An ambulance rushing to an emergency site is pictured — Photo by White Star

Babul Khan, the man in charge of Edhi Foundation’s office in Quetta, suffered serious injuries during a January 2013 bomb blast that hit an area populated by the city’s Hazara community. Even now, almost a year after the blast, he cannot hear properly from his right ear. His passion for helping others, though, remains unvanquished. “When I go to help and carry the injured, I don’t think about my own life or safety; I’m just focused on doing my job which is saving lives,” he says.

Brave words indeed. But they also highlight the dangers facing the workers of rescue and ambulance services. Those assigned to help others, when fatal disruption and deadly chaos set in have to risk their own lives to save others — and voluntarily.

This is exactly the situation Mursaleen, a paramedic working for the Chhipa Welfare Association’s ambulance service in Karachi, faced while on a recent rescue mission in the city’s troubled Lyari neighbourhood. “It was very dark when I arrived there along with another colleague and there was a lot of firing going on,” recalls Mursaleen. He saw a man trying to run to safety amid a hail of bullets. “I saw him fall to the ground and die on the spot.” There was another injured man lying on the ground and as Mursaleen reached close to him, heavy shooting broke out behind him. “The bullets missed me by inches,” he says.

Mursaleen, however, managed to take the injured and the dead to the ambulance and transferred them to the nearest hospital. “I was praying to God for my safety the entire time and I am thankful I got out alive. I was able to help another person stay alive,” he tells the Herald.

Does anyone care about the safety of ambulance workers at a time when the level of violence and crime in the country is extremely high, leading to several deaths each day? Most crucially, isn’t it the state’s responsibility to provide a rescue and ambulance service to citizens, one that is not just effective and efficient but which also provides safety and protection to its own workers?

Dr Rizwan Naseer, the founder and director general of the Punjab Emergency Service which oversees Rescue 1122, says there are two issues involved here: One is the need for rescuing those facing emergency situations and second is the security of the rescuers themselves. “All human beings have a basic right to [receive] timely emergency care which the state is responsible for,” he says, suggesting that the state should be the main, if not sole, provider of emergency care and rescue services in the country.

This makes it easy to conclude that it is also the state’s responsibility to provide security to rescue workers. In Naseer’s department, which is the first state-of-the-art rescue and ambulance service in the public sector in Pakistan, this is ensured by providing proper training to the staff as well as equipping it with safety tools like helmets, protective vests, fireproof clothing etc. “We ensure our staff undergo training for at least six months before going on emergency rescue missions,” he says.

The security of the rescue workers, however, is strongly linked to the state of the institution they work for. Better-financed, professionally-run and well-equipped institutions are likely to provide more protection to their workers than charity-based initiatives. The only way to guarantee the safety of rescue workers, therefore, is to improve the institutional capacity of the organisations and institutions providing rescue services across the country.

And this is not the only reason why rescue and ambulance services need immediate improvement. A report by the United Nations Development Program (UNDP) highlighted the need for a state-provided ambulance and rescue service as early as 2002. “It would not be wrong to say that the residents of Pakistan are living at God’s mercy as far as emergency services are concerned,” read the report. It continued, “…[I]f you have an accident, will anyone ever come to your rescue, will you get an ambulance, how will you be transported and managed in the hospital? It is indeed shocking and haunting to even think about it.”

The report created some a realisation and some alert among official circles in Punjab which led to the creation of Rescue 1122 in Lahore, in 2004, as a pilot project. “Initially, we only had 50 ambulances with a staff that was not adequately trained. So, at the time, we were simply a transport service moving bodies from one place to another,” says Naseer. “We were not an emergency rescue service and we could not provide timely rescue services either.”

Since then, Rescue 1122 has spread to all the district headquarters in Punjab. It is manned by hundreds of well-trained workers and officials, operates well-equipped ambulances and has legal cover for its operations under a provincial law passed in 2006.

Its ambulances, perhaps, provide the most important service to the citizens since they are what callers seem to need the most. According to the Punjab Emergency Service website, more than 97 per cent of emergency calls received by Rescue 1122 are “still related to the Emergency Ambulance Service”. This leads to an obvious conclusion: Any organisation working in the field of emergency rescue and relief must focus on providing an efficient and effective ambulance service.

Working under this philosophy, Rescue 1122 has acquired such a leadership status that it now provides training to other institutions and organisations looking to set up a similar service. For instance, it trained the rescue staff hired by the Karachi-based, non-profit Aman Foundation to run its own ambulance service in Karachi.

Aman Foundation came up with the idea of setting up an ambulance service which could offer all of the above facilities because, according to its website, “the existence of an advanced life-saving ambulance service in Karachi was unknown.” The website also explains what an ideal ambulance service should offer. It should “stabilise and transport patients from the site of injury or illness to healthcare facilities; solve issues of access (physical and financial) and quality vis-a-vis in-transit care; address common emergencies such as cardiac arrest, accidents and injuries and obstetric emergencies [and] reduce the incidence of loss of life due to inadequate emergency response.”

Other features of Aman Foundation’s ambulance service are also in accordance with internationally recognised standards and include a response time of less than ten minutes, over 750 emergency medical technicians and more than 100 doctors, “real-time tracking of ambulances throughout Karachi and ProQATM (a software that guides the caller of an ambulance through medically approved protocols until an ambulance reaches him).”

In places like Peshawar and Quetta, hardest hit by incidents of violence and terrorism over the last few years, such well-equipped ambulance service remains an unfulfilled requirement. The intensity of violence is sometimes so high in these cities that running even the most basic ambulance service becomes difficult. “One of the main problems we face is getting to the destination on time [due to the bad security situation],” says Sher Gul, the head of Edhi Foundation in Peshawar. “Some of our drivers have been injured in the cross-fire [between the security forces and the militants]”.

Babul Khan, who has been working for Edhi Foundation for about 15 years in Quetta, claims that his organisation provides the only ambulance service in the city. But, by all accounts, the few ambulances working in Quetta are little more than coffin carriers. “We have only 12 ambulances to cater to the emergency needs of a city which has faced violence, bomb blasts and other acts of terrorism quite regularly, in the recent past”, he says.

Even in Karachi, a city of more than 17 million people, the 100 ambulances operated by Aman Foundation (80 of them are available around the clock, while 20 serve as backup) are certainly not enough. There are many other ambulance services, including one by the Edhi Foundation and another by the Chhipa Welfare Association, running in the city, but as the Aman Foundation website states, “… a majority of Karachi’s ambulances merely served as transport vehicles with untrained staff and little or no lifesaving equipment or supplies.”

Ramzan Chhipa, a Karachi-based businessman who runs Chippa Welfare Association, a charity organisation, however, measures the effectiveness of an ambulance service in terms of its speed. “An effective ambulance is one which is able to reach the patient in a timely manner and transport him to the nearest hospital,” he says, though he adds that the ambulance should also have the facility to provide first-aid and cardiopulmonary resuscitation (CPR).

Of the 200 ambulances that Chhipa operates, having these facilities means including an oxygen tank and a first-aid kit. There are no doctors, no arrangement for emergency blood transfusions or for monitoring the vitals. Instead, a lone paramedic accompanies each ambulance. Chhipa argues that time is of the utmost essence during an emergency situation, such as a bomb explosion, which means that the victims of such a situation need to reach a hospital as quickly as possible rather than getting some “fancy facilities” within an ambulance. “Our objective is to retrieve patients from dangerous situations and transfer them to the nearest hospital as soon as possible,” he said.

The man who brought the first ambulance service to Karachi not operated by a hospital is Abdul Sattar Edhi, the internationally renowned activist who runs a number of charitable activities across Pakistan. He started the ambulance service by making a public appeal for funds and continues to take donations to keep it going.

Edhi has a fleet of 1,800 ambulances all over the country; these are divided into regular ambulances which include an oxygen tank, a stretcher and a first aid kit, and the Emergency Medical Service (EMS) ambulances which have more medical facilities. In Karachi alone, the organisation runs approximately 300 ambulances, 60 of which are EMS ambulances.

In recent months, the Edhi Foundation and Aman Foundation have joined hands in Karachi to improve the speed at which an ambulance becomes available for those who need to reach a hospital at the earliest and offer increased services to those who need extensive healthcare during transportation to a health facility. “We have signed a Memorandum of Understanding (MoU) with Edhi so that it can refer severe cases to us [such as those who need extensive healthcare during transportation] and we can refer other cases to Edhi,” says Dr Ali Kashan Malick, the assistant manager of command and control at Aman Foundation.

These are all noble initiatives in the private sector but they are providing a service that, essentially, is the responsibility of the state and almost all of them, even together, do not have the capacity to cater to all the emergency and rescue requirements in one city, let alone throughout Pakistan. As the UNDP report pointed out, even if some services are present, their personnel and equipment fall well short of what is needed on the ground.

This assessment is as relevant now as it was in 2002, for most parts of the country except Punjab. The situation is condemned to remain as dire in the future, if the government doesn’t make a serious and concerted effort to change it.