., indigenous community, aging population, immigrants, and migrant workers).

There is a rising demand for health care talent across the globe. Canada will face increasing competition with other countries to attract such a talented and qualified workforce. Without proper pathways for ITMDs to pursue their careers in Canada, ITMDs will eventually choose to migrate to countries that would enable them to have fair and clear pathways of integration into the healthcare system that will utilize their expertise.

Systemic barriers and inequity exist, and as a result, over 13 000 immigrant doctors are not called ‘Doctor’ in Canada. Only 26.4% of the total number of physicians in Canada are internationally trained medical graduates.

However, In Ontario, hospital care is overwhelmed with an estimated backlog of almost 257,000 surgeries. Also, Canada is the 12th lowest among OECD (Organization for Economic Cooperation and Development) countries in the number of doctors per 1000 population. This implies the need for more doctors in Canada, which can be achieved by opening more opportunities for the thousands of international medical graduates in Canada to practice medicine.

However, it can be argued that the number of doctors has increased by 1.8% from 2018, with a total of 5.2% between 2015 and 20191. Additionally, the number of international medical graduates becoming family physicians in Canada has increased from 28.7% in 2015 to 30% in 20191. Can this be interpreted as increased opportunities for internationally trained medical doctors? The answer to this question requires further exploration of opportunities and residency match processes. Internationally trained specialists with multiple years of training and expertise choose to do family medicine in Canada as the process gets extremely difficult for the specialists to do their respective courses in Canada. This is also evidenced by ITMDs being only 17% of practicing surgical specialists compared to 30% of practicing family physicians.

Furthermore, we cannot ignore that international graduates with specialty training from only certain countries are recognized to pursue Royal College Certification in their respective specialties. However, graduates with specialty training from all other countries have to undergo compulsory residency training despite years of experience in their respective fields.

A recent survey conducted in 2021 by the Internationally Trained Medical Doctors program at Ryerson University showed that 35% of the international graduates who participated in the survey have completed all necessary licensing exams but have not yet been able to secure a residency position. Likewise, 47% of immigrants with internationally obtained post-secondary health education credentials are underutilized: they are either unemployed or work in non-health occupations that require only a high school diploma. Also, the World Health Organization projects a worldwide shortfall of approximately 18 million health care workers by 2030, with certain consequences for patients, economies, and communities. This shortage may fuel global competition for skilled health workers.

Internationally educated and licensed doctors face differential access to opportunities to meet the requirements to practice medicine compared to those trained in Canada. While most immigrant doctors are required to do additional residency training here, there are very limited spaces available. In 2020, only 418 ITMDs obtained a residency position, while 2,895 medical graduates trained in Canada were matched to residency programs. At the end of the match, 56 residency positions were unfilled, 49 of which were in Family Medicine. Furthermore, of the spaces reserved for ITMDs, a majority were filled by Canadians who went abroad to study medicine. On the brighter side, however, 83% of Canadians agree that we should do more to ensure that doctors trained internationally have a fair and reasonable opportunity to practice medicine in Canada.

Hopefully, we will soon reach a stage where we, ITMDs, could look back and say that our time has finally come! Policymakers need to consider existing barriers and take steps forward in utilizing immigrants’ skills to address our society’s demands. ITMDs, let’s stay strong together–tomorrow is a new day! Diversity matters. Together, let’s act now to make our Canadian health system equity-focused and accessible to all.

• The authors are from Asia, the Middle East, Africa, and South American countries.
• The co-authors are Drs Bhuiyan S, Azam S, Krivova A, Orin M, Mukoko P, Radwan E, Adelekan O, Abdulhameed M, Mehrotra M, Anuradha D, Gaby V, Tasnim N, Abolurin A, Dare A, Telchi J, Mariano K, Bukhari S.

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Many pharmacies and herbalists in Egypt prescribe their own 'wasfa' (secret drug or herbal elixir). Credit: Cam McGrath/IPS

By Cam McGrath
CAIRO, Aug 10 2014 (IPS)

Magda Ibrahim first learnt that she had endometrial cancer when she went to a clinic to diagnose recurring bladder pain and an abnormal menstrual discharge. Unable to afford the recommended hospital treatment, the uninsured 53-year-old widow turned to what she hoped would be a quicker and cheaper therapy.

A local Muslim sheikh claimed religious incantations, and a suitable donation to his pocket, could cure the cancer. But when her symptoms persisted, Ibrahim consulted a popular herbalist, whose wasfa (secret drug or herbal elixir) was reputed to shrink tumours.

“I felt much better for a few months and thought the tumour was shrinking,” she says. “But then I got much worse.”

When she returned to hospital the following year, tests revealed that the tumour was still there, and the cancer had spread to her lymph nodes. Moreover, the herbal mixture she was taking had caused her kidneys to fail.“Successive [Egyptian] governments have done a poor job at both regulating the medical sector and educating the public on health issues, leaving Egyptians unable to afford their country’s two-tiered health care system vulnerable to ill-qualified physicians, spurious health claims and quackery” – Dr Ahmad Bakr, Egyptian health care reform lobbyist

Egypt is a “minefield” of bad medicine, says paediatrician Dr Ahmad Bakr, a health care reform lobbyist. He says successive governments have done a poor job at both regulating the medical sector and educating the public on health issues, leaving Egyptians unable to afford their country’s two-tiered health care system vulnerable to ill-qualified physicians, spurious health claims and quackery.

“Our health care system is deeply deformed,” Bakr told IPS. “It’s not just a matter of low funding and corruption, ignorance (pervades every tier of) the health system, from government and doctors to the patients themselves.”

He says Egypt’s lax regulation and poor enforcement has created room for unqualified doctors to perform plastic surgery out of mobile clinics, peddle snake tonic on satellite television, and dabble dangerously in reproductive health.

It is estimated that one in every five private medical clinics in Egypt is unlicensed, and thousands of medical practitioners are suspected of using false credentials or having no formal training.

“There are a lot of so-called doctors who practise medicine in Egypt,” says Bakr. “They mostly work out of small clinics, but you’ll even find them in the most prestigious hospitals.”

The incompetency goes all the way to the top.

In February, Egypt’s military announced it had invented a device to remotely detect hepatitis C – along with acquired immunodeficiency syndrome (AIDS), swine flu and a host of other diseases. The device, which is said to work by detecting electromagnetic waves emitted by infected liver cells, is based on a fake bomb detector marketed by a British con artist.

The military also claimed that it had invented a revolutionary blood dialysis machine that can cure hepatitis C, AIDS and even cancer in a single treatment.

“I was shocked when I saw these incredible claims were being made with barely any clinical evidence,” says Dr Mohamed Abdel Hamid, director of the government-run Viral Hepatitis Research Lab (VHRL). “With any new medical treatment you should perform peer-reviewed, double-blind clinical trials before announcing it.”

Critics say Egypt’s government contributes to a climate of medical irresponsibility. State media routinely exaggerates health threats and feeds public hysteria, while the knee-jerk reactions of government authorities – including high-ranking health officials – are coloured by popular sentiment and political motives.

Reacting to the global swine flu pandemic in 2009, overzealous parliamentarians passed a motion to slaughter all of Egypt’s 300,000 pigs.

There was no evidence that pigs transmitted swine flu to humans, nor had the virus been detected in Egypt. But officials, swayed by the Islamic prohibition on eating pork, appeared to seize the opportunity of a like-named virus to rid the Muslim-majority nation of its swine.

“The pigs were kept almost exclusively by poor Christian zebaleen (rubbish collectors), who used them to digest the organic waste,” says Milad Shoukri, a zebaleen community leader. “Thousands of families lost their livelihoods to this absurd decree, which had no scientific basis.”

Global pandemics such as severe acute respiratory syndrome (SARS), avian flu and the latest contagion, Middle East Respiratory Syndrome (MERS), have presented golden opportunities for Egypt’s myriad quacks and swindlers to fleece the uninformed masses.

“With each health scare we see the same patterns,” says Cairo pharmacist Amgad Sherif. “People panic and throw science out the window. The low level of education and high illiteracy among Egyptians makes them susceptible to believe even the most ridiculous medical claims.”

When a swarm of desert locusts descended on Cairo, enterprising charlatans took out ad space in local newspapers offering a “locust vaccine” to anxious citizens.

Not surprisingly, the injected serum, which turned out to be tap water dyed with orange food colouring, offered no protection against “locust venom”. But it did leave duped households poorer, and at risk of blood contamination or hepatitis C infection from jabs with unsterilised needles.

“The people doing this only care about getting money from people who don’t know any better,” says Sherif. “They know nothing about medicine and do not follow even the most basic hygiene practices.”

In one popular scam, people claiming to be state health officials troll low- and middle-income neighbourhoods offering costly “preventative medicine” for infectious diseases. The fake medical personnel, dressed in lab coats and wearing official-looking badges, administer bogus vaccinations to unsuspecting families.

“Sometimes they give people injections – who knows what’s in them,” says Sherif.

Health officials say the sham physicians create confusion that affects legitimate health campaigns, such as Egypt’s national door-to-door polio eradication campaign.

Egyptian authorities have also found themselves in a cat-and-mouse game with thousands of “sorcerers”, whose superstition-based folk medicine draws desperate working-class patients suffering physical and psychological ailments. The self-proclaimed doctors and faith healers are particularly difficult to catch, say prosecutors, because they tend to work out of rented apartments and advertise mostly by word of mouth.

An Egyptian judicial official told pan-Arab newspaper Al Arabiya that despite attempts to prosecute sorcerers for swindling and fraud, most cases are dropped when the sorcerers reach a settlement with their victims. “There is almost one sorcerer for every citizen,” he concluded.

(Edited by Phil Harris)

IDPs in Jabal Al-Akrad, in Syria's Latakia region. Credit: Shelly Kittleson/IPS

By Shelly Kittleson
REYHANLI (TURKEY), May 19 2014 (IPS)

As once-eliminated diseases resurface and barrel bombs and alleged chlorine attacks target civilians, doctors in rebel-held areas and across the border struggle with issues of how best to serve their profession.

Up to 70 percent of Syria’s health workers had fled the country as June last year, according to the World Health Organization, and many of the country’s medical facilities have been destroyed or heavily damaged by regime air strikes.

‘’Even blood bags are controlled by the ministry of defense...You go to jail if they find you with one" -- Dr. Omar
Though regime and opposition fighters are often said to share the blame for obstructing access to medical care for civilians, Dr. Omar, who works with the Syrian Expatriate Medical Association (SEMA), said that his organisation has not experienced problems with any rebel groups while working in Syria. However, he stressed that his work ended when the patient – whether rebel fighter, regime soldier or civilian – had been treated.

“My work stops there. What they do with them afterwards is not my business,” he said, stressing the need for neutrality in order to continue operating in areas even when they change hands from one group to another.

Doctors Without Borders (MSF) has long been known for the same code of ethics, but nevertheless had five of its expatriate staff taken hostage in early January, most likely by the fundamentalist group Islamic State of Iraq and Al-Sham (ISIS). More moderate factions have pushed the extremist group out of much of rebel-held territory in the north in recent months but the medical workers’ whereabouts remain unknown.

MSF decided to pull all foreign staff from Syria after the incident but continues to operate several makeshift clinics and mobile facilities in the country using Syrian personnel. It also supports local hospitals.

The international NGO – which, Dr. Omar notes, was ‘’the first group to send us money and support in 2011’’ – has not been able to register with the Turkish government and is thus unable to establish official offices across the border.

He said that he had recently been in Kasab, part of a coastal area seized in late March by rebel fighters, to set up medical facilities for ‘’damage control and sending them elsewhere. That’s all we can do right now’’.

Save the Children recently reported cases of doctors forced to give children unnecessary amputations and patients choosing to be knocked out with metal bars rather than undergo surgery without anaesthesia, which is in short supply. There have been outbreaks of vaccine-preventable measles and polio that have begun to spread across the country’s borders.

Dr. Omar initially left regime territory in early 2012 to avoid arrest, after working as one of the first to coordinate clandestine treatment to those injured in protests across the country. The work involved considerable risk, because ‘’even blood bags are controlled by the ministry of defence, not by the health ministry.”

‘’You go to jail if they find you with one,’’ he said.

He was later one of four doctors working inside the country who met secretly with Syrian expatriate medical staff in the Turkish border town of Reyhanli in November 2011 to start working alongside the Union of Syrian Medical Relief Organizations (UOSSM).

Of the other three doctors, “one has been killed under torture, Mohammad Osama Baroudi, one has been in prison since 2012, and one is working at a field hospital inside.’’

At least 440 medical personnel have been killed in the ongoing conflict, reports Physicians for Human Rights, while many hundreds of others continue to be held in regime detention facilities.

The border town where Dr. Omar works when he is not inside Syria has changed dramatically since this IPS correspondent’s first visit in 2012. A few makeshift care facilities and injured fighters propped up on porches under ‘internet café’ signs or treated in disused hotels and homes have been replaced by a more organised system.

Several medical facilities cater to the masses of injured, amputees and patients with spinal cord injuries who have made it to this side of the border, and ragged-looking Syrian children begging in the streets are a common sight. A clinic specifically for prosthetics, the National Syrian Project for Prosthetic Limbs (NSSPL), has been set up on its outskirts, and short courses are held for would-be physical therapists, many of whom are medical students forced by the conflict to abandon their studies.

A 29-year-old physiotherapist working here told IPS that he had been arrested in early 2011 on terrorism charges and briefly joined a rebel group after being tortured in jail. He found, however, that he was unable to make himself kill anyone. He claims to be one of only a few fully trained and medically certified Syrian physiotherapists now in the town, as he graduated from the faculty set up in 2006 in Homs that closed only a few years later when war broke out.

He and his younger brother were taken from his house in the middle of the night, and he spent ‘’34 days, 6 hours and 28 minutes’’ in detention. His family eventually found a trusted contact to whom they paid 30,000 dollars to have him released. His brother, who worked with the Red Crescent, is still in prison. His family has meanwhile paid several thousand dollars to get him moved to detention facilities where they can occasionally visit him and refuse to leave the area unless his brother comes with them.

The physiotherapist feels he can be more useful here than inside, but admits: ‘’I am afraid of myself. If I go back inside I know I won’t come out again. My old friends would like me to work with them again. But I am still wanted by the regime and would put my family in even more danger than they already are.’’

A demonstration in support of abortion rights in Dublin. Credit: Irish Family Planning Association.

By Silvia Giannelli
ROME, Apr 5 2014 (IPS)

Two out of three doctors in Italy are ‘conscientious objectors’ to abortion, according to new data. The Italian Ministry of Health reveals that in 2011, 69.3 percent of doctors refused to carry out abortions, with peaks of over 85 percent in some regions.

In the face of such numbers, the ruling of the European Committee of Social Rights of the Council of Europe against Italy earlier this month over a complaint for violating the right to protection of health came as no surprise.“Many doctors object simply because they have nothing to gain from doing this extra work.”

“The Italian situation really worries us, and this is why we filed the complaint,” Irene Donadio, advocacy officer at the International Planned Parenthood Federation European Network (IPPF_EN) told IPS. “We believe that there is a problem with the functioning and application of the abortion law, which, in fact, would be a good law but is often violated.

“We acknowledge the fact that the right to conscientious objection is included in the same law, but the right of women to access a service that is legal and fundamental for their health needs to be respected as much as this right.”

IPPF_EN sees the high number of conscientious objectors in Italy as the main cause behind refusal of women’s right to termination of pregnancy.

IPPF_EN, with the help of several Italian associations, presented to the Committee a scenario of never-ending waiting lists and arbitrary suspensions of the service. It listed many instances where women were forced to travel for abortions within the country or to go abroad.

“According to data from the Ministry of Health, the number of voluntary interruptions of pregnancy per year is around 110,000,” Giuseppe Noia, president of the Italian Association of Catholic Gynaecologists Obstetricians (AIGOC) told IPS.

“If we consider that there are about 1,500 non-objecting physicians, each physician carries out around 74 abortions per year, that is an average of five or six per month. The fact that non-objectors are overloaded and cannot guarantee an efficient system is therefore absolutely false,” Noia said.

In its response to the Council, the Ministry had said that due to a decline in abortions, “the workload for non-objecting doctors was cut by half in the last 30 years” and therefore “it appears difficult…to maintain that the high number of conscientious objectors would be an obstacle for accessing the interruption of pregnancy.”

The ministry’s note does not elaborate on the geographical distribution of objectors across the country. This is what, according to the Council of Europe, creates a disparity in treatment depending on where the woman seeking an abortion resides.

In the southern region of Basilicata, according to official data, 85.2 percent of physicians are conscientious objectors, in Apulia they account for 79.4 percent of the total, and in Sicily 81.7 percent.

“The situation is generally worse in the South, but also Lombardy [in the north bordering Switzerland] has serious problems, and we know that this is because is a not very laic region,” Silvana Agatone, president of  the Free Italian Association of Gynaecologists for the Application of Law 194 (LAIGA) told IPS. Law 194 is the law that regulates abortion in Italy.

The decrease in abortions claimed is subject to different interpretations. The ministry maintains that this is due to “the promotion of a higher and more efficacious recourse to conscious procreation.” But Marilisa D’Amico, a lawyer who was involved in presenting the complaint, says that the increase of cases of spontaneous abortions, or miscarriages, “can only be explained as an increase of clandestine abortions” presented as miscarriages. There were less than 57,000 such abortions in 1990, 68,000 in 2000 and more than 76,000 in 2011, according to ISTAT.

The official figures show a constant increase in the number of miscarriages through recent years.

LAIGA provided a list of 45 hospitals that have a gynaecology unit but do not perform terminations of pregnancy, disregarding Article 9 of the Italian law on abortion. This article states that hospital establishments and authorised nursing homes shall ensure that procedures for the termination of pregnancy are guaranteed.

Clandestine abortions continue to take place, says Massimo Srebot, head of the department of obstetrics and gynaecology at the Lotti Hospital of Pontedera in Tuscany region, the first structure in Italy to introduce RU-486, a pill that blocks the action of the hormone progesterone in order to cause abortion without surgical intervention.

“Women who find obstacles in public hospitals seek alternative channels with physicians who, upon receiving a bribe, are willing to simulate a spontaneous abortion. These are conscientious objectors only when they have to work for free. They turn a blind an eye to their conscience in their private clinics.”

Srebot says “many doctors object simply because they have nothing to gain from doing this extra work.” Also, “carrying out abortions doesn’t help a doctor’s professional career because it is not a high-level specialisation operation.”

Srebot has proposed new solutions to ensure the respect of Law 194. One option would be to nominate a non-objector as a sub-head physician for every public hospital.

“I truly respect the real conscientious objectors, but there are those who speculate on women’s difficult situations, they don’t sustain them, they don’t help them preventing further incidents, they only wait for them to get pregnant again, so they once again cash in.”

A strike notice at the Lady Reading Hospital in Peshawar. Credit: Ashfaq Yusufzai/IPS.

By Ashfaq Yusufzai
PESHAWAR, Pakistan, Dec 16 2013 (IPS)

The city’s top pediatrician, Prof Abdul Hameed, who foiled an attempt to kidnap him in September, has been spending most of his time at home. Dr Sawar said, “After the incident, he has stopped examining children.”

Nurses treat an injured child at the Lady Reading Hospital in Peshawar. Credit: Ashfaq Yusufzai/IPS.

By Ashfaq Yusufzai
PESHAWAR, Pakistan, Nov 16 2013 (IPS)

Ajab Gul is haunted by bloody scenes. He hears women crying and children screaming. “I can’t sleep,” says the 25-year-old health worker at a well-known Pakistani hospital in the frontier city that tends to terror victims.

He works at Lady Reading Hospital (LRH) in Peshawar which is said to receive 98 percent of all terror attack cases in the restive Khyber Pakhtunkhwa province.

And Gul’s job is particularly difficult. Posted at the hospital’s accident and emergency department  – one of the largest in Pakistan – he has to stitch and bandage wounds.

“I see flashes of bloodied faces and bodies. The cries of women and children who are brought here for treatment ring in my ears every night,” Gul tells IPS.“They asked me who attacked them and why? I had no answer.”

The ferocity and frequency of bombings and suicide attacks in Khyber Pakhtunkhwa and the adjacent Federally Administered Tribal Areas (FATA) have had a chilling impact on the lives of doctors, paramedics and nurses in the region.

Their wounds may not be visible, but run deep. “Most of us develop psychological problems,” says Gul.

Peshawar, the capital of Khyber Pakhtunkhwa, used to be a peaceful city. But after the Taliban government in Afghanistan was toppled in 2001, many of its militiamen crossed over to Pakistan and took refuge in the border areas along FATA.

For years now, the Tehreek Taliban Pakistan (TTP) has been targeting the armed forces, government installations as well as public places like markets and schools.

Police say at least 210 attacks have been carried out by the Taliban in Peshawar since 2005.

Professor Arshad Javaid, chief executive officer of LRH, says, “Healthcare providers treat terror attack victims and see their trauma from a close range. Many use anti-depressants, tranquillisers and sleeping pills to avoid nightmares.”

There are around 12 big hospitals in Khyber Pakhtunkhwa, which is home to 22 million people. But most terror attack victims land up at the 1,650-bed LRH.

The state-owned LRH has treated more than 6,000 victims of violence since 2005, says Javaid.

“It is our mission to reduce mortality from terror attacks,” Javaid tells IPS.

But close encounters with severed limbs, bloodied faces, tears and screams leave their scars on the most dedicated of health workers.

“I keep seeing the charred bodies of children in my dreams,” says Rifat Bibi, a 28-year-old nurse at the hospital. “Many times I wake up.

“It is heart wrenching to see children suffering or dying for no fault of theirs,” she says. “They remind me of my own children, sisters and mother.”

Some are unable to put up with the trauma of their jobs.

“About a dozen of my A&E colleagues have got themselves transferred to other wards because they couldn’t stand the stress,” she says.

The twin suicide bombings at All Saints Church on Sep. 22, in which around 80 people were killed, are still fresh in Bibi’s mind.

“A woman, with a bloodstained face, who lost two young brothers that day, wept so much over their bodies that the memory still haunts me,” Bibi tells IPS.

Jauhar Ali is the president of KP Paramedics, which works with various hospitals in the city. He says its 560 paramedics provide diagnostic services and treatment to all kinds of patients.

“But our priority is those who suffer multiple injuries in bomb attacks. We need to stop the bleeding, and bandage their wounds,” he says.

“Even when we are not working, the scenes keep flooding back to mind,” says Jauhar Ali, who also conducts X-rays.

Two years ago he encountered three severely wounded children who were in Grade I. “They asked me who attacked them and why? I had no answer.”

Now he worries endlessly for his own children.

“My children are the same age, they too could become terror targets some day.”

Dr Amjad Ali, a psychiatrist at LRH, says healthcare providers are also vulnerable to rough treatment at the hands of victims’ families.

Citing the Sep. 22 church attack, he says, “That day we received 233 victims within one hour. All were provided treatment. But the angry relatives of some victims attacked health workers.”

Nurses and paramedics often develop mental health problems, he says.

“They burst into tears when they see people in pain. One in 10 shows symptoms of psychological illness. I have examined dozens of health workers who required anti-depressants and counseling,” Amjad Ali tells IPS.

“When you see bloodied bodies so often, how can you not be affected?”

Paediatrics waiting room in Albert Schweitzer Hospital, Rio de Janeiro. Credit: Agencia Brasil Marcello Casal Jr/EBr

By Fabíola Ortiz
RIO DE JANEIRO, Aug 23 2013 (IPS)

Brazil plans to import doctors to provide healthcare in poor suburbs of large cities, impoverished regions of the interior and border areas. But is there really a shortage of doctors in this country?

Dr. Pedro Henrique Grezele was 24 years old and fresh out of med school when he enlisted in the army in 2010. He chose the Amazon region to put into practice the medical knowledge he had acquired at the University of the State of Rio de Janeiro (UERJ).

He engaged in many missions in the Amazon jungle, boating up and down rivers to provide basic healthcare for hundreds of riverside communities.

“I treated patients on board the boat, with the medicines we had in stock. There was no possibility of doing lab tests, blood counts or X-rays. We treated everything according to instinct, based on the knowledge we acquired at the university,” he told IPS.

In the first half of 2010, Grezele spent several weeks on a mission up the Ipixuna river, in the southwest of Amazonas state in the extreme northwest of the country, close to the state of Acre. There were no municipal or state doctors: all treatment was provided by the army medics.

“That was where I diagnosed my first case of cancer, in a patient in the community of Boca do Puca. But we were on a boat in the middle of the Amazon river, with no chance of providing treatment,” he said.

Boca do Puca is a village of 130 people. The patient had penile cancer. “Fortunately we were able to remove it, after taking the patient to army facilities in Manaus (nearly 1,400 kilometres away). If it had been up to the state or the municipality, he would certainly have died,” he said.

Amazonas is the largest state in Brazil and has 4,000 doctors to tend to 3.5 million people (1.1 physicians per 1,000 population). The World Health Organisation (WHO) recommends a minimum of 1.4 per 1,000.

The graphic below shows the ratios of doctors to population in Brazil and other countries:

But it is not necessary to go to the remotest corners of Brazil to meet with deficient healthcare, even in countries where there are doctors to spare.

The state of Rio de Janeiro in the southeast has more than 58,000 doctors to treat 16.2 million people – that is, 3.6 per 1,000 population in one of the smallest states.

There, medical student Marcelo T. attends classes at a leading university hospital, where he bears witness to the daily shortages of materials.

“Once we had to cancel an operation because the roof was leaking, when the surgeon, anaesthetist and patient were all ready and waiting. Sometimes we are out of saline solution or other basic materials,” said this student of the Federal University of Rio de Janeiro (UFRJ).

Brazil has fewer doctors per capita than some of its neighbours, but it is not below international standards, and is even ahead of several industrialised countries.

But the authorities say this country of 198 million people is short of 53,000 doctors.

On Jul. 8, President Dilma Rousseff announced the More Doctors (Mais Médicos) programme, designed to remedy the deficit in healthcare by attracting foreign physicians to practise in areas where Brazilian doctors are reluctant to work, either because of their distance from reference hospitals or the lack of infrastructure.

“The Health Ministry is not trying to bring doctors from other countries to compete for jobs with Brazilians,” Health Minister Alexandre Padilha told foreign correspondents.

“This programme will not take a job away from any Brazilian; foreigners will have restricted authorisation to practise basic healthcare only in the outskirts of large cities and in municipalities in the interior, which are the least served areas,” he said.

According to Padilha, available medical personnel is insufficient to meet demand. In the last 10 years, 143,000 vacancies were created for doctors, but only 90,000 were filled.

The first phase of selection for these vacancies was completed in early August. Out of 16,530 medical professionals with Brazilian qualifications, or who validated foreign degrees, and who registered under an earlier call of the Mais Médicos programme, only 938 confirmed they would actually participate, equivalent to six percent of the 15,460 vacancies in the municipalities.

This handful of doctors will be deployed in the neediest areas of 404 municipalities. The remaining vacancies will be filled by physicians from abroad.

The Health Ministry says that Brazil has 1.8 doctors per 1,000 population, more than the minimum of 1.4 per 1,000 recommended by WHO.

But of the country’s 26 states and one federal district, 22 are below the national average and five are in a situation of “severe shortage,” according to the WHO definition of less than one doctor per 1,000 population.

“There are 700 municipalities where there is not a single resident doctor. We have too few doctors, and they are poorly distributed,” Padilha said.

According to official sources, there are 374,000 practising doctors in the country. The goal is to have 600,000 by 2026. And the Mais Médicos programme aims to raise the ratio to 2.7 per 1,000 by 2017.

But the idea of bringing in foreign doctors has received a hail of criticism from the medical association, which stresses poor working conditions and facilities as the reason doctors are reluctant to practise in the places where they are most needed.

“This policy is doomed to failure,” Mauro Brito, a member of the Federal Medical Council (CFM), which controls licensing of the nation’s medical professionals, told IPS. “President Dilma was wrongly advised and she made an electorally-motivated announcement. It is a fallacy to say that there are not enough doctors.”

The government’s figures differ from the CFM’s, which says there are two doctors per 1,000 population.

“Increasing numbers will not ensure high quality care for the entire populace. Health professionals must go to the interior, where sometimes the working conditions are deplorable,” Brito said.

Forty percent of total national expenditure on health comes from the federal government and the rest from state and municipal authorities and the private sector.

The CFM is calling for a health budget equivalent to 10 percent of GDP, up from the current four percent.

In the view of the president of the Brazilian Medical Association, Florentino Cardoso, the main problems are shortage of funds, bad management, and corruption that prevents resources being used as intended.

“Some health posts operate out of rented houses, without stretchers to lay patients on for examination, water for hand-washing, or facilities for doing a simple blood count or chest X-ray,” he said.

The worst conditions are found in poor suburbs of Brazil’s cities and in the north and northeast, the least developed parts of the country.

The minimum monthly salary for a doctor is 1,100 dollars.

In an attempt to promote Brazil to foreigners as a work destination, Padilha said the call for registration was aimed both at young graduates and at “experienced professionals who would like to move here and retrain.”

“It will be possible to attract well-trained, well-qualified young people, who are interested in getting to know Brazil,” he said.

By IPS Correspondents
RIO DE JANEIRO, Aug 23 2013 (IPS)

The controversy is on: the authorities in Brazil say there are not enough medical professionals, and to resolve the problem, they decided to import this “non-traditional product”. Doctors, on the other hand, are opposed to both the diagnosis and the treatment. But there is one thing everyone agrees on: the areas suffering from a shortage of health professionals are the poor suburbs and impoverished areas in the hinterland and remote border areas. The situation in Brazil as compared to itself and to other countries can be seen in this series of interactive maps and graphs.

Data: Fabíola Ortiz. Design: Ignacio Castañares