COMMENT: Life must go on —Dr Syed Mansoor Hussain

The concept of brain death has allowed heart donations to occur in people who are no longer functionally alive but their hearts are still working. In Pakistan, this concept is now legally established but is obviously not yet publicly accepted

The need to write about the horrific attack on Data Darbar (tomb of the sufi saint Ali Hajvery) in Lahore is overwhelming but I will resist the urge to do so. Not because I do not want to say anything about it but rather because there is nothing I can say that will in words express the anguish and utter despair I feel about it.

A week or so ago I was invited to attend a seminar in Karachi at the Sindh Institute of Urology and Transplantation (SIUT) on the issue of donation of organs from ‘brain dead’ donors. This was a time when targeted killings, especially of minority physicians in Karachi seemed to be on an upswing. Many of my physician friends in the US wondered why I would be willing to travel to Karachi at such a time. My answer was that if we become incapacitated by fear, then we will have handed an uncontested victory to the terrorists.

In this context I will always remember Thomas Friedman’s book, From Beirut to Jerusalem. Friedman describes life in Beirut during the height of the Lebanese civil war when Beirut had become the poster child of the post-apocalyptic city. Yet his description of Beirut also tells us how the life of ordinary people went on. And because life went on, today Beirut as well as Lebanon are very much on the mend. So, we in Pakistan must also make sure that life goes on and in that perhaps lies our eventual salvation.

Therefore, I am going to talk about transplantation of organs and especially of heart transplantation. That is what I talked of during the seminar at SIUT and I think it is an important enough topic that I must try and present some ideas and information about it. The first thing to say is of course that any major transplant operation is an expensive proposition. There is some truth to the point of view that Pakistan cannot afford such expensive procedures when a large number of people in the country lack even basic medical care.

In spite of this, kidney transplantation has already become an established medical treatment for patients with ‘end stage’ kidney disease that are dependent on dialysis to survive. While I was at the SIUT, it was announced that 3,000 kidney transplants had already been done at that hospital and all of them completely free of cost to the patients, including all the medicines required by them for years on end.

Over the last decade kidney transplantation got a bad name in Pakistan. Unscrupulous hospitals and doctors bought kidneys from the very poor for a pittance and transplanted them into rich patients, usually foreigners, for a lot of money. This made Pakistan an attractive destination for transplant ‘tourism’. However, after the laws were passed banning ‘non-related’ organ donations, this activity has virtually stopped.

So, why not heart transplantation? The major problem with heart transplantation is of course that there is no such thing as a living donor. The donor has to be dead but still have a normal ‘beating’ heart. The concept of brain death has allowed heart donations to occur in people who are no longer functionally alive but their hearts are still working. In Pakistan, this concept is now legally established but is obviously not yet publicly accepted and that is a big hurdle for future heart transplants.

But even if such organ donations become accepted by the public and become available, the next big question is the cost of such procedures. Heart transplantation is frightfully expensive. Frankly, for the cost of a single heart transplant, a few dozen of the other regularly performed heart operations can be done. But then if we push this comparison further down the line, a single coronary bypass operation is expensive enough in itself. Perhaps dozens of children can be immunised and provided with dietary supplements to prevent vitamin deficiency diseases for the cost of one such operation.

Yet, thousands of heart operations are being performed in Pakistan every year and the number is going up steadily. Clearly the high initial cost of a medical treatment is not in itself a reason to abandon it. What is, however, necessary is that even if available, expensive procedures like heart transplants should be properly supervised. Fortunately, one thing we have learned from the history of medicine is that once a treatment becomes established and is proven useful in time, it does become less expensive.

This of course does not mean that heart transplantation should become available in every hospital or ‘clinic’ that wishes to offer it. Initially, one or two transplant centres should be set up in the entire country, they should be closely monitored and the number increased only if needed. The infrastructure will first have to be developed, people trained, a ‘pool’ of prospective recipients identified and a well staffed cardiac centre with advanced technology set up to take care of this pool of patients as they wait for possible transplants.

A side benefit is that heart transplantation will create an environment where considerable amount of research, training and development of ancillary procedures and methods of treatment will become available. All this will also give a tremendous boost to existing cardiac services in the country and provide a higher level of expertise to even non-transplant patients with heart disease. Also, one donor for heart transplantation can provide many organs like the liver and kidneys for other desperately sick patients.

Once heart transplantation is started, initially there will probably be no more than a few dozen of these operations every year in the entire country but the numbers will go up with time as more appropriate donors become available.

Finally, for the few dozen people that might directly benefit, a heart transplant is indeed a ‘gift of life’ and that in itself is a pretty good reason to start such a programme in Pakistan.

Syed Mansoor Hussain has practised and taught medicine in the US. He can be reached at smhmbbs70@yahoo.com