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SNI Digital, Innovations and Learning, a new video journal which is interactive with discussion, now offering all of its programs including this program on podcasts on Apple, Amazon, and Spotify,
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in association with SNI Surgical Neurology International, an internet journal with Nancy Epstein as the editor-in-chief, are pleased to present another of the SNI Digital's series of discussions
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with clinical neuroscience experts.
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In this series, we'll be talking with Asif Bashir and his brother Qasim Bashir and Gauss Malek, a mentor, who is from Pakistan also, on how we developed a major neuroscience center in Pakistan.
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My Seth Beshear, who is one of the three presenters today, is a diplomat of the American Board of Neurosurgery, and now professor and chair of neurosurgery and the executive director and dean of
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the Punjab Institute of Neurosciences in Lahore, Pakistan.
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An institute he and his family have founded. He was formerly a professor at the JFK Neurosciences Institute in New Jersey and the reconstructive and spine neurosurgery section, neurosurgeon and the
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JFK Neurosciences Institute in New Jersey. His email is listed below his picture.
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Qasim Ashir, the
1:51
brother of Asif, is now head of the department of neurology and the Services Institute of the Medical Sciences in Lahore, Pakistan.
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He's director of the neuroendovascular surgery section of the Punjab Institute of Medical Sciences in Lahore.
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He's the focal principal person in the development of the Stroke Management Center for the region of Punjab, Pakistan, which has 160 million people. He's a fellow of the Royal College of Physicians
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in Edinburgh, and he's certified as a neurocritical care specialist by the United Council of Neurological Specialties in the USA. He's certified as a vascular neurologist by the American Board of
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Medical Specialists. He's had a fellowship in neuroendovascular surgery at the University of Illinois at Chicago. He is certified in neuroendovascular surgery by the Committee on Advanced
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Subspecialty Training, cast under the Council of the Society of Neurologic Surgeons in the USA.
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His e-mail is listed there.
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Osmalek is the Executive Vice Chair and the John R. Davis Endowed Chair in the Department of Neurologic Surgery and Henry Ford Health in Detroit, Michigan. He is originally from Pakistan and has
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spent a great deal of his life helping build neurosurgery and neurosciences in Pakistan.
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So, first of all, thank you so much, Dr. Asman is such a player to actually talk to you after a long gap. So,
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and again, and Dr. Wasmanik and Dr. Asabashir being in the audience also, thank you so much for your time. So, I made a presentation like about what I want to say is like, it's more of like a
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journey And I thought like maybe I'll just like
4:01
do the topic of mitigating the barriers to hyper acute stroke care in low medical countries. And since you already mentioned that we are based in the
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hall in Pakistan and Pakistan is in that category. So, I have no conflict of interest here. So, I'm just going to start off like by quoting George Skola, who actually is now a fellow at World
4:20
Stroke Organization He came to know about stroke and then later became a very active member of the WSO after, only after suffering the stroke himself. And if you look at his statements, surviving
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stroke is the easy part. You either do or you don't. And while you're in the hospital, you're looked after and receive all the care you need. But the day you're discharged, it changes. That's
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when our lives as stroke survivor begins. But what I wanted to point out over here is that fortunately George lived in a European country and was able to get the best of the stroke care that exists
4:55
in the developed world. But if you are living in a low-medium country, the things are not going to be the same as what George experienced. So it's not going to be easy even to survive, let alone
5:10
facing the major morbidity associated with some majority of the strokes. And when you discharge, yes, that's the common thing, because when you're discharged in a low-medium country, your life
5:20
definitely changes. But I would say that it's even worse than when you're discharged in a developed country. So when I was in US. like a startup under your mentorship
5:32
in 1998 to 2000, when I was also working with you and Dr. Gerard de Bruin. In 1996, the first IV thrombolytic drug by new was approved. And just to give you a baseline in Pakistan, this drug was
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approved in 2021. And in
5:50
February of 2025, the second IV thrombolytic drug connective plays was approved by FDA. And you can see how far we are from the developed world. For anything that you want to do, and you have far
6:07
more experience than anyone amongst us here, Dr. Vosmelek has been very instrumental like
6:13
in developing the neuroscience program in Detroit. But for me and myself, like here, like for any objective, for me, it was more of us developing a stroke infrastructure. You need a champion,
6:24
you need funding, social mobilization, and you need a lot of technical support. But when you are in working in a low-median country, I think
6:33
the most important part is actually the funding and the social mobilization, and I'll tell you why. So when we're talking about the barriers, let me quickly go through some of the barriers that
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actually affect which are coming from the developed world into the low-median countries So this is the 2014 framework for controlling the non-chemical diseases and Pakistan became the signatory outfit
6:59
in
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2014. And at that time, when the Pakistan became the signatory, I think the timeline given to Pakistan and the other countries was 10 years that they need to make a major progress in cardiovascular
7:13
diseases such as like non-chemical one in cancer and then the cardiovascular and respiratory disease. But the problem that you see over here is Hylatoris cardiovascular. So when you are in a low
7:23
middle country, the word cardiovascular is going to be construed in a different manner as compared to what is perceived or used in developed countries like stroke or heart disease.
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So keeping in that context, the other problem, the thing here is
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that I'm not going to
7:48
go straight into how we did it. In
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Punjab, we have two health departments. One is specialized health and the other one is primary and secondary. Now in a country with 250 million population, this is the largest province by
7:58
population and contributes more than half of
8:02
the population of the country.
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And this is the only province where you have two health departments unlike the other three major provinces where you have one health department. So when you are working for the health department here,
8:16
you have to deal with two departments separately. So now coming back, to that terminology. So if you have several vascular and you do not differentiate between stroke and heart disease, that
8:29
becomes a major problem for us in the low medical country. And the reason is that there are so many barriers over here which I've highlighted, there are even more. And I'm not going to go into each
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and everything that I've listed over here, but these are some of the major ones that we get affected for developing neurosciences or anything which has acute emergency care. When I came back in 2012,
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end of 2012, it took me
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one or two years only to realize that you cannot copy and paste exactly what you see in
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the developed world because our demographic, our problems, our infrastructure is totally different So if you have a guideline, It's not very easy to follow that guidelines strictly to the core.
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And since we're talking about the stroke, so I'm going to stick to it.
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So
9:30
in 2013, I joined CMH Medical College, which is Combined Military Hospital College. For a person like me who came back with the best of the education, three fellowships, it was not an easy thing
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to get into the public sector, first of all. So this was the only place where I could join But the program that I wanted to start actually should have started in 2013, but it took me seven to eight
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years to make my way to the public sector. So in 2020, I was able to join the public sector only after they actually were the ones who realized what I was doing in the city and the things. So they
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offered the position and I'm joined the public sector. And that's where now this program comes in. So these are the big concerns. that I've listed, you need to identify the problems. We have a
10:19
major problem, the human resource, career infrastructure, career growth, planning, which obviously the regulatory authorities and the health department has a major role to play infrastructure,
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communications, population, is one of the major problems because it's, the population's growing at such a rapid rate that whatever you come out with, it becomes like a major problem within a short
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time So you have to think again how to deal with the new problems. And then the other thing is standardization, the corporate industry, and the health insurance system. Brief note on the human
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resource. Again, 250 plus million population as of 2025, there are only like 414 neurologists. And I would say like maybe close to 500 or maybe less than 500 are able to tell more neurosurgeons
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for this population, which is too short to deal with the whole population.
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The other problem here is that the whole mantra actually revolves around providing treatment. And in this era of social media and those kinds of things where everyone who has a problem with the
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health care in a lower income country, they instantly go to the social media, put complaints and large complaints at those times, it becomes a major problem. So the focus has been on providing the
11:36
treatment, but not on the prevention. So that's another major thing that has to change, a shift, how to prevent these problems. So this is a stroke chain, which is globally recognized and
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advocated by American Stroke Association, American
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Academy of Neurosurgery, American Capital Neurology. So I'm gonna just sum it up, they have five blocks, but I summed up all of them into four, and I'm gonna go each one of them as we developed
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the
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infrastructure here in the province So starting with the - the community, dispatcher, hospital, and then the rehabilitation.
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So in 2020, March, I was offered to join the public sector, which I did. Immediately, I already had kind of a blueprint for number of years when I moved back. So I reached out to the health
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department to give me the funding just to start IV thrombolytics, because at that time, the service hospital where I'm working still right now, and I also work at Punjab in
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St. Louis, where Assif is. We don't have the cath lab over there, but we didn't have the TPA in 2020. And TPA was not even registered with our drug regulatory authority of Pakistan, which is
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counterpart of
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FDA. So I reached out to a patient's family who had seen me in 2019 and offered that whenever I joined the public sector, I have something for the public they were were willing to offer. So they
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were kind enough. since the government didn't provide me the fund. So they were kind enough to give me 100, 000 brands. And then I reached out to the Alpac San Association of North America to act
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as a medium for moving the funds from APNA to Borhanger, Engleheim, Germany, which is the main company that manufactures TPA for the world. Now the world is divided by the Borhanger into two
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regions. One is USA, the other is the rest of the world outside the USA. For the USA, the TPA drug is made by the company Genetic because they got the license from Borhanger to manufacture TPA by
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themselves for the US population. The rest of the world, it was Borhanger. So
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Borhanger, Engleheim didn't have any presence in Pakistan at that time. So the only way I could get the drug into the country was A, arrange funding and then have a medium the funding could be
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transferred to them and then the drugs could be shipped to Pakistan. And that's what we did. And we got an institution based permit that allowed us to import till the drug was approved. So I made
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that program, started running the program and then using the social media, the WhatsApp and those sort of things started educating and highlighting to the health department, what we were doing,
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showing them the outcomes. And then short enough in 2023, a break came in and then again, at that time, the career government wanted me to reached out and they said, why don't you replicate the
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same local project of yours for the whole province. And in October 2023, the provision stroke management center was created. So these are the five things that we laid our foundation on that we're
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going to follow the same principles laid out by World Stock Organization. We're going to work on hyper acute inpatient prevention, stroke rehabilitation and community reintegration
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So, I'll miss you more. Can I interrupt you a minute? Sure. So what
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you've, I mean, it's incredible what you've done, what you and your whole family have done there, it's incredible, but so basically, they didn't even recognize your talent and ability to begin
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with, it took you a great deal of time and patience to get into the system, which is the success sector, which you were going to benefit And then you got the TPA, or you got
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a drug that would be thrombolytic, and you would get that going. And then you had to - you'd develop this set of guidelines that you were going to use.
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And you were able then to get some help from my people who were private donors, I assume, and they were - and that was helpful. But you said one thing that was really important, And I think that
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people listening to this want to know this. is you said, well, we use social media. How did you communicate your message to the people? I've been to Pakistan. I mean, the streets are filled
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with people. I'm not sure how many of them read with the literacy rate is. So you have to communicate with them somehow. I mean, this is not just a one sentence summary. I mean, this has got
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to be a major hurdle to get over to educate people to say, don't stay at home, go to the doctor, come to the hospital, the things you can do for stroke. And the other thing is I'm sure you are
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arguing against old habits and old traditions, which where they have a stroke, there's nothing you can do for. So I mean, in a couple of sentences, you
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cover a lot of territory that's very complicated. Do you wanna expand on that a little bit before you go on, or are you gonna do it later? No, no, I can do it right now. So Dr. Asman, I'd like
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to add one couple of lines before that. So what Kasim went through
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was this is an incredible journey, what he's not that he's my brother. I say this to the top people in this country who interact with us, and I had a different start, and I'll tell you when we get
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to my side. But what he has achieved, just to tell you, comparing with US, US is not even 400 million We are like 370 million, maybe, in US. Punjab, where Kasim is leading the Punjab Stroke
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Initiative, he's covering 160 million people right now, with 18 centers and maybe more 27, I think, the target is. But till he came to the public sector, where our father had started in 1960s,
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1966, he was working through the army institution, which was CMH, which was a single institution at the end. It was in their favor, not for it to, they wanted him. They didn't even allow him to
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do intervention there. So he scaled it up to a level which nobody in the world can do it, in my opinion, as regards stroke and intervention, what he's doing. And I'll show you some of those many.
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So Kasima, let you continue.
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So thank you, Asif. So Dr. Asif, like, so social media. So my target on the social media was the health department So all the contacts that I was making in the process, like I kept their
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numbers and then the doctors. And my, when I talked about the physicians, I was concentrating more on the Lahore area only, because obviously the center that I was working and trying to do the IV
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thrombolysis program was in Lahore. And that was a first and the only center at that time doing IV thrombolysis in the country in public sector. So I'm not talking about the private in the public
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sector So whenever we had a case, either a good outcome or a bad outcome, majority of the time and the things were good outcomes because we were very selective initially. The first 20 cases that we
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did with the TPA, we were very selective, we wanted to have good patient, we wanted to build up the conference of the neurology residents, we wanted to build up the conference of my other
19:18
colleagues in the neurology and obviously the referring physicians. So we would make small videos like one or two minute videos and send them through the WhatsApp to the contacts and that's how we
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were propagating. I tried to reach out to the media outlets but unfortunately if they were kind of from my patient or I had some kind of that link, they invited me maybe very few times for a few
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minutes talking those times but it wasn't working that way because at the end of the day, they always wanted some form of like the
19:57
money. There was a fee associated with it if you want to do highlight, even though this was. a life-saving program and a community-related program, but it wasn't selling in the media. So we
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relied on the most cheapest one that was the WhatsApp. And that's how we started doing it. And it took us two years for the government to actually reach out again and then saying in 2023 that, you
20:25
know, let's replicate and we'll give you the initial seed money And that's how we converted a philanthropy into the public funding. So I hope this answer is like what you were trying to - It's
20:39
terrific. Also, do you have any comments? 'Cause you saw this develop from the very time they came back and the time they were building this. I think people
20:51
can underestimate. I'm glad I said for me it is, and I'm glad that the committee's talking about 160 million people with nothing to begin with. And within a few years, he was able to get this
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going. Any comments you had about what went into this story? It just reminds me
21:13
what Professor Bichiran went through
21:19
as he turned back from UK to start neurosurgeon in Pakistan. There was only one other neurosurgeon who wasn't very active in education. He was
21:33
trying to provide care to, he was in Karachi. Lahore, which was at that time, combined
21:45
province West Pakistan.
21:49
They told him that there was no position available in Lahore or him to practice neurosurgeon So he was given a position in Moulton, and he had to struggle through finding the operating facilities,
22:11
trying to educate people, you know, he had interest in addition to general neurosurgery, in stereotactic neurosurgery, and Parkinson's disease. So
22:25
I remember that
22:28
he was the first one to get a CT scanner
22:32
in 1978 and a few times, I accompanied him to go to the government offices and they would not approve it, even though it was through a grant from Sweden, was not even the money that the government
22:48
was spending. So those are the challenges and, you know, I have been encouraging, both Carson and Arsev,
23:01
stay steady and keep working and ultimately you become successful if you are sincere and working for the public and they're doing just a tremendous job. I understand. And Dr Asman, let me, let me
23:19
add a few. So when I moved in, Gasm had been, he moved in 2012. I moved in end of 17. So like Dr. Malik mentioned, neurosurgery had, they were like 250, 300 neurosurgeons by then already.
23:34
But there was no neurology, stroke intervention, forget about intervention. Well, when I came in also, I joined the public sector and Dr. Gasm Malik, I'm thankful to him because I've discussed
23:50
with him so many things. Even to a point that when I joined the dominant sector, it was such a pathetic I would be operating in the same condition where my father had left in 1990s. That I said,
24:02
I'm going to leave. I'm going to resign because this is not hard. And what do we do with two acoustics, five centimeter, with a great five CP angles, and a couple of hundred aneurysms, which are
24:15
being
24:17
taken to nobody's taken care of them. So he said, you do your job, just stay in there. He and my wife, my man, and they said, just give it a week, maybe a month. And I think eventually, I
24:30
think that's the best thing that happened. I did not resign. And my staying inside, if I had not stayed, Carson would not have survived or gotten in, to be honest, right? Because we made
24:40
context to a point that from the lower person to the top of this country, everybody eventually gets to us. And by the way, I just messaged my wife, my man, and to come and see you on video,
24:54
Today, Kasim wasn't there, but I was with our time with you because we all owe it to you to be getting to where we are. Of course,
25:07
you pick different people as you go and you learn, but you learn to swim, but somebody has got to give you a platform to get in. But today, I was fortunate to be involved
25:22
in a blind school auditorium opening, which was, in fact, opened by the same person who's going to be inaugurating our father's book on the 20th. Say it, Barbaralee. He's 99 years old and eight
25:39
months old. So you are a spring chicken in Dr. Aspen in front of the way he is. And he's the founder of all these, you
25:49
know the large business empire. as well as the lambs, Lahore University of Medical Sciences, what are truly
25:58
gifted? He's been gifted recently a couple of times by Harvard and all that. So I think if you keep on it, and now, by looking at you and Gauss pilot today, we have been revived also. And so
26:15
we'll continue this journey and then tell you our side
26:20
It's terrific. I think there are a couple of points that I want you to go out and consume. But one is there's always a silent person in the room. He's always been that way. That's Gauss.
26:33
And he was a real rock and a really important person. And Henry Ford, we drive together to work in the morning. We talk about all kinds of things. He's just got a wonderful soul. And he's
26:48
continued on, and I'm sure his help has been very invaluable. And people like that don't get enough credit. And the other thing is you guys have all overcome what are incredible obstacles. This,
27:04
we do a grand rounds with Sub-Saharan Africa. In Sub-Saharan Africa, there are one billion people, one billion people in 50 countries And they have different levels of accomplishment because the
27:21
same problems you have. And now we've had our, we're gonna have our 16th meeting, tomorrow, grand rounds, it's been going on for over a year. And I've gotten a lot of participation in it, but
27:34
it isn't an easy job, isn't that's the point I wanted to come out from what you were saying? 'Cause then it is not easy. And it takes a lot of persistence, a lot of. a lot of. help getting to
27:49
the goals. And that's why I wanted you to bring it out a little bit so that if this doesn't fly past people and say, well, I'll just go out there in a year from now, and I have a stroke center.
27:59
It doesn't work that way. And so I'm sorry to interrupt you for this, but why don't you go ahead and really appreciate that, okay?
28:10
So this is how then we decided to replicate the initial program So since I already come across the major problems and what I was facing when I was making the first center. So the couple of things I
28:25
wanted to highlight was that I wanted something where I could bypass our local hospital administration, especially the finance department and the administration because what happens is that when
28:37
you're working in a public sector, if you're the head of department, you have a particular plan, you will reach out to the administration, They will first approve it. then all the paperwork will
28:48
go to the health department and then the communication will go in fourth. And you can, if you don't follow on both the sides, the project will not fly. So I had already learned my message, my
28:59
thing like in the first two years, so that's why I went straight. I restarted with the health department, they refused. I didn't stop, I just restarted with the donor and thought, you know, why
29:08
don't I produce results? And that's what actually my late father kept on telling me when I came back in 2012, because I was getting frustrated because near intervention was not at all developed the
29:22
way neurosurgery was. And I was, no one was giving me the access to the cath labs in the private sector
29:29
wasn't in the public sector either. So there were no distributors, no companies like Metronic or Microvention and none of those resources were existent even in the private sector at that time. But
29:41
he kept on telling me one thing that Kasim just produced results, show good patient outcome. Just like Dr. Wasser just wanted to highlight it. And that's exactly what he was telling me, that
29:51
Kasim just see patients produce results and people will just follow and then they will know. So this cost center was created in services hospital hall. The cost center was the idea that all the
30:05
funds for this project will come to this cost center directly The hospital administration will have no saying over it. And the end user, that is the physician, will decide what they want to
30:16
purchase. And in our case, we wanted to purchase thromboletics. And this cost center will just be the distributed center as well for the rest of the province. Wherever we go and open primary
30:26
stroke centers, the cost center will be the point of communication for that particular primary stroke center and it will not be their local administration or the health department So I was the bridge.
30:39
between the primary stroke centers that we have now created and the health department, all the problems, HR, money, whatever it's needed, actually come through me, and I'm the one actually now
30:50
trying to streamline, like, you know, how to help each center and how to grow the process. On the left side, you will see the primary stroke centers. So our first emphasis was to replicate as
31:01
many primary stroke centers as we can across the province, because the major hurdle that we were facing even at our center in Lahore was that people were coming so late. We started with the hyper
31:12
acute therapy. We tried to do the awareness through the social media, but it was not hitting the projected target. So now you have a drug, you have people trained, but people are coming late.
31:25
And we were getting patients six hours or 10 hours away from the cities from Lahore. And even by the time they would land over here, they would out of the window for the IVTPA as you know the
31:35
windows up to four and a half hours. So the first thing was to open centers in the smaller cities, take the drug over there so that they can be administered over there. And only the large vessel
31:47
occlusion patients eventually start coming into the urban areas. So
31:53
now creating the primary stroke center brings along the first part that you need to have in a awareness. There is no point, it's a struggling to ask that you bring in the hyper acute therapies or
32:04
you train the infrastructure staff, but then the people don't know what you are offering over there. So what we did was we kept with the global stroke awareness sign. So this is the fast acronym.
32:16
So we translated that into Urdu. We kept on, we made a Facebook page, which is calledProvision Stroke Management Center. We started posting all of these things there, started circulating, and
32:27
our biggest social media platform right now is either the Facebook or the WhatsApp
32:34
So,
32:36
of things about the awareness. So in the developed world, you will see that you will come across so much literature on the fast knowledge, stroke of illness knowledge, children, stroke definition.
32:47
So you will search any of these categories and you'll come across papers after papers. So but what happens in the low-median countries? You do not get any funding for awareness. When I went to the
32:57
public for this program and I said, you know, I need an X amount of money for the awareness, they said, oh, doctor, like I would, we would suggest, you know, stick to the medications. Maybe
33:08
the next day, we'll give you some money for the awareness. So again, a roadblock over here. So the other thing is that Pakistan is a country where there's a two-tier system and I'll explain you
33:19
quickly what the two-tier system is. When you are in high school, we have all levels, which is British education degree coming from the Cambridge or the local degree called Metric. when you clear
33:38
that you go into the high school and then you do either the FSC or what we call as A-levels. I would say that the people who can afford the private schools, they are able to do all levels in the
33:51
A-levels. So there is again now a dichotomy and the two-tier system starts right from your basic education. When you want to come into the medicine, you come into the medical school, now you have,
34:02
and then you go into the post-graduation, then you have another two-tier system One is called University of Health Sciences, the other one is called College of Physicians, Surgeons of Pakistan.
34:10
Now, two different standards of training. Again, at that part of me, you cannot standardize. And then the other problem, which started again, probably 15, some years ago, was that the
34:25
cardiology started to create their own institutes across the country. And then it became like, you
34:31
know, a standard that, you know, every city or every province started to follow that platform. what over the years happened was now we have two emergency systems, one for cardiology, because
34:41
they have separate institutes where they are just doing cardiology and they have allied positions, but there's nothing allied there, meaning no medicine, no surgery, no neurosurgery, and you know
34:54
that all of these patients can also have complications. So in a separate ER, and they blossomed over the years, and then the rest of the body has general hospitals, and that's where the emergency
35:06
systems get created. Now when you have a country where you have a literacy rate of around 60, how do you go in a community and educate them about stroke awareness and which emergency system to use?
35:18
Because every time they have a problem, they think it's a heart attack, even when you have a stroke, full-fledged stroke, they walk straight into the cardiac institute, which is right next door,
35:28
and a couple of hours later, the cardinals will say, Oh, you don't have anything cardiac. They are not even trained to identify stroke as well. And they will say, go to the next door, you need
35:39
to see a neurologist. And by the time they will land to the hospital, they're out of the window. So
35:45
this is what I was saying, that if you look at the literature of all the people who come with acute chest pain, it's only a 10 with the non-injured visits. And
35:56
of those people who are admitted, only 25 will have a diagnosis of acute converse syndrome. But then in Pakistan, you have these huge cardiac institutes with emergencies and all the resources going
36:06
in and infrastructure, HR, and then the rest of the hospitals are totally separate. So this brings in the territorial gains. This is where the multinationals also, I would say, that played a
36:18
little bit of a dirty role in our part of the world because what they did was that when I am in US and I want to do neuro intervention, I will have to do neurology, neurocritical care, basket
36:31
neurology, boards, fellowship, and then two ways of new intervention. So it's a eight years standard training program, whether you're coming from neurosurgery, neurology, or radiology, but
36:39
what started happening here was that these multinationals through their distributors will fund for a two-week course or for a month on simulator, send them to you somewhere in Europe or lately I'm
36:53
also hearing places in the US. So just to see how they're doing the stroke, they don't have any hands-on experience and then come back and start open the shop in your own cardiac institute And this
37:05
started to create more problems because when you have worse outcomes or bad outcomes because people are not properly trained, the public awareness and the public conference starts dropping and so
37:15
does the referrals. So again, another challenge that stems in. So this is something that I now, you know, I'm very vocal about these things when I go to the conference and I have these battles
37:28
with the cardiology that, you know, instead of having a combined multi-disciplinary institute, This is a problem that we are now facing. in our part of the world. So unlike the developed world
37:39
where the ratio is 80, 20, 80 is skimmick and hemorrhagic. We actually are 70 and 30 and some of the literature now it's coming actually that is skimmick stroke is 65 and the hemorrhagic is now
37:49
exceeding to 35. And the reason is we have more diabetes, we have more hypertension, we have now more drugs problem because of the brand war and subsequently the years that I've been following. So,
38:03
and the lifestyle has changed A lot of westernized diet and those type of things fast food. So, and then hepatitis and those type of things. So, all of these things contribute directly or
38:15
indirectly to this stroke prevalence. So, like I told you before, how do you educate the people when you're going and creating these centers which emergency system to use A? Now, we have for the
38:28
first time like a dedicated public, similar to 911, we have 1122 in Pakistan, which has now expanded to
38:36
all of the country. But then, because the population, the resources, there is a lot of philanthropic support coming into the healthcare as well. But even though that is helpful, but
38:50
when you're trying to standardize something, it doesn't become like a
38:56
very helpful, because again, how do you train that philanthropic EMS system, which is, you know, there are so many in a city, how do you bring them into one standardize umbrella? So that
39:07
becomes a very challenging task as well, how to educate the people which ambulance to use and where to come. So this is how I've been adopting right now, like, you know, take the guidelines from
39:20
abroad, but deal with the problems locally So we came up with our first version in 2025 where we published all the standards for stroke care ESMC. The second was published in September 2025 and
39:34
being co-operated, both skimmick and hemorrhagic strokes. IV thrombolysis, neuro-divascular primary stroke centers, comprehensive, everything is contained in this book. And as part of our
39:46
manifest goal that you know, we're going to standardize wherever we go to
39:50
different cities, we're going to try to standardize even the order sets are the same. You know, if you have magic stroke, you can just take the order sets from this booklet, put in your hospital
39:59
logo and then follow the same so that the care is the same, even if you have a hemorrhagic stroke in Lahore, and you have a stroke, let's say in Cial Court,
40:10
and they're using the same booklet, it's going to be the same standardize protocol, and also helps in the training of those physicians in those hospitals. So the first, we are still in the first
40:24
blocks of stroke awareness since we're We were not getting any money from the government, so I reached out to. another giant pharmaceutical company in Pakistan. And I said, you know, why don't
40:36
you fund me for the video? Because we don't have anything in our language. We, you know, just copy what's being posted in American Stroke Association. We need something in the local language. So
40:42
we brainstormed and then since we use the acronym FAST and for the
40:48
Pakistan, the most favorite game is cricket and we have fast ballers. So
41:01
we came across like a scheme, you know, where we will link the cricket match, a fast baller playing bowling and then link it with the stroke symptoms. And I'm going to quickly show you the video
41:13
as well.
43:16
So this video is a very powerful message, how to recognize a stroke, what to do, which emergency system to use, and the timely treatment intervention and then the outcomes And as of this month,
43:33
this was released in August on August 18 of this month. It took us little around six to eight months to
43:42
make this video, get all the paperwork done and everything so now from this month onwards we have now signed MOUs with the leading airline, local airline. It's a cineplex theaters. So they're
43:56
going to be displaying all of these videos, a few banks. So it is going to expand our network of awareness. And we allowed them at the last four at the end of the video, you can put your own logos
44:10
and whatever, and we have no legal binding on it. So this is going to be how the latest part is going to come. Now quickly moving it to the dispatcher, what we did was in the same booklet, we
44:21
signed an MOU with our 112 main ambulance and we have been going there. I started going to the main headquarters which are based in Lahore, a very nice training ground for the EMS,
44:32
the
44:34
EMTs and all of those people involved. So we created these special booklets for them and the order sets so that they can also be aware and how to recognize the stroke, standardize the recognition
44:48
and then use a triad system when they're transporting the patients and which hospitals they're going to bring the patients. They're not going to go to every hospital which doesn't have a stroke
44:58
center. And as part of the pre-notification system which we still don't have, so we also started training them and they were already doing this thing that we said that you are going to draw the
45:11
blood samples because we have shortage of nurses. majority of the public sectors in the ER because the ERs are so heavily busy. So if you draw the samples when you're bringing the patient in and you
45:23
pre-notify us, it will save a lot of our important time probably around 10 to 15 minutes. So and this is again learning from the pre-order, you know, when you're going to the traveling, you can
45:37
pre-order on the airports, your food is ready, and this pre-notification system in the hospitals is pretty much the same thing and that's what we have been now doing and using the pre-notification
45:49
awareness things with the 1-1-2-2 and this started taking place as of March of this year. So how to integrate now 1-1-2-2 with our stroke centers, we don't have the pages anymore, we don't have the
46:03
high-tech, you know, the software that The Western countries have linking the ambulances of service with the hospitals. So we decided to have WhatsApp dedicated, WhatsApp stroke numbers for all of
46:14
these primary stroke centers. And we entered those numbers into the cold centers of the one round two to in every major city where the stroke centers were being created. So they called the WhatsApp
46:25
number directly from their own cell phones and said, Tell us that we have a patient coming inand give us a brief history. And this is a work in the progress. A lot of work needs to go, but
46:36
obviously this whole program started was conceptualized in October 2023,
46:43
but actually it became functional in April or May of 2024. So a little over a year now.
46:50
So the pre-notification, and this is how we do it. We have these WhatsApp numbers, and we don't share the number with the public. Only the institutional physicians know about it and the local
47:01
emergency 1122 call center knows about that number And that's our way of communication to win. in a low middle country, any political crisis brews, and they shut down the telecom sector so that
47:16
they can't spread the information, they don't want the public to know anything. All this, what we are doing at the health on our end gets really affected. So this is another major obstacle in our
47:29
part of the world because any political crisis or anything, the instant knee-jerk reaction is that shut down the towers and then the communication barriers starts coming in. So quickly moving to the
47:41
hospital site. So
47:44
Dr. Osman, I didn't care about to have these fancy ER stroke-based things. So based on wherever the city was, based on the local resources, we gave them a genetic that you can build from anywhere
47:58
from one bed to four beds of stroke beds in your ER That was also part of our technique. to improve the awareness in the emergency systems, emergency rooms so that you have a dedicated stroke base
48:12
listed over there so every time patients are coming in, they are seeing that there is something called stroke there also and then have a stroke unit. Anyone who gets a thrombolysis goes to a stroke
48:22
unit for the follow up. So quick word again on the cost center. What does a cost center do? The cost center procures the thrombolytics for all the centers, distributes, maintains a quality So
48:35
Borhanger and the World Stroke Organization were kind enough, and they gave us this rescue online platform. It's a very nice data collection. We don't have any national data or a promotional one in
48:52
Pakistan. So this is our way of trying to build up a stroke data, at least from the public sector. So rescue is a pre-made software cloud-based Every patient who comes to these primary stroke
49:06
centers is getting the IV thrombolysis, is listed. Their outcomes are listed up to three months, and we can do research, whatever, and we can monitor the quality and all these things. And I told
49:18
you about working with other associates. So as of today, we have 14 centers. The one listed in the two listed in the yellow, actually there's only now the two listed in the yellow, actually are
49:32
what put on hold a month ago because their human resource got a little bit disturbed. But the rest of the 14 centers are working. There is four, these are 14 primary stroke centers and one
49:44
comprehensive, which is a Punjab and neuroscience, which are simple, so heads. So this is an important slide. You can see that the population of the country is 250, 51 million, Punjab is around
49:56
130 million So as of these 14 centers are only covering 305 million. and we still have more centers to build. But at least it's a good start. First time anyone in the province is doing it, at
50:13
least in Punjab, and it's not being done in any of the province in the country at the moment.
50:19
So, just to give you an example, this is a data that was shared by BI and Martindam in 2023. You can see in Punjab in the red in public sector, only 18 patients got TPA out of the total 205 and
50:35
out of those 205 majority were in the private sector. They were getting the TPA's, but in the public sector, only 18 patients got TPA in 2023 when we did not have this program. When we started the
50:46
program, this is what happened. So, we delivered around 570
50:53
miles of TPA out of those 511 were used We treated 600 patients and
51:00
instantly within a year, this result came out. we went from 39 percent utilization in three months to almost 90 percent of TPA, which is far higher than reported in any developed country at this
51:14
point even. So this is an effect that just came out within a year. But the another important thing that came out was this thing, that out of the 600 patients that we treated, 463 were those
51:28
patients who were treated outside the Lahore. Previously, all of these patients would be coming to Lahore to seek care for their loved ones. But these 463 saved a lot of money trying to arrange for
51:40
the transport to Pakistan and saved a lot of major morbidity and mortality by just giving them the drug in their area of residence. So this was a very dramatic shift that we started noticing. So the
51:54
health department last year invested 135 million into this program. I did
52:01
thrombolysis and you can see the utilization rate.
52:04
And this year, our target is to expand from 14 to 24 centers. We are going to be adding on top of two pediatric centers based in Lahore, because in those two pediatric centers, at least one to two
52:19
pediatric children are coming with strokes, which are potential candidates for thrombolytic therapies. And if we are able to achieve the 24 centers by the end of this year, which are in calendar
52:32
year ends June 12th, 2026,
52:35
we'll be covering close to half the population of Punjab at that time within two years.
52:42
We are going to be switching to Teneti Place. The US has already switched, I think, somewhere around 2020, 2021. Park Sun is now the second country in the region after UAE this year to be given
52:56
Teneti Place and the company's Boringa is going to graduate a place at TPA And the reason the Pakistan was chosen was because of this program. And that's a fact, because that's what they said, that
53:07
they looked at the performance in the public sector, how we were doing, and they decided to choose Pakistan, which actually on the list was five years down the line, but they decided to bring
53:16
Pakistan after UAE, because of the stroke incidents and the requirement for the thrombolytics. A quick word on the comprehensive stroke center, this is where I signed the MOU with the ourselves
53:29
institute because they had the biplane and geography, they didn't have an operator, it was installed
53:36
in 2023. I'm based in another medical facility which by driving time is close to 20 minutes, one way depending on the traffic. So started the program in 2023 at the Punjab and St. Louis science,
53:49
which previously was called the Heart General Hospital, which was, as you know, our late father had the foundation stone to lay out over there and Dr. Wasmolek was also there And I'm just going to
54:02
be sharing these numbers that.
54:05
In 2024, we did 511 diagnostic and 223 therapeutic. And this institute actually is kind of the mucka for hemorrhagic strokes, aneurysms, ABMs, fissures, trauma. You name it, and it's there,
54:21
adults and pediatrics. And it's so much volume that you just cannot handle it. But all of these patients have been treated without any charge Everything was funded by the government. A lot of
54:35
credit goes to ASEF also for getting the funds in timely fashion. And for next year, our funds have increased. So this is another part of the PSMC Association with them to build the campaign stroke
54:47
center and stop over here. So in July 2025, the Punjab Institute of Neuroscience became the first center in the country to have the first accredited stroke near intervention fellowship.
55:03
funded by the government. And we had started doing the fellowship on honoree basis a year, two years ago, since 2023. And it was funded by the same person which Arsev initially mentioned, say
55:15
Barbara Lilly, his organization, I really give him a lot of credit and thanks because they were the ones who initially gave us a seat money to start the fellowship. But after two years of showing
55:25
them, showing the government the outcomes, they decided to approve the fellowship And we are taking one neurology, one-year research we resident every six months. And it's a two-year training
55:38
program accredited so that they can work anywhere in the country. It's not going to be just like an experience certificate.
55:46
So the things that we were learning from the Comprehensive Stroke Center was the value of the time and the infrastructure. One of the things that we really lack in this part of the world are the
55:58
engineers, are the architectures who design hospitals. especially in the public sector. And because the infectious control things, how to move the patient between the departments, especially the
56:10
emergency OR, that those are the things that are not taken into account for. And this, the medical architecture field really needs a lot of investment as well. So just to give you an idea, since
56:24
we were short of the trained neurologist, so I wanted to have more people 247 in the emergency room So we took this institute, the Punjab Institute of Neuroscience as our pilot project area. And we
56:36
just like in US, and I learned so many things from US, I continue to do so. So we developed this program called Snap, Stroke Nurse Advanced Practitioner. We trained them for three months,
56:47
trained them how to recognize a stroke, how to read a basic CT, how to administer IVO thrombolytics, everything a neurology senior resident is supposed to know, we trained them and we put them on
56:59
three shifts. 247 in the stroke emergency rooms in the emergency rooms in the stroke pace so that we have a dedicated face in the stroke pace and patients can be recognized very quickly because
57:11
Pakistan still is following the old path of the emergency system. We don't have our own emergency emergency program. So historically anything medicine or medicine allied will go to the medicine
57:22
emergency and then anything surgical will go to the surgical and then they will be filtered into orthopedics or neurosurgery and that actually creates a lot of delays for the patients. So we wanted
57:33
to overcome this thing. So this is now a team of these nurses who have been trained the two new fellows who have joined us for the fellowship.
57:44
And just to give you an idea, in February 2024 to March 2025, that's almost a year. In the same emergency room, same stroke bay, they were only able
57:59
to filter
58:01
large vocal occlusion out of the 20 patients, nine cases. For last one year, we only were able to do thromvectomies in nine cases, but we were doing left and right oilings, tendings, like I said,
58:12
the hemorrhagic stroke volume is far higher than the skimmick in pungemants and neurosciences. But in
58:17
just five months, when we've stationed these nurses, you can see that they were able to identify 27 large vessel occlusions out of those 20 benefited. So this is how the change came about just by
58:29
training these nurses into the basic stroke large vessel occlusion training pathways. And you can see the difference, even for the IV thrombolytics in nine months, they were able to filter in 56
58:44
patients for IV. And in five months, we were able to do 50. So again, the major change, but just training these nurses instead of relying on the neurology HR
58:57
So, this year. We decided to just last month
59:03
we are going to be launching our diploma. It's going to be funded by the practice foundation, the same SEGA Baba relief that Asa mentioned. His foundation has been kind enough that they are giving
59:13
us the initial funding for two years. We are training, we are designed to diploma for one year. We're going to be training 30 nurses now, which are going to be a hybrid type of nurses working in
59:27
the stroke base as neuro-ingeography nurses
59:33
after 2pm and managing the patient in the ICU. So these are going to be the nurses which are going to be working in three different domains and be trained and certified.
59:45
So a quick word on this year, initially we started with the target of 60 minutes, door to needle time. Now this year, our whole whole campaign is now focused on. to reduce the door to nearly 30
59:59
minutes, especially since now we have connective plays and you just have to give a bowl of struct for connective plays. For the, and we now introduce the hemorrhagic stroke also because the easiest
1:00:08
thing to do for hemorrhagic stroke is to give them timely anti-hypertensive, which is ignored so easily everywhere. And this is going to be another focus for us now as part of the PSMC initiative
1:00:21
that we're going to be going and doing trainings with the neurosurgeons as well And the emergency rooms and train them that you see a hemorrhagic stroke, how to manage and give them these very cheap
1:00:29
IV anti-hypertensives and target the blood pressures to reduce the morbidity.
1:00:36
Coming to the patient timeline thing, one of the things that we learned in the Comprehensive Stroke Center was just to move that patient that we recognize for the large vessel occlusion, the
1:00:46
emergency room is located around 150 meters away from our cath lab. But in order to come to the cath lab, You have to wield the patient on a stretcher, which is in an open airways. The family
1:00:58
usually pushes the patients, brings them to the basement. You have to wait for the lift, which is heavily crowded, busy 247, and then come to the basement. So we were losing 45 to 60 minutes,
1:01:10
even after we had identified the patient, there was a large vessel occlusion. How do you overcome this thing? You cannot build a new building within 24 hours. So again, came up with an idea to
1:01:23
convert, come up with these e-stroke ambulance for the local hospital things. We again reached out to two or three donors, imported this golf cart from China. It took us four months to import it.
1:01:39
A local company that actually
1:01:43
makes the ambulances for the governments across the country was kind enough. And they refurbished this golf cart into an ambulance. So we take the patient from their emergency room, our fellow who
1:01:59
is in training fellow, a doctor actually is a driver, our nurse and the driver, when they get a call that we have a large vessel occlusion, they open the cath lab, they take the cart out while
1:02:08
the other staff is setting the cath lab up, they go and bring the patient in safety and with respect from the ER. And then under the monitoring condition, they bring the patient to the cath lab
1:02:20
straight. And with this, we have reduced the 45 to 60 minutes to 15 to 20 minutes. A simple initiative required money and just a little bit of how to do and bring the other stakeholders on the same
1:02:34
page. I'm gonna quickly go into the last part. This is right now, the services hospital order is probably right now. The only, this is where I'm stationed as a professor of neurology. So we
1:02:48
converted our major ward into a rehab center Again, the. got some seed money from the government and from the philanthropy to build an inpatient rehab. So this, you can see the stroke patient
1:03:00
numbers from 8 am. to 2 pm, which are the offshore working hours. Each patient gets 15 minutes of physical therapy twice from 8 to 2 pm. Even on Sundays, which
1:03:14
is a local holiday here also. So seven days a week, they get two sessions when they are admitted to our unit And this is another thing which now I'm advocating to the government that we need to
1:03:24
replicate to all the primary stroke centers so that they have their own inpatient rehab because as part of the initiative for the global stroke recovery, the World Stroke Organization this year and
1:03:35
last year added to their agenda that the stroke rehabilitation and the community reintegration has to be part and parcel of the stroke programs. And this is the rescue, which I was talking to you
1:03:47
about the cloud-based software that each center now has. They quickly enter the data and each one of us can see the progress every center has a number. They don't we don't see Only I know which
1:04:02
center has which number but the rest of the centers don't know that which Everyone is given a different number
1:04:12
So this is a summary that I want to share you that we the health department and philanthropy a total 20 million rupees invested into Punjab stroke program both the primary and the comprehensive We
1:04:28
were able to create primary stroke centers comprehensive stroke centers in first year treated Our expectation was 300, but we ended up treating 600 patients more than a thousand got near a Devasker
1:04:39
treatments created a Predictive fellowship training for neuro intervention and the awareness campaign the video the first one that came out and I told you that now it's going to be
1:04:51
hosted in major businesses. And we're just signing MOUs with them because it's far more cheaper than trying to get the money and trying to do the media and pay them the media houses, the money,
1:05:03
which I think if you can just reach the public through these banks and the cinema theaters and those types of things, it is far more effective that way also.
1:05:14
So I'm just going to, this is, I don't know if you're talking about movies, but this one just came out this year, had very strong some dialogues. And
1:05:24
one of the things that I really like was it's not absolutely about the money. And the same passion here that, you know, it's absolutely not about the money. It's just pure stroke, wanted to do
1:05:37
what you, Dr. Ross, and everyone has been instilling in my mind that when you go back, you need to serve the community and, you know, get the care up and going. the people and I think that's
1:05:50
the motivation that I inherited from my parents, my father and from all of you and that's what is a driving force. Thank you so much and this is now the first slide that I showed you that now we
1:06:03
have the manager or the champion as a BSMC dealing with the funding part, the social mobilization and the technical support that we have now created on the same grid that I showed you in the
1:06:15
beginning. Thank you so much That's an outstanding job that you've all done there. And what I'm going to do, I have a whole bunch of questions here for you. But what I'd like to do is we'll come
1:06:30
back to that afterward if you have time. But I think what you're presenting us consume is
1:06:38
an extremely well-conceived and developed plan that can be utilized across the world in many countries. And I'm. I'll talk to you about it at the end, but I'm sure people want to hear your
1:06:53
presentation. They want to probably come there. They want to have some way to become educated to do this. Obviously, you're saving lives, and so we'll get into that and so forth So what I'd like
1:07:06
to do is I'm going to do a video.
1:07:18
A Seth Beshear, who is one of the three presenters today, is a diplomat of the American Board of Neurosurgery and now Professor and Chair of Neurosurgery and the Executive Director and Dean of the
1:07:33
Punjab Institute of Neurosciences in Lahore, Pakistan,
1:07:40
an institute he and his family have founded. He was formerly a professor at the JFK Neurosciences Institute in New Jersey and the reconstructive and spine neurosurgery section, neurosurgeon and the
1:07:54
JFK Neurosciences Institute in New Jersey. His email is listed below his picture.
1:08:04
Okay, so just to give you, so I'll give you a few over because I was just invited to speak as one of the honoured guests at the Apla meeting two months ago in Dallas. And this was addressing almost
1:08:19
4, 000 physicians of US, Pakistani descent in the US. So I gave them what we are doing and where we moving forward. And what these last seven, seven and a half years of my journey have been,
1:08:34
which has been shorter than Qasams. But fortunately, I was at the platform, which for neurosurgery, people knew what it was all about, thanks for a father, as well as so currently, I'm heading
1:08:46
the dean of Pakistan's neurosurgery. I'm also the president-elect for the Pakistan Society of Neurosurgery, which was my leg, as well as Jim Osman and Professor Bashid, and all of them founded in
1:08:57
the 1980s. My job, I take it as, after this point, leading this institution, which is the institution in the world as I take it, is I call myself a facilitator in chief. I don't call myself a -
1:09:13
I like to ensure that anybody who wants to do something gets to do it. And
1:09:22
let's see moving forward, we'll be from here. Okay. So talks of a surgeon who probably has learned a lot, but like I always say, there's always much to learn. Physicians as leaders, we've
1:09:36
developed a lot of leaders here also. It started with 1964 with a father, Professor Bishiramal, who came back to Pakistan, and then he started in Nister, and then this is where he started from.
1:09:49
Nister, Moltan, King Edward in 1966, which in fact, at that time, like Dr. Malik mentioned, he would not even be offered an honorary job. So I finally had to go to Moltan, and he started
1:10:03
there and moved, and now this is what is the horror journal hospital has been converted into a
1:10:12
autonomous, this is a history of Pakistan neurosurgery. started with Professor Juma, Dr. Khazi, Professor Bashir Ahmed, Iftakar Ali Raja from the 1960s when he came back, Dr. Ayatwati, who is
1:10:26
still living, and many to follow after that. Parks and Society of Neurosurgery was set up first meeting in at King Edward in 1987. Professor Bashir was the first president, first WF and SNT
1:10:42
meeting where all of you were there, Jim Osman as well as Waspalik, just to give you a recap after almost, I would say 40 years, and recognized a membership in Barcelona, and I'm very, very
1:10:58
fortunate that in a month's time, I will be the president of the same society. I'm the president-elect currently. You know, I show this picture to every forum, by the way, and it turns out it's
1:11:13
Jim Osman, Professor Beshear and Ghas Mahalik in the good old days and I think Armando Basso and
1:11:21
in the center at one of the WFNS meetings. This is where from 1985 to 2018, this is a 500-bit plus facility, which is out of that 450 are neurosurgery beds. This is one of the largest, if not the
1:11:39
largest, neurosurgical neurology neuroscience institute in the world. I think there's one in Beijing, which is bigger, a little bit about me. I don't need to go into the details, but started
1:11:55
with you at UIC in 1997, and it's been no looking back, trained at Syracuse, moving forward, came back in 2017 to date. One of my favorite slides, I think Pakistan needs this at every level,
1:12:11
starting from the
1:12:15
but everybody has a big ego here, less knowledge. And it's a 10-story building. It houses neurosurgery, neurology, neuro-radology. We run 10 11 operating rooms now, including with the cat lab,
1:12:29
which Kasem is running. And then over, close to 10, 000 cases are done. Almost 9, 000 elective and emergency procedures. Over 9, 000. We have a three-test LAMRI. This is a public facility
1:12:43
Everything is done free of charge. We have 45 neurosurgeons. In fact, it's over 15 now, 173 residents out of that 70-plus neurosurgery residents. It's home to everything we get to do in US,
1:12:58
except a few things which we do in the private sector.
1:13:05
The human resource is over 1, 300 people who work there that does not count. some of the security personnel and all that, which are there, and the budget, as we were trying to move the stroke and
1:13:21
neuroendovascular program, we had to
1:13:32
increase the budget to 33 billion, which is about over about12 million roughly. This is what we get to spend in a public sector facility We have a board of management, and this is one of the only
1:13:43
facilities in the public sector, which is recognized as a job health care facility,
1:13:50
which has passed the test with 94. This is how we operate. Can I have you go back to two slides where you were just slide before this one, yeah? That's right, okay Because I think that you
1:14:05
mentioned the private sector and this is the public sector. So I talked about the private sector at the end. And I know this was a, this is true all over the world. This was a very complicated
1:14:17
road to maneuver. And now what you've done is, you said before, your official father couldn't even get an honorary position in a public sector or hospital. I mean, that's how far you've come.
1:14:32
And so now you have this public sector, this is public sector, neuroscience.
1:14:38
Do you guys run this? Yes, so fortunately for the last few years, so I joined here as the professor, a lot of resistance at that time, but I became the Dean and the Executive Director of this
1:14:55
almost three years ago. And that's when we brought Kasim, we put in the cath lab in 2023. And with me being in charge, we just facilitated everything which needs to be done the right way. It's
1:15:11
all about begging the government. And I'll give you my resolution at the end because in this public sector, both Qasem and myself, you know what we get paid till about 3 pm, 2 to 3 pm. in the
1:15:23
afternoon. I started in 2017 when the dollar to be careful was 100 to one.
1:15:33
It was about1, 000 salary a month. Now it's gone down to 750 bucks a month So if we look at that, that's something which you cannot look at to even surviving. So in the afternoon, we found in was
1:15:47
pins, Pajamas to This two things.
1:15:52
neurosciences, which came up about a year before I moved. So I was able to become the director of that. And I stayed in there, otherwise these things would not have carried out. But there's
1:16:02
always a time to exit also. Like you say, you always want to exit at the top What we founded in 2020. a BNI, which is like a baro neurological institute. That's the private sector. They are two
1:16:15
tiers in this country. One for the private, one for the public. Public is totally free. Every implant, custom does, every pipeline that it does, every instrumentation we use. By the way, I've
1:16:28
made a couple of trips to China during this time. And if you have a medical screw, it's 1, 200 bucks in US. We get it for 30 bucks, because the same company is making in China, Kanhui And we
1:16:38
have direct account tenders with them through the government. We should do the same thing in the private sector. But after 2 pm, we go private. And that's at BI, which we are now looking to build
1:16:50
into a real large-scale hospital network also.
1:16:55
Moving forward, this is the same scopes which we use in US. This is how we teach. Like today, it was an operating day for Thursday Every day, six days a week. eight elective rooms are running.
1:17:12
And this is exactly the way we have all facilities, all microscopes, we have six microscopes, we have endoscopes, we have, but it is
1:17:24
a constant struggle. Like what the fund's casting talked about, I had to, for that endovascular stuff, with a personal connections, this is all, I don't think this is possible without what we do
1:17:36
in the
1:17:40
private sector, because all these people, starting from an average person to the prime minister, we treat all of them in the private sector. They don't want, they don't come to the public sector.
1:17:50
And this is the difference between 50 years ago and now. And this is based on a similar, goal is to treat the needy and poor, same as the
1:18:03
people who can afford. And we've been very fortunate to be able develop the system Uh, uh, from on the model of barrows and some of the slides that I got from Dr. Spessler also many years ago when
1:18:15
I was looking to move back. So Neuroscience Institute which is already made private and public, all these things philanthropy like Barbara Lisa Gassen had mentioned a couple of times. We're doing
1:18:27
all these things, you know philanthropy, sub-specialization, education and Dr. Aspen you'll be surprised to know that we have residents now rotating from US University of Missouri in fact October
1:18:42
20th when you when we had invited you also when we're doing the Congress. You know we have Mayo Clinic, we have Duke, in fact Faridish Arbelisk coming himself also, David Hassan from Duke. We
1:18:57
have Charlie,
1:19:01
Charlie from Big Four. Charlie Bridge. Charlie Bridge. Yes No, no, not Charlie Hives.
1:19:15
Charlie Branch. Charlie Branch is the North American president and he's been instrumental doing a lot of work in Africa and all that so we are going to, in fact, this morning I called Dr. Malek
1:19:28
and I said you have to be here because we are also inaugurating Professor Bishirama's book and Dr. Asman, we still have time. We talked to you about how we can get you on a flight to get here at a
1:19:40
short notice.
1:19:43
We founded a foundation also. This
1:19:47
is the same model where we are a US Medicaid charity care hospital. We are all, but the government pays for it. We are not allowed. Nobody is allowed to even charge 100 rupees to a patient.
1:20:02
Everything Everything is done free at
1:20:06
this facility. Funding comes from the back and then we have to struggling for two years. What we did was, you know, I was able to get at the funding for customs program added to our budget so that
1:20:20
we don't have to beg for it every year for the stroke program because we have to buy all these spoils and implants and stents and all that. So that has been now added into the pins budget for 2025-26.
1:20:33
This is the only way We just founded the editorial office. We donated it as a family. It's named Almas Bashir, editorial office after my mother. The auditorium at pins, LGH is named after a
1:20:47
father, Professor Bashir Ahmed Auditorium, which is almost a 500-seated state-of-the-art facility. We're doing all these things at the facility similar to this. We have our own journal coming up
1:21:01
We are
1:21:03
in the local journal and now I think close to a hundred publications have come up in this,
1:21:10
and for this coming World Federation meeting in Dubai, as well as the one in South Africa two years ago, pains was the highest number of stand-up talks from anywhere in the world. In fact, this
1:21:21
time, it's 73 presentations at World Federation meeting. So this is the difference which is happening academically in that. So every resident has to come up with at least one of the publications,
1:21:34
which modified the training program also. And now Cosm is now changing the -
1:21:42
this is the cat lab, which was put up. This is Siemens biplane cat lab, which Cosm is the director of this. And this started in '23 as I became the director for this. And now we have a listing.
1:21:57
This is a weekly since 2018 when I came in presenting MM was a no-no. Getting a post-operative CTE before my predecessors was a no-no. Nobody could get a post-operative CTE also. Every patient,
1:22:13
after every surgery, gets post-operative imaging within a few hours now. It's at the government expense, but this is the only way you can learn. We have a Wasting Prof program. Dr. Malik has
1:22:23
been a Wasting Prof. We have professors and all these coming from all over the world. We had a Vasto conference yesterday, all the cases for endovast, combined endovasto, just like you had Ford
1:22:33
and UIC. There's a Tumor board, there's a journal club with Aga Khan University. Arthur Anam and I, we have worked very closely. And somehow, Arthur says that you were able to achieve in three
1:22:46
years what took me 15 years to do. And I think one of the things was that I tried to stay within the system and work on the politics and not just speak against them, but try to convince them to come
1:23:01
on board and let us get into that but always keep.
1:23:04
your hand on the top leadership in the country also because, you know, you can get things done by just benevolence. You know, some of our visiting profs over here.
1:23:15
This is a weekly thing. You know, we've had, Suhil Mirza was the chair of Dartmouth. He's an orthopedic surgeon. He talked was fine. Hassan is coming again for this. He's the chief of pediatric
1:23:26
surgery at
1:23:29
Washington, DC. This is the Bishir Ahmed auditorium. So, Dr. Asman, you must be very pleased to see. This is, you see, all the pictures of previous shares, including if the Carmelik, and
1:23:41
this is where we do all our meetings now. Leadership, you know, I talk about this all the time. Muhammad Ali, I met as a student later as a physician also, but these are the things we try to
1:23:54
impart. Muhammad Ali Jinnah, our leader, Abbas al-Ili, you know, he's
1:23:60
the biggest philanthropy person in the country who has to be. couple of years back. And of course, we get a lot of support from our army also. You have to - we basically covered the army hospital
1:24:12
also in the hall in humility. And this was the first DBS we did in 2018, which was also at a private setup when I came in. But now we've done close to 100 of these cases.
1:24:25
Couple of fellowships which we started, patient quality measures are we have an EMR, a spine fellowship, neuro endovascular fellowship, as I mentioned, pediatric neurosurgery fellowship. And
1:24:38
another train which I've now done is anybody who's done a local fellowship. I encourage them to take USMLEs instead of going for training for residency because they start to get in. We are sending
1:24:48
them for one or two year fellowships. One is going for a functional fellowship at Kentucky. Then one of my former fellows is currently is with Paul Clemo at St. Jude's this week. we're trying to
1:25:04
get them and all of them need to come back also. This is this is a deed which we have them. You know, Scenic Society, Vosmalik was instrumental and now I'm also probably the only outsider to be
1:25:17
part of the Scenic Society and we we are we are rotating residents from them. All of these people have come in and visited us and
1:25:28
some of our Kendall Lee who I trained with Fred Meyer, you know, well Ross Mopman, Dr. King, Charlie Hodge, of course, this is my graduation and this is the baking who I saw operating in '93
1:25:43
when I was looking for a job in Houston by the way. So coaching, this is what we're doing.
1:25:49
You know, I was going to be Wimbledon play by the way before I became according to this. So we've we've cultivated our our friendship with some of the German neurosurgeons. We've done a lot of
1:26:00
robotic. is what I'm looking into, and
1:26:06
I don't want to get into politics, but where US stands today, I think they already lost the game, because most of this technology is coming out of China now, other than the electric vehicles and
1:26:17
all that, we are getting a lot of stuff from. So the centers of excellence in neurosurgery, we have, by the way, we do two to three aneurysm clippings. By the way, we are publishing a paper
1:26:27
which is going to be an eye opener We are doing all interior circulation, aneurysm clipping, ruptured, eyebrow now, all of them. This is a couple of hundred cases. Like yesterday, we did three
1:26:41
eyebrow clippings. And the teaching was that you stay away from - you know, minimally invasive. But we have crossed this border as long as we approximate control this is what I teach. And we've
1:26:53
been able to do that. Functions to your tactic, neuroendocrine, All of them get post-operative, Andrew Graham and CTH. spine center has been started. We have a 247. A patient comes in for the
1:27:06
last few months now, any trauma which is shipped to because we are the center for the country, not just for Punjab, because this is the only neuroscience institute in the country. And
1:27:18
neuroendovascular costume is leading it pediatric neurosurgery, the separate departments and the three neurosurgery professors with us. And similarly for neurology also, all these are specialized
1:27:29
now, neuro rehabilitation,
1:27:32
neurovascular, general neurology, epilepsy, so specializing into all of these. Education,
1:27:41
I want to take you to, you know, a lot of clinical research, a lot of publications, whatever we do, we're trying to publish now, all are required to do in a journal, even if it could be
1:27:53
Pakistani, but it has to be a PubMed index. And I think we are coming up with the Supplement with Search for Neurology also. Our team is working with your team, Dr. Osman. This is the first
1:28:06
Congress, which we're starting, which is going to be on 19th to 21st October. And all these specialties will be participating. And with this, we are also inaugurating this book, which Dr. Osman,
1:28:21
you've already reviewed and you've given your comments. Dr. Malik has been instrumental in recollecting and giving comments from a partition from India where he moved as a 12, 13 year old child to
1:28:33
becoming a pioneer. And of course, the offspring, which has us, have taken it to the next level. But above all, I feel, after doing all of this,
1:28:49
all the patients who treat in a private sector,
1:28:53
all of them is done through the private sector And in order to get these times, we - We use our first two favors from the government to do this. That
1:29:04
is not a solution to this. And I'm very convinced, like India has done, we have to go into a private sector network, because that's the only way you can pay the bills, and you can do everything
1:29:16
under one roof. They don't allow private practice at this institution. Even if you did, you can mix a county hospital, unfortunately, with a private state-of-the-art facility So now we are
1:29:28
proposing this BI Health, which is almost a 200-bed facility. The first one, just like Apollo, came up in India in 1980s. And we started the small one. This is the BI currently. And we are
1:29:43
coming up with a large travel with funding. We are tapping into IFC, DFC, OPEC. And in fact, I asked me, I would need your help. We would need your help also to guiding us, because we're
1:29:55
trying to fill in the gap with the funding. We have, just this week, we have a vascular surgeon who has moved from New Jersey. We have most US trained physicians in neurology, neurosurgery,
1:30:10
vascular, internal medicine, endocrine, nuclear medicine, all of them joining as being part of it, and some of them are investing also. So our vision, I think, this is the only way you can
1:30:24
transform, and we just filed for the first private neurosurgery training program on the BI and meat and teeth, which is the hospital, which we do, because currently we cannot select our residents.
1:30:36
We cannot fire a resident. I cannot hire a resident. You just pick the residents which are given to you from the government, and then you just work on them, and maybe, so unless you train people,
1:30:49
you cannot have a legacy to move forward for the next generation And this is a first move at vantage. This is what we're doing. I presented it in Dallas also. And there's been tremendous interest
1:31:01
from so many physicians who want to move, and especially with the conditions in the US. They all are looking for a backup option or more productivity or freedom to work. This is the plan, future
1:31:16
medical university, educational research hub. It'll be a sustainable growth engine. This is going to be, I've been, I go to Dubai, I go to Middle East, I'm going to be in Saudi, at the end of
1:31:28
the month, again, Riyadh. Pakistan, Saudi Arabia has signed very close relationships now. Currently, US and Pakistan are at very good terms also, which may or may not stay long-term, but you
1:31:42
have to come up with a chain of certain, which we can't alone do it. It has to be all specialty under one rule, spine orthopedics. The top orthopedic setup is also a BNI, stroke end of S for your
1:31:54
customers, the top person in the country. oncology, cardiac, radio surgery, gamma knife, all these being put up under. And then this is the real front here I work on, minimally invasive
1:32:07
surgery, which we have crafted to a level which not in the US can even compete now because of the sheer volumes. If somebody does two cases a day in a program, we do five cases a day here because
1:32:19
of the sheer volume, where else would they go? In all these, we need to have digital health, patient management, today we were at a meeting with the US company also started by a Pakistani
1:32:31
entrepreneur in Florida, and we decided that that is the way forward. We cannot afford Epic or Surna here, so I think we are developing these things here locally, and we have to be the leaders on
1:32:44
that. So this is what we are looking forward to, and we welcome you to all the either attended in person in person. which we would really, really appreciate, but otherwise maybe remotely also.
1:33:02
Thank you. Hi, excellent presentation. Let me ask a couple of very simple questions because the viewer needs to understand the structure. When you guys finished your training in the US, you went
1:33:13
back to
1:33:20
Pakistan. You, correct me if I'm wrong You couldn't work in the public hospital. They wouldn't pay you. You couldn't live off that. So you worked in the private sector.
1:33:33
Okay. Custom, you should go ahead to the customer lens of first - Yeah, so I joined, yeah, I joined kind of a semi-public, but run by the military hospital. But then in the evenings, I would
1:33:45
be doing private practice because that's the only way you can make a living. Well, it's true in a lot of countries around the world. People work for the government, say up to two o'clock in the
1:33:57
afternoon, and then the rest of the day there's in the private sector. The point I'm trying to make is that what you did is you continue to do that, but we're still dedicated
1:34:10
to developing and enlarging what was happening in the public sector, correct? Correct, right? In order to do that, you had to first of all, because then you did this, you started your programs,
1:34:23
and one thing you said stuck with me, and that is, and I'm sure I get the message of gospel for this, and that is pick the patients correctly so that they come out to be successful. Otherwise, if
1:34:38
it's not, you're finished because And so, you have to start out with successes. And once you start out with successes, And it's true in the business world. Once you start out with successes,
1:34:53
then people are willing to invest more in more successes. And so I'm sure as you started with your your interventional treatments and your treatment of stroke, people saw the results, they invested
1:35:07
some more money. But now you're getting money from both the public sector and the private sector into what it has pins, right? Yes. So, okay, I'm developing this for a reason. And so as people
1:35:26
try to adopt this, you don't go back and walk into the head of the public sector hospital and say, I just come here, I was educated at super duper U, give me the money. It doesn't work that way.
1:35:41
It's what happened to your father. It's you've got to wait, Even though you were educated in the UK.
1:35:48
And you got to work your way up and it takes patience and time. And eventually what you did is you had a long range plan. That's the next thing. It wasn't a two year plan. It was a long range plan,
1:36:00
right? Your whole education, your whole development was a long range plan that Gauss, your father and I and you guys had worked on it. And it's two, I think you were in the hospital. You were in
1:36:13
the United States getting educated for 10 years before you went back, but you went back, yeah, I think by the time I have 50, 16 years. Yeah. And so it was a long investment, but it was a long
1:36:25
term plan. And that was the goal. And so you got there, you got into the system. It's very political, same as in our countries. And
1:36:37
in order to navigate that, this is, this is politically frustrating. You finally wind up getting to have some leadership. which they accept after your success in the public sector, which allows
1:36:51
you to determine what you want to do, but you're keeping the private sector going, correct?
1:36:58
That's correct. As I see it, what you're now you're getting, generous funds from the public sector, which has got to be an amazing accomplishment in a developing country. I mean, the demands
1:37:13
they have for that money are have to be excessive And you've got to make a case that this is very important and you're going to get a, you're going to get a big return on your investment. I mean,
1:37:25
you're going to come in and you're going to, I'm going to treat you with a stroke and most of these people would be wind up paralyzed and devastated and you're showing him, you can get him back to
1:37:36
work. Well, my God, that's an enormous accomplishment. And you keep building on that. And so they give you some more money and you expand it and you develop it as you're doing it. Is that the
1:37:48
correct scenario? That's absolutely correct. And I feel like, you know, for me, when I think I'm done, the difference between the private and the public sector in special reference to the stroke
1:38:02
is that I came to a point of view, and I still hold that, is that the stroke care is extremely expensive even for someone to come into the private sector. And the reason is that we still need a lot
1:38:16
of RD in the stroke area, because unlike the acute conry, where even if they open up a vessel, the worst, what can the worst thing happen is that you can have a low ejection fraction and you can
1:38:29
live with a congested for heart failure with medication, but in the stroke, if you open up a vessel and the people's expectations are that our patient is going to start running after six hours of 24
1:38:40
hours that some. It depends on patient to patient. And if you keep that patient in the private sector for five or seven days, that keeps adding up the bill. And so I would say that majority of the
1:38:53
stroke patient population by far, lands in the public sector. And that's where the majority of the strokes are also happening in that category of patients. So that's why for me, it was very
1:39:06
important that the stroke development comes in the public sector because otherwise they cannot afford thrombectomy devices, connective plays and those sort of things. And also the post-hypercube
1:39:19
therapy stays in the hospital because in the public sector, the hospital stays not even calculated in the budget. So you can stay even for a month and no one will even question you about it. So but
1:39:30
the main cost is the cost
1:39:33
of disposables and the medication. So that's one big difference that I have from the private sector that stroke. in my opinion, needs a lot of public stroke programs because majority of patients
1:39:46
cannot afford it here. Let me ask you another question 'cause I'm coming to a key issue here. Asif, you guys alluded to this. You alluded to this that, as if you said, you cannot hire a resident.
1:39:59
You've got to take what you get. Well, I know you're not satisfied with that. And so you've also said that you can't get people into programs in the United States, so you get them fellowships.
1:40:13
Very interesting development. The point
1:40:17
I'm trying to drive at it because I'm going to tell you something in the end that's going to shock you about American healthcare.
1:40:27
But it looks like if you guys were not in charge, and I'm saying this, you're not saying this, and Gus, you can answer this. If you guys were not in charge of what you're doing. this wouldn't
1:40:41
work, is that right? Yes, that's, there's no second thought about. If I wasn't there, I can assure you the casting may have started giving TP and all that, but intervention would not have been
1:40:54
able to survive. And if, you know, this is coming from our personal context. So, Dr. Aspen, I didn't mention about it, the casting has just mentioned, but when I came back after I joined just
1:41:06
as a professor, not even as the director and all that, even though I was offered to be the director at that time, because of the certain context which we had, the cheapness at that time. They
1:41:16
took me to course. We didn't even know who was swinging, right? I'd never been sued in US. They took me to course only that the training, the certification is fake. He's got a fake degree, you
1:41:28
know, things like that. And I was looking to resign anyways, but when that happened, you know, I said, okay, I'm gonna resign after one week, then maybe after one month, but after six weeks
1:41:38
when they sued me. I'm not gonna resign now, I'm gonna fight it. So that's where I think I really survived and I think it is my survival, is directly related to Carson's survival
1:41:51
and his survival is related to mine. We coexist each other. But once I got into being the in charge, now we decide what needs to be done. As regards to residents, all the residents are selected
1:42:04
to a central induction system of the government.
1:42:13
So the government gives you this, they have to do under service area and all that. And by the way, coming back to that, we fought them in the court. We got it verified from US again that I was a
1:42:19
full professor in US and the Supreme Court and the court threw it away. This is how it happened. And those people were, they said, you know, when I asked him who the guy was suing me, I said,
1:42:28
who's behind you? He said, you know, all those professors who are retired and you're stepping on their private practices, right? That was the reality. So I said, I'm not even stepping on
1:42:37
anybody's private practice. teach these kids how to operate. They were, you know, the youngsters were not allowed during residency or they were just doing stuck work. So now after their residency,
1:42:49
I required them to spend three years as senior registrar. That is when they rotate every four months through, we don't use ENT, we do our all endoscopic skull base thing. We know they do six
1:43:02
months of vascular, they do functional, they do all of their rotate. And by the time after these three years, that's altogether seven years, seven, eight years, that becomes comparable to the
1:43:12
US training now. But once we have trained 40 plus of that, I think you've already done your job, right? Because these are competent people, which are outside, our trainees are now sitting in
1:43:26
Kabul, other than Peshawar and all that. So I was able to use a place, leverage it, and use all those people to allow them to get trained. I didn't hand train them, Facilitated their training so
1:43:39
they get to do things which you know that the endoscope was not allowed by even an assistant professor They could not touch it only the professor could use the microscope or the endoscope This is how
1:43:50
they were these were these were being used that you know don't use it. It'll get broken They were not using drills. We bought them six drills They were using jiggly sauce even in this time, you
1:44:01
know, how can you have so so there's a lot of things which we did But how could I have delivered if I was not the boss? Right, let me give you a story when I went to I was asked to come to Henry
1:44:13
Ford And and Henry Ford built Henry Ford the the real Henry Ford
1:44:21
I'm gonna. I'm gonna just I'm just gonna grab the charger. Also. I'm listening to you. I'm going to die So you keep on speaking. I'm listening. Yeah, Henry Ford had a son And he wanted him
1:44:34
treated at the University of Michigan, but for some reason he had difficulty. We got so angry that he said, I'm gonna develop my own hospital. And correct me if I'm wrong, right, gosh. And he
1:44:46
went ahead and he developed his own hospital where he hired his own doctors, and it
1:44:55
was basically socialized medicine, they were all salary. And it did well initially, but it didn't, it wasn't going the right direction People were incentivized. They didn't work like Ghost did.
1:45:05
They came, they put in their time and left and so forth. And so when they came, there was Dan Nelson who came and he said, We want to establish capitalism at Henry Ford Hospital. We want you to
1:45:19
do it. And so we came, and remember that cost, we got together, we said, If we're going to do this, we're going to have to have our own incentive program. No salary. We'll take, you can give
1:45:31
us 50 of what we make on a second, but we're gonna make the rest of whatever it is we make, and we
1:45:39
built the program on that basis. The reason I bring this up is
1:45:45
because what that system allowed was entrepreneurial spirit, private enterprise, and private development. Medical care in the United States has gone the reverse We have returned to government
1:46:03
dominated, socialized medicine. Is that correct, Gus? That's correct.
1:46:09
And so what you, the reason I asked you guys, and the reason I asked you, and same for a sieve, is would this work, and I asked you this, Gus, because I can sit with me. Here you guys have
1:46:23
established this with tremendous patience, and that's a Gus characteristic. And tremendous, let's go and be patient. We'll get through this. Now you're in charge, you're in control. You built
1:46:38
this basically with some government support, but you built it with an entrepreneurial spirit. And if they came and said, You can't do it anymore, you're gone. You're right. And so the problem is
1:46:55
that they don't understand that And they certainly don't understand that in the United States. And so what's happening in here, we have a health system that's basically a disaster from everybody.
1:47:09
Very true. You, disaster. And so you said before, 'cause you're
1:47:16
getting instruments from China, you're getting instruments from elsewhere, and which is fine. There's nothing wrong with that. What it's called is competition breeds excellence.
1:47:29
And that's what you're trying to do.
1:47:33
If we have central control, that becomes mediocrity. And that means mediocrity isn't excellence.
1:47:45
So that's why I'm going full circle until you guys came back, you worked through tremendous difficulty, you worked yourself in from the private sector, into
1:47:57
the public sector, a tremendous sacrifice, because you didn't get a paid lot for that. But your motivation was there. You didn't go into this to make money. You had that on your slide. You went
1:48:09
in this to help people. And that's never ending. And so that's the spirit they have. That's what's going on. If you kill that spirit, it's dead, the program's dead. And that's what's dying in
1:48:23
this country
1:48:26
So, one of the.
1:48:28
You go ahead. One of the critical factor there, and over the years I have had the opportunity to talk to some of the government officials kind of
1:48:45
privately, there has to be same
1:48:52
solution that you manage to initiate at Henry IV. There has to be some degree of privatization
1:49:10
of work within those public hospitals. That is the only way those institutions can grow, people can stay there, they can academically be active, they can train people, because if they can be paid
1:49:24
for all of their private work, and the institution can get funding also are taking care of those people who are going into small private hospitals that would grow the academic institutions and so I
1:49:41
think one of the you know the solution that RFS is very legitimate considering the local circumstances but at the same time if you got the ears of the hierarchy I think having a change in public
1:50:01
institutions academic institutions is also very very critical because private enterprise is not going to be able to solve the problem of that population.
1:50:17
Okay I agree with that let me just ask a couple of questions and we got to wind it up it's been I hope you guys have found this worthwhile because it's gonna help. help a lot of people around the
1:50:29
world to see that it can be done
1:50:33
against incredible odds, starting decades ago and being patient. So let me see what I had here. So you really went and you you establish this program, you had you had a key point in your slide,
1:50:53
it's time is brain. You're constantly working against time is brain. So so if somebody had a stroke and they were in an outline community, you would get them treated there, which means you had to
1:51:06
educate them there, which means you I think at the ambulances is to take them there. And the nurses to triage them, they got to understand what the difference is between a cardiology problem and a
1:51:16
neurology problem. That's not a small thing to do. That's difficult. Okay.
1:51:22
And then they have to triage it if it pretty much more complicated. to the major center. And that's where you guys take care of them down in the major center. So there's a whole bunch of parts that
1:51:35
go together here that are all dedicated to time is brain. You had too much triage time between when they hit the emergency room in the cath lab. And you found very creative ways to overcome that.
1:51:48
You cut the time in half. Time is brain. It's like keeping you up at night It's constantly driving you to do that because time is brain and that is stroke and that is functional recovery. And let
1:52:02
me see what else I had down here. So I think people get that. One of the things I encourage you to think of all you Bill, you probably have done that. I think people will see this video. I think
1:52:16
if you need to go and you went to Dallas, but you both have stories to tell a different take on the same story coming from two different directions. You need to go out and use this video or whatever
1:52:30
it is and in a broadcast your experience around the world Particularly to the low to middle-income countries Working with Africa and as I told you there are 50 countries. There are a billion people
1:52:43
That's that's that's five times what you've got him in in Pakistan and and and they're Extremely creative and so you got to let them have some freedom. You got to let them have some time to create
1:52:57
We've come up with very creative solutions. They had a solution there We had it two weeks ago, which which will revolutionize surgery and neurosurgery. It's it's it's uh, it's like an exoscope But
1:53:11
it isn't it's all done through an endoscope and it's indirect. It's it'll revolutionize surgery We had a presentation about how can you tell if they've got raised in Ukrainian pressure From some
1:53:23
intensive care units and there's a simple product you can use, you can put it on the patient's eye, and you can, again, with computer help tell if there's a raised intracranial pressure. So if
1:53:36
somebody comes in and they're, we're observing them, we're using, and there's nothing wrong with that, we did it pretty well for years, and they're deteriorating. This gives you some help in
1:53:47
quantifying it. So that means that people all over the world, something we talked about, many times goes They're bright people all over the world. They just are just not in Europe or the United
1:53:60
States. It just doesn't make sense. And we got to open it up so we get all those creative ideas. You guys have had a ton of them here. So I think you got to reach out and educate people some more.
1:54:14
And let me see what else.
1:54:18
Yeah. And that's what you're saying Well, just do it. The Nike principle, right? I'm talking about the state I'm in now, which is Nevada. You can see that on the screen.
1:54:31
And Nevada has three million people. And like all states throughout the United States, they're losing money in healthcare and over fist. If you look at what the people think about healthcare in the
1:54:46
country, they're totally dissatisfied. You can get figures anywhere from 60 to 90, including doctors. Nobody knows what to do about it. Everybody's giving up their hands about it. They're trying
1:54:59
to put bans aids on the system. They use this graph here, which is a graph you've seen before, which is life expectancy in the United States
1:55:09
is about, is here in the red. And here we spend 10, 000 boys on a person. And the rest of the world spends half that amount and has longer expectancy There's a problem with the statistics. but
1:55:22
that's basically what's going on. And so here the answer is, these people say, this is basically we make up 5 of the world's population consume 55 of the medication and it's not increasing our
1:55:37
lifespan. So there are major problems. And so I put together something to help them. I am not sure they're gonna listen. Gouse, we've been through that many times And this
1:55:52
is just a little slide to show how doctors started out. This is your father. Your father started out the doctor-patient relationship. That was it.
1:56:04
And they had a contract between your father and the patient about this is what I'm gonna do for you. And there was excuse for not spending whatever he could to make sure that patient was better.
1:56:17
That was what it was And now what we have is a system. And these are all the people involved in health care, doctors, hospitals, government, lawyers, workmen's compensation, insurance,
1:56:28
biomedical and pharmaceutical companies, corporations, paramedical people, local and state money, state government. We want to start out with a pot of gold here, which is money to be spent on
1:56:40
health care. And we wind up with nothing left over for the patient. The patient now comes last I show that to you because beware, beware. This is most of the socialized health systems throughout
1:56:57
the world. It's UK, it's Europe, the United States, what they like to admit it or not, it is in socialized medicine. You're trying to establish something that's individual and entrepreneurial in
1:57:11
a place that's desperate for help, and you're spending the money appropriately When I went to Peru, I asked the head of the health system there. I said, And he happened to be a cardiac surgeon. I
1:57:25
said, If I gave you a billion dollars, what would you do with it?
1:57:29
I was thinking to me, I know what he's gonna tell me. I was wrong. So he thought for about it in a minute, and he said, I'd spend a billion dollars on sanitation. And
1:57:43
he said, Because I'm gonna help the most people with those dollars. You're making a case that if you give me some of your money, which is short supply, 'cause every country in this world is in
1:57:57
debt. Every country, including ours, major problem in the future. Especially ours, especially US. Yeah. Unless the highest debt in any country holds. More of a 40 trillion. You got it. Right,
1:58:13
it's a trillion every
1:58:16
hundred days. So you're gonna go to them and ask them for money? Are you kidding me? and to have achieved what you've achieved. is remarkable because you've shown a return - this is a business
1:58:26
principle - a return on investment. If I put meaning in you, I get it back. Most people in the socialized medicine world in the socialized world said, give me the money. And I'm not sure I'm
1:58:41
going to tell you what the return on investment is.
1:58:45
And that doesn't fly. But that's what they're selling So anyway, that's it. And I have a whole plan here to go through to tell them how they can get over this. And maybe sometime I'll show it to
1:59:01
you. But the answer turns out to be the answer is to return the health system to the doctor-patient relationship and get rid of the socialism, get rid of the government.
1:59:17
And the reason for that is the government can't run anything But you two guys. have shown the government how it can be run, which is why I asked you the question 10 minutes ago, if you're not there,
1:59:29
what's gonna happen? And Gao says it fails. That's exactly right. So the question is, how do you ensure that from the future? Because you're fighting a worldwide trend for government support of
1:59:43
everything and everybody. And there isn't enough money in the world to do it. And what you have to do is a slide I just showed you before in the end you have to make the patients responsible for
1:59:56
their own healthcare. Nobody does that. They give them a credit card. They take it to the hospital and somebody, everybody uses a credit card. And we don't know what they use it for. But it's a
2:00:06
patient out there establishing a great health behavior. It's a patient trying to control his blood pressure. Is he checking up on it? Is he eating the right diet? Those are all challenges in the
2:00:17
end you have to come to. You're not there yet You're just working on the cute face.
2:00:23
That's how people are going to have to look at it here. So I don't want to take you into it, but what I'm telling you is what you're telling me you're doing in a part of the world that most people
2:00:34
want to ignore. While the rest of the world, it's going to pot right in front of everybody and they've given up knowing what to do. Because what they've abandoned is the fundamental principle that
2:00:49
we establish when we went to afford or that you have to establish in life, you have to give people a chance to do things on their own, the government can't do it. It's not smart enough and there
2:01:04
won't be enough range to do that. I don't know if you agree with it, but that's what that's where I'm coming from. You know, I totally agree with you, Dr. Aspen, also because there's a little
2:01:15
difference in how we are doing it government doesn't want to do it. Do you think they are. It's in their favor. They have to do it because they need us. If something, whatever, so all these,
2:01:29
all these physicians I'm talking about, we have a control on their health care in the private sector. I'll give you an example today. You know, the health minister of our province, or XYZ,
2:01:43
whatever, you know, on a Saturday, they have to look for us for anything related to neurology. They look for Kasim or anything related So if they are in our hands, then we say, okay, why don't
2:01:53
you get this done for us, also in the public sector. You know, why don't you, you know, this is the funds we need. Give us another billion for the equipment and all that. So this is, we are
2:02:04
doing it as a personal, but
2:02:08
I'll tell you what I think of the US system. I think that growth is going to happen in this part of the world where we are now, because you mentioned a billion people Pakistan is almost 300 million
2:02:19
people, China. India, Bangladesh, that's two thirds of the world,
2:02:27
right? So all the growth is going to be happening in this part of the world. How sanity prevails in the Middle East, I think that's important. But I was offered to come back to US a couple of
2:02:39
years back to lead the entire network. Like Henry Ford, we have 19 hospitals. I politely convinced one of my senior partners to take the job because for a couple of million, that impact does not
2:02:53
translate to what the impact we are making here. Correct. Right. It reminds me a short story. The hospital where the PNI is right now was in the outskirts of Lahore. And in order to get down
2:03:11
there, it would take significant amount of time. They had to pass over a railway line And the guess would be -
2:03:21
closed, so it might take sometimes 15, 20 minutes if there was rain, there were floods. So there was a patient that Professor Bashir had at the hospital, who was related to the governor. And so
2:03:38
he invited the governor, he raised a question, he says, Yeah, yes, sure, you can come and visit and we'll be glad to help you And he got stuck at the railway line. And so when he got to the
2:03:53
hospital, he says, This is very terrible, you know, I will stop there for 20 minutes or 30 minutes. And first, when she told him, You know, I have to make these rounds two or three times a day,
2:04:06
sometimes in the middle of the night. And the next thing was that we got a bridge, an overpass over the railway line, which helped the rest of the public crew, not only the hospital.
2:04:20
So as if it's right, I think being at the right point and taking advantage of those relationships is very, very important. Yeah, remember one thing, 85
2:04:33
of the diseases occur in the low to middle income countries. And
2:04:42
that's where the action is. And people in the high income countries don't get it. That's where the action is So you're right, doesn't mean what is at, what place does that mean for a place like
2:04:55
the United States or Europe, Europe is as gone. The United States are losing its way. They've got to maintain, be creative. They've got to be innovative. They've got to find out ways to help and
2:05:10
become involved with this 85 of the world that has 85 of the population and 85 of the disease.
2:05:19
And that's what you're in the center. So you're at the right place. I agree with Gao, so at the right time, doing the right things. So anyway, thank you. Gao, do you want to say anything at
2:05:30
the end? No, I think we did a great job in representing what is being done. And as I said before, I have all along and encourage them to stay in there and keep on working In a little improvement
2:05:49
has a tremendous benefit as costume has shown, you know, and sure to the people, things can be done.
2:06:01
You have to agree. One last thing I want to add, this is an observation and a reality which is happening in the health system in US. So, where you're right, Dr. Asmin, you've always nailed the
2:06:16
way it was done supposed to be. The hint? system and US. is collapsing. And, you know, this is, I say this, when I went to the Apna meeting, I said, you know, your time is over,
2:06:26
unfortunately. You guys have to look at the outside world because our insurance company in US, because both of customers and I still maintain privileges, we still operate there, I said, United
2:06:37
Health Care, I know patients who are being shipped outside US. For instead of a 200, 000 procedure, they can get it done in 20, 000 in India or Bangkok. Why should it not be Pakistan? Because
2:06:51
if the same physicians who are licensed to practice in US. are doing your surgery, if they are available, and they are better trained now because they have touched 10 times the volume which are
2:07:03
resident in training in US. would not get to clip more than 10, 15 aneurysms. Here, they do 50 plus in two months. So we wish to the senior society and they are seriously thinking how to make it
2:07:16
possible for them to come and spend a month. We just had a student, MD program from University of Arizona. In fact, he lives in - he's from LA. He spent a month here, James. And the type of
2:07:29
stuff he did in a month, he probably would spend in two years in US. So I think this is where the sheer volumes, as well as the economic direction is also going to dictate down the road to stay
2:07:42
competitive for the US physicians The reimbursements are going down in our bill next year. The big beautiful bill, I call it the breakup of the blood brain barrier, the way it was described. By
2:07:57
next year, before the Medicaid is going to go away, Medicare reimbursements are going to go down. If they go down, the private insurance will go down. This will hurt the physicians and the
2:08:08
hospitals. It may not hurt the hospitals, but the physicians will definitely be at loss. So look outside.
2:08:19
I think that's reasonable. We talked to some young people in Glasgow who are not getting enough patience, experience in England. And they were looking for places to go. And so I'll tell them about
2:08:32
Pakistan. It's the same. Africa offers the same opportunity. It's not at your level yet. But you can still learn a great deal from a lot of pathology. So you guys have done a phenomenal job. I
2:08:45
congratulate you and everybody who's worked with you on all your achievements. And I wish you to have many, many more and
2:08:56
keep looking forward. So when are you coming to visit us? You have to make one trip again. If this is a golden opportunity, I call Dr. Malik this morning also He is celebrating his 105th
2:09:10
anniversary of Andrew Ford, I think 110th or 105th. So I said, you know, this is going to be even a bigger milestone if you come in. attend this first prince congress and dedication to the book
2:09:23
which you have both contributed. Well, we appreciate it. We'll keep thinking about it. And I just said a little setback about about three weeks ago. And well, we'll keep thinking about it. Okay.
2:09:37
Thank you, sir. Thank you. Okay, now thanks for coming.
2:09:42
And I assume just a phenomenal job. And Sif, you need to come to work and and wear a super protection.
2:09:55
I'm sure everybody's aiming at you. So
2:10:01
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