A critical analysis of the current state of neurosurgery training in Pakistan.

While visiting the ‘Sub Continent’ of Asia, the Indiana University Chancellor, Herman B. Wells, offered West Pakistan help in developing additional Medical Schools, as only one was left in there after it had been separated from India in about 1950. Soon after that the Pakistani Physicians arrived on the Indiana University Medical School (IUMC) Campus, to become better acquainted in teaching Pre-clinical subjects. After several of those physicians returned to Pakistan and started teaching Medical courses, requests were made for Teachers of Clinical subjects, and eventually Residency experiences. I was asked to spend several months learning what would be needed to establish speciality training in the new Medical School Hospitals being established throughout what was then East and West Pakistan, that is, before East Pakistan became Bangladesh. My plane arrived one late afternoon in Karachi, West Pakistan, and I was taken to my quarters near the Pre-clinical part of the recently-built Medical School and older adjacent hospital. Soon after my arrival, I was invited to have dinner with the family of an IUMC teacher of physiology, who was helping to establish the pre-clinical part of the Medical School, and also to establish a serious interest in herpetology and the development of snake anti-venoms. While waiting for dinner, one of the young daughters moved my arm off the arm of the chair, and replaced it with a short fat snake, unlike anything I had seen before. She explained that that particular snake was a family pet, as she showed me how to pet it. Dinner was excellent India-style fare, and I had a restful night after a long day of travel. The next day a British-trained neurosurgeon, Omar Jooma, MD, took me on rounds of several 20-bed wards with a variety of well-cared-for neurosurgical and general surgical patients. In a few days, I was deep into the neurosurgery schedule myself, with Dr. Jooma, but more often by myself, assisted by one or another of the younger general surgeons. The operating room, was large with a wooden floor and light-colored painted walls and a large open window, which overlooked a courtyard where the patients’ and their families’ horses and donkeys were kept. Braying and scuffling animal feet were heard through the open window, particularly in the early mornings, before they were fed. After operating there for a few days I persuaded the nurses, who were very good and attentive, to move the head or back to be operated on away from the open window to the other side of the room. Quite adequate operating room (OR) lights could be moved around on castors to provide good illumination of the operative sites. There was no air-conditioning, so the nurses would wait until the surgery progress was such that they could put a towel wrung out in ice water over the surgeon and his helper's backs for a few minutes of wonderfully cool comfort. In spite of these unusual means of completing surgeries, neither I nor Dr. Jooma had any wound infections. Dr. Jooma and I each performed many operations, but I will mention a few that I remember clearly, with the understanding that there were many more. A young man had been carried piggy-back almost a thousand miles from the Himalayan mountains in the north of Karachi. I have no recollection of the diagnosis, but I remember removing a well-encapsulated abscess arising from his mastoid that compressed one of his temporal lobes. A short while post the operation he was able to walk joyously back toward his mountain home. I never saw or heard from him after he walked off from the hospital ward, and had to assume he remained well enough to help care for his family's farm. He also walked off the ward among his many relatives. Length of hospital stay seemed never to be an issue. Another similar case had a medium-sized acoustic neurinoma removed, without the use of magnification or other current amenities. He also walked off the 20-bed ward without difficulty. I remember one elderly gentleman, from whom a benign spinal tumor was removed, sitting up on his bed, both pre- and post-operation, while one or the other of his sons squatted behind him rubbing his back. The patients’ families brought their own bedding, and convenient places were supplied for relatives to wash, and clothes lines were provided to dry their clothes quickly in the warm sun. It was impossible to count the number of relatives attending each patient, as they provided much of the care except for medication or vital sign recording. Relatives cooked the best-liked meals of the patients on small stoves, on the balconies surrounding each ward, and fed them, making a real family affair of each hospitalization. When x-rays were needed, the families were told how many and what sizes were needed, so relatives could go into the city to buy and bring them back to be properly exposed by the x-ray technicians. The time came, after I had become somewhat accustomed to this routine, for me to visit other sites where new medical schools were being developed in both East and West Pakistan. The first was King Edward Hospital in Lahore, West Pakistan, many miles north of Karachi, where Dr. Bashir Amid, who had seven years of neurosurgical training in one of the world-renowned neurosurgical centers had started to practice. During training, Dr. Bashir spent all the money he earned buying neurosurgical instruments and sending them back to his home in Lahore, so only a few days after he completed his training he was able to start operating. Other neurosurgeons with similar training had to wait months after arriving for sufficient instruments to start operating. Dr. Bashir and I made a lasting friendship, as we discussed Pakistan's medical needs, particularly with regard to resident training. He had a strong reputation for his diagnostic and surgical skills, and eventually became the principal of the enlarged King Edward Hospital Medical School Complex. My next visit was to Peshawar. Work on the building for the new medical school had not yet started, and the elderly surgeons I met there were not sure if neurosurgery should be a separate discipline from general surgery or resident training. I assumed, but had not confirmed that this new medical school was one of the ten that Pakistan was planning. I visited several other locations, one of which was Abbottabad, where Osama Bin Laden was found during the last few days of April 2011. My only recollection of that stop was a walled courtyard full of beautiful little black and white goat kids frolicking. On my way back to the USA I landed in the city of Dakar, what was then East Pakistan, now Bangladesh, where a new pre-clinical medical school had opened, essentially only classrooms and laboratories. The friendly professor who showed me around learned that my father was one of the early leperologists, and suggested that I visit a leper community on the Changregoona River, not far east of Dakar. I got up early on a Sunday morning and caught a launch to take me to visit British missionaries who cared for the lepers in this community. The launch went slowly against the flow of the river, stopping at many docks to load and unload passenger, animals, and various bundles of goods. When we reached the landing for the leper community, I was directed to the mission house. I found no one was home, so I wandered around the leper village, watching women making cloth and men doing other chores. I recognized the signs of leprosy among the friendly people, whose children seemed to be uninfected. The British missionaries shared their lunch with me and arranged for a three-wheeled taxi to take me back to Dakar. On the way back to the USA I stopped in Burma, now Myanamar, where I was privileged to sail a ‘lightening’-styled sail boat, Bangkok, and then went on to the Large Island of Hawaii, where my family joined me on Kalikakua Bay, where Captain Cook was boiled and the volcano started pouring out red hot liquid rock two days before we were scheduled to leave.