Building Both Neurosurgery and Healthcare in Peshawar Pakistan
Tariq M. Khan Dean, Professor, and Head of Neurosurgery Northwest School of Medicine, Peshawar, Pakistan
After graduation in Peshawar, Pakistan, I spent two years in the Pakistan Armed Forces as a medic. I left for Ireland in December 1981 for the Primary FRCS course in the Royal College of Surgeons Dublin. I passed the FRCS part 1 and landed my first job in Orthopedics in January 1982. During the interview for my next job, I told them I wanted to do Neurosurgery. They selected me since one of the interviewers was a neurosurgeon. I passed my FRCS Part 2 in June 1986 and did most of my neurosurgical training in Royal Victoria Hospital and University Hospital Cork. Although my neurosurgery mentors wanted me to stay on in Belfast, I felt I should return home to Peshawar. In agreement with my decision, they all visited me in Peshawar at different times. I returned to Peshawar to my parent institution, Lady Reading Hospital, in January 1990 as the second neurosurgeon in the Khyber Pakhtunkhwa (KP) province. At that time there were less than 30 neurosurgeons for a population of 150 million in Pakistan. We were given eight beds in an informal arrangement with our patients spread all over the hospital and only two days a week to operate. Lacking a CT scan the first year, for head injuries I did exploratory burr holes under local or no anesthesia. I recall that at a later date one night we had a patient with an extradural hematoma who was stable – so I thought I would show the junior doctors how to do a craniotomy. When I made the incision I asked for the monopolar diathermy and was told it was non-functional - so again I had to do a quick craniectomy. The hospital was very much helped by donations of disposables and instruments (including an old diathermy) from Belfast and Cork. By mid 1990s we had operating microscopes plus intensive care and improved anesthetic services so that we could do brain tumors and other complex brain surgeries. In 1997 a new hospital, Hayatabad Medical Complex, was commissioned and I was asked to start a new Neurosurgical Department there. Since by this stage I was an approved supervisor for Fellows of Neurosurgery for the College of Physicians and Surgeons of Pakistan, I was able to train a number of young neurosurgeons. Some of them are Professors now and have themselves trained many more neurosurgeons to have a good number across the KP province. There are about 75 trained neurosurgeons now in KP province and nearly 500 in the whole country – roughly 1 neurosurgeon for 500,000 population in both the KP province (40 million population) and the entire country (220 million population). In 1997 I also realized that prevention of head and spine injuries was essential for quality, full-service neurosurgical care. We started a Head Injury Society in Peshawar in that year. I gathered a group of people from the community and convinced them of the importance of prevention. We started regular public awareness events, e.g., walks, seminars, and poster competitions. As a part of their curriculum, the College of Home Economics made it mandatory for students to visit school children and make them aware of the importance of prevention. At my request the Pakistan Society of Neurosurgeons started these awareness programs as part of their Annual Conference. Around this time the International Committee of the Red Cross started a rehabilitation unit for spinal cord injury patients, a facility that was later turned over to the KP provincial government. In 2001 a watershed moment came when the provincial government wanted to enforce new rules. These new rules many of us felt would not help the poor patients who would come to the public hospital to get free medical treatment. This was a very difficult juncture but along with many senior colleagues we had to bid goodbye to the public service with a heavy heart. We wanted a state-of-the-art setup that could not only care for the patients who could afford to pay but also care for those who could not afford to pay. We also wanted to train young doctors and allied specialties, so that we could improve healthcare in the province and the country. With this in mind, a company called Alliance Health Care was set up in 2005. Getting like-minded people together was a difficult task and getting money together was even more difficult. The ten initial shareholders pooled our resources together. We then approached different banks for a loan, but most banks were very skeptical since no doctor groups had previously developed a big hospital in this region. Finally one of the banks agreed to loan us 500 million Pakistan rupees (about six million US dollars at that time). Interestingly, many years later a former CEO of the bank told me that when he took over the bank, he told his staff that giving us a loan was a big mistake and we would never be able to repay. We not only repaid that loan without a hitch but later we received more loans. The bank showcases us as their triple A customer. Our first hospital, state-of-the-art Northwest General Hospital with all specialties, became functional in 2008. This hospital was initially 130 beds and ultimately increased to 300 beds. The hospital organization was nominated as the fastest growing company in the Arabia 500 Competition held in Dubai under the auspices of Harvard University. In 2012 we asked the College of Physicians and Surgeons of Pakistan for approval to train in most specialties, which was granted after the college carried out an inspection. The following year, we were approved by the Pakistan Medical and Dental Council for residency training in all specialties. In 2015 the foundation was laid for the Northwest School of Medicine. The same year four BS programs were started in Nursing, Anesthesia, Medical Laboratory Technology, and Radiology. There was a great dearth of four-year BS-trained people in these disciplines. Along with this a five-year program in Doctor of Physical Therapy was also launched. The medical school was inspected and approved for 100 students per year by the Pakistan Medical Commission, with the first intake for the session 2016 – 2017. Reinspection in November 2021 resulted in approval for an additional 50 students per year – remarkable progress in five years. We have been approved by the Higher Education Commission to establish Northwest University of Health Sciences and are on the verge of approval from the provincial cabinet. This will be a first of its kind university of the health sciences in the private sector of KP province. Another 300 beds were added in the second hospital. These beds were not-for-profit and were run through our endowment fund, to which both the company and shareholders contribute regularly. This was seen as a very successful model and has been studied by a group at Harvard University, as well as cited in a publication.1 This not-for-profit hospital is making a big contribution to healthcare in Peshawar and the KP province. As a commitment to raise public awareness, the WFNS Neurotrauma Committee, during my tenure as Chairman, partnered with ThinkFirst International for this purpose.2 The first joint awareness seminar was held in Peshawar at the time of the International Conference on Recent Advances in Neurotraumatology in November 2019. This event had approximately 1000 participants and was widely reported in both print and electronic media in Pakistan. I was also presented with the 2019 ThinkFirst International Chapter of the Year award. Another essential aspect for neurosurgery, especially in low- and middle-income countries, is effective prehospital care. Although the government has established an excellent network of ambulance services, our hospital added to that with our own ambulance service launched in 2017. The ambulance service is staffed by paramedics trained in basic life support and equipped with life-saving drugs and equipment (including transport ventilators). The charges for the ambulance service are very nominal. In addition, we have a campaign to make people aware of this ambulance service for transporting acutely ill patients to hospital. For over 25 years now, I have dedicated myself to improving both neurosurgical care and general health care for the people of Peshawar and the KP province. Thanks to the many others who have shared this vision, we have made significant progress. Present affiliations include the following: Chairman/CEO Alliance Health Care Professor and Head of Neurosurgery, Northwest School of Medicine Dean, Northwest School of Medicine, Peshawar Dean, Neurosurgery, College of Physicians and Surgeons of Pakistan Member, National Medical and Dental Academic Board, Pakistan Medical Commission Convenor, Neurotrauma Section of Pakistan Society of Neurosurgeons Executive Director, ThinkFirst International Pakistan Member, Dost Foundation Board Alternate Member, Pakistan Human Development Fund Member, Hashim Khan Trust Member, WFNS Global Neurosurgery Committee Past affiliations include the following: Member, WFNS Neurotrauma Committee Chairman, WFNS Neurotrauma Committee President, Pakistan Society of Neurosurgeons
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