From Karachi to Johns Hopkins, Dr. Junaid Razzak is Leaving His Mark

Published on October 29, 2015
We have created a series of articles where leaders in academic emergency medicine and global health share their experiences. We asked Dr. Razzak to be the first to share some of his stories in EM development with EPI.

Karachi, Pakistan, is among the world’s largest, densest cities, with a population exceeding 23 million people. It is where Dr. Junaid Razzak, a native of the city, has helped shepherd EM development for the past decade, and along the way becoming very well attuned to the challenges of this work that are inherent in such highly complex settings.

After completing his medical training, and following several subsequent clinical and academic posts in the United States, Dr. Razzak returned to Pakistan’s Aga Khan University in 2004 as an assistant professor of Emergency Medicine. He is a member of the Global Emergency Medicine Acadamy (GEMA), which has over 150 members worldwide. The core purpose of GEMA is to improve the global delivery of emergency care by leading the advancement of academic emergency medicine. With this purpose in mind we have created a series of articles where leaders in academic emergency medicine and global health share their experiences. We asked Dr. Razzak to be the first to share some of his stories in EM development with EPI.

EPI: You have a long and substantial history of EM and public health work in Pakistan. What is some of the work in Pakistan that you’ve been involved in that you’re proudest of?

Razzak: There are a couple of areas, both very critical for healthcare systems. The most important area is developing the capacity of individuals and the institutions. The challenge in many settings is not the lack of money—it is the lack of a critical mass of well trained people. We have put a lot of effort into building that capacity at various levels. For example, we now have a nationally accredited five-year EM residency training program in Pakistan. It took a long time, and we had the program approved just during the past three years. The second area of capacity building was the prehospital phase, where we were able to set up a paramedic training academy. The academy, called the Aman Urban Health Institute, has now trained several hundred paramedics in the country and done a fairly good job at providing EMS services in the city of Karachi. Third, we’ve had a big focus on developing researchers—those who can think about issues and work to find local solutions. Over the last ten years, we have sent ~10 researchers from Pakistan to Johns Hopkins School of Public Health for training. Later on, we started a local research training program that includes mentorship from faculty members at Johns Hopkins. There are several young men and women who are completing their formal research training in this program. These are the broader areas I’m very proud of.

The second area of our focus was to try and develop a health system that is relevant to the local needs and resources and not necessarily a replica of a system that works well in a differently resourced setting. When we set up an advanced life support ambulance in Karachi, over half of the patients using the service were critically ill or injured, many of whom ended up at the wrong hospital and required inter-hospital transportation. We had to recruit and train physicians to effectively care for these patients in the ambulance. We also had to work on developing capacity of peripheral hospitals—a reversal of roles whereby EMS was leading a hospital-based practice. As a city of 23 million people, Karachi is a very complex setting; people hear about the violence and the terrorism there all the time. During the five years that it took to establish this EMS system, we were actually providing care to almost 150,000 people a year.

I was also involved in setting up a telehealth service. We had a simple, direct goal with our telehealth initiative: 24/7 availability of physicians, nurses, and mental health professionals. Anybody from anywhere can call in, register themselves, then have an opportunity to ask for medical advice, for help with an appropriate referral, or to receive counselling from a mental health worker/psychologist. Callers trying to find the best community medical resources were given options closest to their place of residence, the cost of service, contact number, and an estimate of the out-of-pocket expense. Our intent was to make healthcare access easier for the population.

EPI: You recently moved to the US for a position at Johns Hopkins. What are you working on?

Razzak: I’m working in the Department of Emergency Medicine, where I have a couple areas of focus in addition to working in the emergency department at the Johns Hopkins Hospital. My main academic focus is developing the application of telemedicine in emergency medicine. Telemedicine is a global approach to making emergency care accessible through the use of information and communication technology for those who do not have access to it, in the US as well as abroad.

There are two broad approaches we are taking to telemedicine. As we all know, there are overcrowding issues in the EDs all over the world. In the common triage model, patients are first triaged by a nurse, then they wait to be seen by a doctor or a physician assistant, who will then order a few labs and tests, and when labs come back decisions are made. What we’re trying to do is to flip that process a bit. How about if a physician sees a patient early on at the time of triage and orders what needs to be ordered, and the patients can then be seen by care providers inside the ED, who will then have all the information they need to make their treatment decisions. A lot of places are doing that. Telemedicine plays into this process, because much of the decision process of what the patient needs relies on the patient’s complaint and the caregiver’s discussion with the patient, and does not always require a physical examination of the patient.

However, sometimes it is simply not possible to have physicians with the appropriate training to make informed decisions available on the front line. So we thought, “How can we make telemedicine apply to this scenario?” In this instance, that meant having physicians screen patients remotely, from a variety of locations. Similar systems can be implemented not just for screening but for supporting the local patients in other parts of the world who want to have a discussion with a caregiver or seek a second opinion. In that case, again, the telehealth consultant hears the story, talks to the provider, and helps make the decision.

EPI: How much work and work-related travel do you self fund?

Razzak: None. My work is largely supported through grants. I believe there are enough resources around, and if a project is well conducted, society will pay for the emergency care work. This is perhaps one of the biggest misconceptions people early in their global health career have. Sustainable efforts cannot be pursued on a part-time basis, as a volunteer, or while you’re on holiday. Well conducted projects that have a lasting effect will require resources, infrastructure, and—most importantly—time.

EPI: What is the trick to making your work sustainable and giving it longevity?

Razzak: Again, if you develop people, they make the system sustainable. By that I mean you have to engage in long-term development of leaders in the regions you’re working in. Outsiders will need to leave at some point and local leadership will have to carry on their work. And if they are leaders and not followers, then they will find the ways to strengthen and evolve the program. So on the programmatic side that’s how I look at it.

Of course, programs and continuous work within communities require funding. On that note, I believe that in my work—in any business, really—you have to add value and reexamine your business value proposition now and then. In academic EM, we have to constantly reevaluate: how are we changing the business model to respond to the needs of a society, and to find donors or users to support it? That’s always the struggle.

EPI: If you could ask for one thing that would make your development work easier, what would it be?

Razzak: I guess I would say a research base that is not linked to a single project or idea. Many businesses, for example, will invest in developing a new product. They will put in high-risk money knowing that the venture may not work out. They would still invest in the idea and hope that it would mature into something that would produce “profit” eventually. The problem with a lot of academic work, especially in EM, is that its funding is very project-based. It allows for small increments forward in producing data and other results, but it very often does not allow for the freedom to do something very innovative. Innovation comes through the traditional model of center grants or endowments that people or large organizations give because they want the larger ideas to develop and not just to fund a short-term project.

When looking at the global EM community, I feel a lot of people want to do a lot of interesting work; they seem to be excited about getting engaged in various activities, but I think there is a lot more strategic thinking to be done around—again—developing the leadership in the country they are interested in, and getting engaged with them long-term.

Locally, GEMA allows for like-minded people to come together in a community to share ideas and innovations. To strengthen global emergency medicine, we need research, mentorship, education, and collaboration. These must occur simultaneously to create a base not only for research but also for training and systems development.

Within the next year my goal is to establish the first set of exchanges between US institutions and other international EM establishments.

This interview was planned and undertaken in collaboration with GEMA.

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