‘Major cause of death from heart diseases is lack of awareness,’ Prof. Nadeem Qamar, NICVD

Professor Nadeem Qamar is the executive director of National Institute of Cardiovascular Diseases (NICVD) in Karachi and has been with the institute for over 20 years. He earned his MBBS from Liaquat Medical College, Jamshoro; completed his residency in Internal Medicine from Franklin Square Hospital, US; and received fellowships in Cardiology and Angioplasty from McGill University and Ottawa Heart Institute Canada, respectively. BR Research had an opportunity to sit with Prof. Qamar to talk about the health economy in Pakistan, particularly related to heart-related diseases, prevention, and treatments. Here are the edited transcripts of the conversation.

BR Research: Tell us about the heart industry in Pakistan. How many hospitals are there, how many people does NICVD cater to, and what facilities do you offer?

Professor Nadeem Qamar: There are just two hospitals dedicated to heart in Karachi — one is Tabba and the other is NICVD. In Lahore, there is Punjab Institute of Cardiology. There’s also the Hearts International which is in Rawalpindi; Armed Forces Institute of Cardiology and Rawalpindi Institute of Cardiology are also both in Rawalpindi; there are also a couple of hospitals in interior Punjab — in Multan for instance, and it is newly established.

I can tell you that we are the world’s largest cardiac hospital. There’s no other dedicated cardiology centre. Exactly two years ago, we started a programme called primary angioplasty (one that is conducted because of a heart attack). Our patients come from the entire province of Sindh and Balochistan, and we also provide treatment to parts of the Southern Punjab. In 24 months, we have done a total of 7,959 primary angioplasties. There is no other centre in the world to have done this, so we have high volume. Every day, we get approximately 15 acute heart attacks to deal with. We also perform about 3,000 cardiac surgeries per year.

We currently have 650 beds but we aim to reach 2,000 over the next five years. We are also opening our satellites in interior Sindh. Our first satellite is going on in Larkana where we provide similar healthcare facilities. Our second will open in Multan; third in Sukkur, and in Nawabshah next year.

We are also opening chest wing units under flyovers in Karachi. Karachi is a big and busy city with terrible traffic. If someone has a chest pain while stuck in traffic, or lives far away from a hospital, they can easily seek help at the chest unit. We have one such unit right now, but in the next few months, we plan to expand this to seven units.

Our intention is to make healthcare facilities as available as possible, and provide cardiology services to people at their doorsteps. We want that a person spends no more than 90 minutes trying to get to our cardiology services in Karachi, and we are following the international guidelines where it is advised that heart patient should get to you and be treated under 90 minutes to ensure least amount of internal damage.

BRR: What is source of revenue to run the hospital, as well as for the additional projects and expansions? 

NQ: This is a public hospital but we have a few sources of income. We get a grant from the Government of Sindh every year, not a budget. This year it is about Rs4 billion and we also got extra grants to establish two satellite centres in Interior Sindh. We generate some income ourselves as well—around a million rupees through our private practice sector. We have a general ward and a private ward. In the latter, patients come and pay the rates charged similar to private hospitals, and in the general ward, most of the treatment is either free of cost or subsidized.

Over 90 percent of our business, however, is subsidized treatment; hardly 10 percent is private. For instance, children’s cardiac surgery is free here. Primary angioplasty is also free. We have a lot of life-saving devices that cost somewhere from Rs700,000 to 18,00,000 which we provide for free.

Our aim was to become self-sufficient and gradually not require government funding, which we are working toward. Our third source of income is self-generation. In the general ward, we take nominal charges i.e. say around Rs200 from a patient for his treatment. We do this to avoid unnecessary traffic—and only serve genuine patients.

BRR: Medical research is visibly absent in Pakistan. What are you doing in this area?

NQ: We have just established a research wing. It is collaboration between our Pediatric Centre with the Boston Children. A lot of the research we are conducting in collaboration with centres in Pennsylvania. In Pakistan, there is no concept of medical research, and no established database. But we have thousands of people coming to the hospital so the scope of research can be huge. Right now, we are in the process of building this database—gather information and contribute to publications. We are also collaborating with other cardiac centres in the country. The biggest factor is motivation. We lack that in Pakistan—amongst faculty, fellows, and staff who understand the importance of research.

I started this department when I joined. We hired researchers and technical expertise but nothing can be done in the first 2-3 years. At this stage, you are only data mining. We have linked our data recently with the international centres, to make sure that the data and the methodology are correct and coherent, and can be compared across countries.

BRR: The incidence of heart diseases in Pakistan has substantially increased. Cardiovascular diseases are the primary cause of death in the country. What is causing heart problems in Pakistan at such high volumes?

NQ: There are five major causes of heart disease: family history, diabetes, hypertension, high cholesterol, and smoking. You can’t do anything about family history. And all of our efforts are done to modify the remaining four factors. But I would say the major cause of death in Pakistan from heart disease is lack of awareness.

If you look at the data for hypertension, you will find out that 80 percent of the population that has hypertension don’t know they have it. If they do know, only 10 percent of those take medicines for it. Out of these who take medicines, hardly 1 or 2 percent have their blood pressure under control. There is also a lack of understanding as to how important it is to follow and track the blood pressure. Same is the case with diabetes. Many find out when they face some serious complications. And most do not comply with medications.

Diet and the way we cook food is important. I believe it is the responsibility of the government to bring in the awareness related to health to the public in collaboration with the media. The government can seek support from institutions and hospitals but spreading awareness is the government’s job.

A study conducted in the UK found that South Asian population was more prone to getting heart diseases, so we need even more awareness. The real treatment of heart diseases, hypertension, and diabetes is diet and exercise. Angioplasty is only temporary and only prevents emergency conditions.

BRR: What about concerted efforts of hospitals and institutions who can come together and push this agenda to the government?

NQ: There are a lot of individual efforts. We have conducted camps in different places such as press clubs, schools etc. They do make subtle differences. But a major impact cannot be had without the government and media involved. We have recently started a social media awareness campaign but it can only do so much.

A Commission was established during the Zardari regime but it never took off. The idea for a collective to come together, plan, and implement is a good idea, and we can do that but again it requires motivation all around.

BRR: You cater to a large volume of daily patients. How do you ensure quality of your medical service? Is there a trade-off between volume and quality?

NQ: There is not. We provide state-of-the-art care. Our skills are far superior to any of the private sector hospitals. Patients coming into OPD may have to wait more compared to a private hospital but we have made a system where we ensure that every patient is seen by 5 pm. We do two shifts for OPD; one from 8:00 am to 12:30 pm, and the second shift starts from 2 pm till 5 pm.

An evaluation of our performance against a benchmark—in 24 months, we performed 7,959 primary angioplasties with a mortality rate of 4.6 percent, which has come down recently; the world’s average is around 6-7 percent.

BRR: Do you use any locally produced medical equipment, inputs, or technology?

NQ: There is some small equipment that may come from local enterprises but majority of our equipment is imported. In some areas, we have exemptions from duties, but for most equipment we are paying duties which should not exist.

BRR: Is there any potential for medical tourism in Pakistan?

NQ: Yes there is if we market it right. Already, a lot of patients from Gulf countries come here to Pakistan for treatment because they trust Pakistani doctors. But in order for this take off, the private sector has to play a prominent role, not as much the government. The private hospitals however are filled with patients, so they don’t feel the need for medical tourism, and they don’t go to Dubai to market their facilities.

BRR: Why do you think so many people seek treatment from homeopathy and Hikmat? Is there a trust deficit in western medicine?

NQ: The issue is not trust. The core issue is economics. In rural areas, when someone falls ill, people take him to a Peer/Fakeer who would charge Rs5/10, and say a prayer. If that doesn’t work, the patient would be taken to a Hakeem who may take Rs15. A homoeopath would take Rs50, whereas a doctor would take Rs1,000-2,000. The issue is economics. The affluent, on the other hand, would only go to the Hakeem if the doctor’s medicine is not working. The poor do the opposite.

If you look at how medical studies (clinical trials) are conducted, it is a double-blind study where half the people are given a placebo, and the other half are given the actual medicine. We call this the placebo control testing. As an example, we observe that the treatment worked for 40 percent of those who were taking a placebo after a year, and for 60 percent of those who were taking the medicine. In essence, 40 percent of the people got cured after the placebo—it’s nature’s mechanism that cures. Patients who go to the Hakeem, and get cured, don’t feel the need to go to the doctor afterward. But the major issue remains economics.