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Antibiotic overkill – How Pakistanis are putting themselves at risk of antibiotic resistance

Treatment for viral diseases is leading to drug-resistant infections

Antibiotic overkill
We are sitting on the brink of a health disaster. Humans may again reach a stage where even small cuts, minor injuries and seemingly innocuous infections can prove to be killers — all of these are conditions that can be effectively treated by antibiotics. Misuse and overuse of antibiotics is building in our systems resistance to these drugs and a time comes when these medicines are no longer effective in fighting the bacteria and infections they were designed to ward off.

Antibiotic resistance is leading to untreatable infections. Any age group can be affected by it. If care and caution is not exercised in the use of antibiotics, humans could be in serious trouble. We already are, if numbers are to be believed. Self-medication and use of antibiotics without thinking twice is a problem. The fact that Pakistan has, as reported by the Pakistan Medical Association, more than 600,000 quacks who pose as doctors and prescribe antibiotics without any need or deliberation, exacerbates the issue.antibiotic-awareness-poster 1

It is very common practice to go to “pharmacies” which are usually counters in grocery stores, run by people who are not pharmacists, and ask for any random antibiotic that the patient feels “suits” him or her. While it may have been effective the last time you used it, and the time before that, this time it may not work as you have developed resistance to it.

“We see a lot of antibiotic misuse at the hands of general practitioners as well as quacks. The urgency to use antibiotic sometimes also arises from patients demanding that they return with some medication if they have visited a doctor,” says Dr. Nosheen Nasir, Senior Instructor, Adult Infectious Diseases at the Aga Khan University (AKU).

“We see antibiotics being used for viral upper respiratory tract infections and for presumed enteric fever based on typhidot results which are erroneous and misleading.” Dr Nasir adds that antibiotic overuse can lead to increase in drug-resistant infections and significantly increase the risk of morbidity mortality. “Infections which were previously simple to treat now require use of more toxic and expensive antibiotics which are usually given intravenously, leading to unnecessary prolonged hospitalisations.”

World Antibiotic Awareness Week (WAAW), held from November 12 to 18 this year, aims at increasing global awareness of antibiotic resistance, AMR (Antimicrobial resistance) and to encourage best practices. AMR occurs when microbes, such as bacteria, become resistant to the drugs used to treat them. The 2018 WAAW campaign has two key messages: “Think twice. Seek Advice” and “Misuse of Antibiotics puts us all at Risk”.

AMR, as Dr. Nasir adds, refers to resistance among all kinds of micro organisms such as bacteria, fungi, parasites etc. when they are exposed to antimicrobials including antibiotics and antifungals.

She shares an example of antimicrobial resistance that we are facing today in Pakistan. “People get a lot of antibiotics unnecessarily for presumed typhoid fever, also called enteric fever. This has led to a country-wide outbreak of extended drug resistant (XDR) typhoid fever, sensitive to only two antibiotics, one of which can only be given intravenously. This has led to serious life threatening infections particularly in children,” she says.

November 2018 also saw “Call to Action on Antimicrobial Resistance” from November 19 to 20, co-hosted as a second global event by the UN Foundation to help drive action to stop the rise and spread of superbugs. Dr. Fatima Mir, Assistant Professor of Pediatric Infectious Disease at the AKU, explains that “Super bugs are germs which over time have become resistant to common antibiotics through new mechanisms.” She cites some of the lethal super bugs in Pakistan as under:

1.Multidrug resistant gram negative organisms like klebsiella pneumoniae, e.coli and serratia, leading to newborn sepsis.

2.Extended spectrum beta lactamase inhibiting (ESBL) gram negatives like e.coli, klebsiella, enterobactor sp, which can cause gut, abdominal and urine infections in all ages

3.Penicillin resistant streptococcus pneumonia, causing lower respiratory tract infections in all ages

4.Multidrug resistant Typhoid, effecting all ages

5.Multidrug resistant Tuberculosis (TB), affecting all ages

In Dr Mir’s professional experience, Pakistanis generally have a tendency to hurry towards antibiotics, “Especially in cases of Upper Respiratory tract illnesses which are usually viral but also associated with symptoms which make one miserable, like congested nose, throat and body aches, parents feel kids won’t get better without antibiotics, and most physicians succumb to pressure and prescribe antibiotics even for clearly viral illnesses.” She adds that one reason for over prescription is lack of low-cost testing to establish a viral cause. “Usually a full course of antibiotics is cheaper than a test for a single viral antigen, so physicians make a misplaced choice of empiric antibiotics to appease parents (of child patients) in place of expensive testing for an essentially self-resolving viral illness,” she says.antibiotic-awareness-poster 1

The problem of resistance to drugs affects all age groups. The elderly are not spared either. Only tests conducted in the laboratory can confirm whether the cause is viral or bacterial. Lack of mobility of elders to go or be taken to laboratories, plus general caretaker fatigue that sets in when an elderly patient has been dependent for long, means a lot of elderly people end up getting even fewer lab tests run on them than patients of other ages.

The easiest way out is to start them on antibiotics without getting even a simple test done like the “culture” which tells which antibiotics would still be effective for that particular patient. “As older patients may not manifest with typical symptoms of infection, antibiotics are frequently given often causing antibiotic resistance. They often may not have fever, and the infection may only manifest as weakness. This practice can be curbed if investigations are done early to confirm infection prior to starting antibiotic,” says Dr Saniya Sabzwari, Geriatric Specialist at the AKU.

In 2017, a “National Action Plan” was drafted by the Health Ministry in Pakistan to fight antimicrobial resistance, developed in the light of the five strategic objectives listed by the World Health Organisation’s (WHO) Global Action Plan for AMR.

Between the years 2000 and 2010, global consumption of antibiotics has increased by 30 per cent. Some 700,000 people die every year from infections that don’t respond to antibiotics. If this is not controlled, AMR could cause 10 million deaths each year by 2050; this number would be more than the deaths caused by cancer.

While over-dosage leads to antibiotic resistance and other serious side effects, under-dosing is a problem too. “This means that the drug, even if chosen correctly, is ineffective because it cannot reach effective concentration in blood. Incorrect dosage is one of the main contributors to antibiotic resistance in addition to incorrect usage,” says Dr. Mir.

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Wearing second hat as family’s sole breadwinner

November 12, 2018

ASIYA’S day starts at 5.30am. She says her prayers, cooks breakfast for her family, and a curry for dinner, wakes up her three children, feeds them, sends them to school, and then cleans her one-room rented accommodation in a shanty town of Karachi. She leaves home at 9am to work as a domestic helper, and gets back by 6pm. Then onwards, household chores keep her occupied.

Her husband doesn’t have a job since they moved from south Punjab to Karachi. Yet, she is the one doing double duty, managing her home and wearing a second hat as the family’s sole breadwinner.

“Time for myself? Never thought about it,” she says. Her monthly salary is Rs20,000 ($150).

Across a few roads where more affluent Karachiites reside lives Saima (name changed) who earns six times as much as Asiya, her monthly salary as an assistant manager at a multinational firm touching Rs120,000 ($900), more than what her husband earns. Yet Saima’s routine is pretty similar to Asiya’s. In addition she is a caretaker to her elderly mother-in-law once she is back from work.

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UNDP’s human development report highlights that care work, mostly undertaken by women, is what enables a majority of the paid work which drives economies. Yet, as it is unpaid, it is under-documented and taken for granted. According to a recent report by the International Labour Organisa­tion (ILO), globally women perform 76.2 per cent of total hours of unpaid care work, more than three times as much as men.

In Asia and the Pacific, this rises to 80pc, where women spend 4.1 times more time in unpaid care work than men. Around the world, women spend two to 10 times more time on unpaid care work than men. Countries have valued unpaid care work between 15 and 39pc of national GDP.

At the recent United Nations World Data Forum 2018 hosted by the UAE government, Gender Data remained at the forefront of discussion as more than 2000 academics, statisticians, and activists from both the public and private sectors globally sat down to discuss the impact of data, especially Gender Data. Data2X, led by the United Nations Foundation, is a key organisation among Gender Data initiatives, and defines Gender Data as “data that is disaggregated by sex (e.g. school enrollment by sex), as well as data that pertains specifically to women and girls (e.g. maternal mortality rates). This data is critical to determining the size and nature of social and economic problems, the causes and consequences of those problems, how to design policies to combat them, and the effectiveness and cost-effectiveness of those policies”.

While the Pakistan government strives to get over its economic crises and the subsequent cost on human development, half of the country’s population — women — and data related to their needs and their economic contribution remains mostly missing.

Women’s rights proponents like Ume Laila Azhar, Executive Director of Home Net Pakistan, highlight these issues at the policy level.

“If women are counted in statistics, their work must be counted too,” she says. Ms Azhar adds that in the Human Development Index, if women are not recorded in the labour participation figures, it shows low female participation. “If the numbers of women in the work force appear to be too small, women are not considered at the policy level — policies that translate into job opportunities or initiatives for skill development for women,” she says.

Time Use Surveys (TUS), an important tool in this regard, measure how, on an average, people spend their 24 hours in what activities. “TUS are the best instrument to measure unpaid care work, since they measure the time people spent on this work,” says Mayra Buvinic, senior fellow at Data2X and an internationally recognised expert on gender and development. Linking the dots of TUS to the evaluation of unpaid work, Ms Buvinic says that by assigning a value to unpaid care work, “you make this work visible to policymakers who design policies to increase labour force participation rates and provide social services, including paid care services”. “Unpaid care needs to be factored in the design of these policies since it conflicts with labour force participation and it provides an estimate of the need for child and elder care,” she adds.

The 17 Sustainable Development Goals (SDGs) target to improve women’s lives by encouraging their economic participation and financial inclusion. Gender Data is an important tool in the achievement of the SDGs.

A recent tweet by philanthropist Shaniera Akram resonated with the twitterati where she mentioned how women’s multi-tasking and contribution is undervalued. Speaking with Dawn, Ms Akram says that women are often overworked and under-appreciated, not just in Pakistan but all over the world.

“Women can’t be taken for granted anymore. Men can’t just take all the credit, especially when the women — mother, daughter or wife — are taking care of everything behind the scenes,” she says, suggesting that society will benefit from incentivising staying home and taking care of children, the elderly and sick or disabled relatives, with a domestic allowance for women.

“We must focus on getting to a point where women don’t just have the right but also the choice between wanting to stay at home and going into the formal work force,” she adds.

“When families in rural Sindh or Punjab work on lands of landlords with tenancy arrangements, the whole household is working — including the women and children — whose contribution isn’t counted,” points out Ms Azhar. Rural women do a lot of unpaid work like growing vegetables for food sustenance, looking after cattle and milking cows, doing not double but triple duties.

“A woman overworking is a form of exploitation, and she doesn’t get the respect and acknowledgement she deserves for her contribution,” she says.

The author is a freelance writer and her work can be seen at chaaidaani.­wordpress.com

 

The first 1000 days & after: How hunger effects brain development

The crippling effects of hunger on brain development, and in turn on education, employment and quality of life, become worse if certain vitamins and nutrients are missing

The first 1000 days and after

The image of an emaciated, almost wasted, skinny child comes to mind when we talk of malnourished children — children with thin arms, protruding bellies, and light-coloured hair. Yet, the price malnourished children, their parents, and entire nations pay is far more than just what is apparent.

A malnourished child’s ruling organ, the brain, does not develop at an optimal level due to lack of sufficient nutrition. All stakeholders continue to pay the price for decades to come — both on a personal and a collective economic level. Malnourishment, then, may be the silent and neglected brain drain that no one is talking about.

According to Dr Irshad Danish, National Coordinator, Scaling up Nutrition (SUN) Civil Society Alliance, Pakistan, stunted children have 7-months delay in starting school, have lower intelligence quotient (IQ), are more likely to repeat a grade of school, complete one year less of schooling on an average, and are less likely to graduate high school.

“The effects of malnourishment include a low IQ, poor concentration, attention deficit, and memory disorders,” he says. Mentioning the findings of a report launched by the Pakistan Scaling Up Nutrition (SUN) Secretariat at the Ministry of Planning Development & Reform, in collaboration with the United Nations World Food Program (WFP), he adds that the consequences of malnutrition — including healthcare expenses and lower productivity — cost Pakistan US$7.6 billion, or 3 per cent of GDP, every year.

He says that children who are malnourished learn less at school and earn less when they grow up. Iron and Iodine deficiency in childhood reduces IQ by up to 25 and 13 points respectively. Cognitive deficits from childhood stunting, anemia and iodine deficiency disorders depress future adult productivity, valued at Net Present Value of $3.7 billion per year.

Brain development of the foetus starts in the womb of the mother, particularly in the third trimester, explains Dr D.S. Akram, Founder, Health, Education & Literacy Programme (HELP). “If the mother is malnourished and anemic, there are more chances that the brain growth will not be optimal as insufficient hemoglobin in the mother’s blood means insufficient oxygen for the foetus,” she says, further adding that between the age of three to six months, the baby’s brain grows rapidly, and if there are factors like a malnourished mother, premature birth of the child, or the mother not exclusively breastfeeding the child for the first six months, brain growth may slow down.

Dr Akram also says that if the child does not receive enough food as well as brain stimulus in the first two years, it may lag behind in its key developmental milestones. “When the child goes to school, his ability to perceive, to memorise, his motor skills — all will be slow. This will result in a lack of motivation in the child who will not experience the pleasure of learning. It’s a vicious cycle,” she says. For optimal brain development, according to her, it is imperative that timely introduction of a balanced diet of solid food is introduced, containing micro-nutrients, proteins and fats.

Solutions include early initiation of breastfeeding, exclusive breastfeeding for six months, starting complimentary feeding after six months, and continuing breastfeeding for two years.

Quantifying the link between brain function, academic performance and malnourishment, the Hunger in the Classroom report, 2015, by Food Bank Australia, stated that over two thirds of students who miss out on breakfast can find it difficult to concentrate (73 per cent) or can become lethargic (66 per cent), with over half experiencing learning difficulties (54 per cent) or exhibiting behavioural problems (52 per cent).

Perhaps this is why for Saeed Qureshi, the most rewarding part of his decade-long service of leading Aman Ghar (an initiative of the Aman Foundation), was working on feeding underprivileged school-going children in Karachi.

Since last year, Aman Ghar joined hands with Saylani Welfare International Trust, and meals are distributed to deserving students of 15 schools, which serves both as an incentive for children to come to school, as well as helps them perform better at school. Aman Ghar’s motto has been “food for education”.

Qureshi explains that before the inclusion of the lunch programme, the students were reported to pass out during school hours due to hunger, especially in the summers. Since the lunch programme started, there has been a significant change in the academic performance of the students. “I have seen children come to school on a hungry stomach, eating only paapay (rusks) and chai (tea) at most. Their decision power is impacted as is their ability to shine academically. They are dull and tired, and cannot participate in sports.”

Qureshi says that they mix four kinds of grains to make roti for the wraps for the children, which make up for deficiencies like iron and niacin that boost brain activity. “We have also tried to incorporate leafy vegetables, pulses, and meat in the diet,” he informs.

The crippling effects of hunger on brain development, and in turn on education, employment and quality of life, become worse if certain vitamins and nutrients are missing. Neurologic deficits can be a result of deficiencies in micronutrients like folic acid, iodine, iron, zinc, selenium, copper, magnesium, vitamins A, C, D, E, B6 and B12.

These deficiencies can result in learning disabilities, mental retardation, abnormal levels of cognitive and mental functioning, and even depression, anxiety and withdrawal, all detrimental to a child’s focus on academic activity. Malnourishment can also result in behavioural issues, and lapses in memory and concentration.

When asked how parents can avoid this happening to their children, Dr Danish says that “the first 1,000 days between pregnancy and a child’s 2nd birthday sets the life-long foundation for human capital. After two years of age, the impacts of stunting are irreversible”.

In his opinion, solutions include early initiation of breastfeeding, exclusive breastfeeding for six months, starting complimentary feeding after six months, and continuing breastfeeding for two years. Also, it is important to avoid junk foods and sugary drinks, provide diverse and nutritious balance food which should have necessary amount of proteins, vitamins, minerals and carbohydrates, and consume milk, fruits and vegetables.

“If all relevant stakeholders work together and implement joint interventions for nutrition, we can avoid bad impact of malnutrition on learning, earning and health,” says Dr Danish.

 

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Imran Khan: The human-centric Prime Minister

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Imran Khan has been sworn in after a struggle of more than two decades, and his first speech in the National Assembly, muffled by a verbal mob attack from PML-N’s parliamentarians, is being criticized for rotating backwards to the agenda of corruption. Khan’s rise to power is being seen as resting on the narrative built around fighting corruption. But look closely at one of his more shining moments – his victory speech after most of the results of General Elections 2018 were in, lauded by supporters and critics alike. The core agenda, there, was not just corruption. It was human development. If we join the dots, Khan’s sloganeering against corruption has always led to one single point of convergence: Let’s get back the nation’s money from those who usurped it, and spend it on human development. In Khan, then, Pakistan may well have its most human-centric prime minister to date.

Consider the man’s journey from November 10, 1989, when he made a nation-wide appeal for the collection of funds from a match between Pakistan and India on at Gaddafi Stadium, Lahore, to start collection of money for the cancer hospital he wanted to establish. Some five years later, Shaukat Khanum Memorial Trust Hospital opened its doors for the first time. The philanthropic spending to date at SKMT has been Rs 32.835 billion (US$ 371 Million). Namal College in his home district of Mianwali followed, and is a success story in itself. This has been Khan’s focus in life apart from his relentless and eventually successful efforts at changing the country’s political landscape from the platform of his party, Pakistan Tehreek-e-Insaf (PTI).

Perhaps no human is actually ever altruistic, and whatever good that we do for others is actually done because it makes us feel good about ourselves. And Khan is as human as they come. Combustible, emotional, flawed, egoistic, and duly criticized for all of this across the board. But he is also quintessentially gritty, dedicated, committed, sincere and kindhearted. Whether his passion for social causes like public health and education is altruistically driven, and why he invests so much of himself in the human-centric approach, would be a futile and lengthy psychoanalysis. But this human-centric approach, if properly used, can mean definitely better tomorrows for Pakistan’s people, and that is what we must reflect upon.

Look at just a few examples from Khyber-Pakhtunkhwa (KP) under the reign of the PTI from 2013 to 2018. The Sehat Sahulat card is KP government’s flagship health insurance programme, very low on premiums, that allows families to utilise up to a decent sum of PKR 540,000 per annum, not in public sector but also private sector hospitals and healthcare facilities. On a broader level, PTI’s establishing the Right to Public Services Commission has been an effective move. Responsible government functionaries can get penalised if services are not provided to citizens promptly. Some of the public services in this regard include issuance of domicile, death and birth certificates, approval of residential building plans, OPD and Emergency services, release zakat funds, grant of Jahez fund, water connection, clean drinking water, disposal of garbage/solid waste, and issuance of wood permit for construction of house. In an earlier report, Atif Khan, the then Minister for Education, KP, had shared that education of girls was prioritised by the PTI-led provincial government. He had mentioned that 70 per cent of all new schools the government is working on are schools for girls, and also 70 per cent of the work to provide missing facilities in schools is focused on facilities for girls. As an incentive, female education managers in backward districts like Kohistan were being paid 50 per cent extra.

In the 100-Days plan the PTI unveiled a couple of months short of the General Elections was perhaps too ambitious, and even idealistic. Yet, the path was clear. It was mostly focused on human development. In fact even when PTI talks of economic stability and financial growth in the country, the dot is joined to ideas like creation of jobs, especially for the youth, construction of houses, and availability of quality education and healthcare for all Pakistanis. What they are presenting the plan for, then, is infrastructure and business growth that, in turn, helps work on the human capital of the country. For too long there has been a lopsided focus on the building of infrastructure and material expressions of development, but somewhere the average Pakistani got lost. Whatever work was done in the past by previous rulers (leaders would be a debatable and probably refutable term) was clearly not enough. Under the pressure of social media and induced awareness, previous governments sporadically and isolatedly did some work in areas like health and education, it was never the singular focus. Today it is, and this is a refreshing change for Pakistan. A Tabdeeli (change) that one hopes and prays the PTI government, under Imran Khan, is able to pull off, and put into action.


The author is a freelance journalist, media trainer and communications practitioner. Her focus is human-centric stories.

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Pakistan’s fast changing kitchen-scape

Hiring cooks does not mean women, or men, are not homely any more. It is a social change, one that we must accept, and see cooking as an emerging, respected profession

The fast changing kitchen-scape

Once upon a time I used to cook up things like a mean deg of nihari, loads of bihari kabab, and the genuinely ghutta hua haleem for a dinner for 30 people quite frequently and without panicking. If I had a helper to cut up the onions and vegetables and wash the meat and do the dishes, I was good to go, taking smugly all the compliments that came my way.

But somewhere along the road, priorities changed. It was not just the fact that I became more invested in my profession. It was also not just me. The emergence of “cooks” came to the fore.

No, these were not the live-in Khan-e-Samaan breed of cooks that our mothers and grandmothers had who used to manage the entire kitchen and cater to all food-based needs of big families. These are part-timers. A few hours a day or a week. Neatly stacked storage boxes of salan and kabab split into portions in the fridge and freezer, also labelled for convenience. This is what the modern-day cooks on urban Pakistan are like.

Often one doesn’t have one but actually many. I have one in my list of contacts in my phone that is for usual day-to-day cooking — the chawal, daal, sabzi, qeema type of stuff. Then there’s the one you call when there is a dinner at home — biryani, kabab, qorma and the likes of these. But then there’s the super fancy one — the CV or intro says, “can make Chinese, Thai and oriental food”. I have not utilised services of all but there is a comfort in knowing they are there.

In a fast-changing social landscape, the larger joint families have been replaced by nuclear families. In these urban families crunching under inflation, the woman no longer has time to deliberate about the daily menu, then cook it, and then serve it. She is as much an earning member of the household as her husband. Many a times, even the children, once they are young adults, are working part-time.

The good thing that has come out of this is that unnatural expectations from women to focus their lives only around the kitchen and its periphery are decreasing. But that also means cooks are an integral part of life. However, full-time cooks are expensive in more ways than one. Not only is it the salary, but it is also the unsaid pressure to get food cooked daily in order to justify why you have that full-time cook.

It is an expensive proposition to house domestic staff. Thus, part-time cooks seem like a great option — both for the employer and the employee. For the employee as being able to work in more than one house allows him or her more flexibility of timings, and is mostly a more lucrative option.

The good thing that has come out of this is that unnatural expectations from women to focus their lives only around the kitchen and its periphery are decreasing. But that also means cooks are an integral part of life.

A faster-paced lifestyle also means we are less discerning about many things — we don’t get our masalas pounded at home; we are ready to buy ‘heat and eat’ items, and we use a lot of easy-to-cook meat options, mainly poultry. Fried onion packets have found a way in our homes, as have frozen chopped vegetables. Plus we eat out way more than our counterparts a few generations ago.

Pakistanis are serious about their food so it is not that cooking has taken a back seat. However, other more pressing things have taken precedence. We still cook, but now it is more sporadic, and limited to certain specialties to remind our families and ourselves that we still have not forgotten how to make food. Hiring cooks does not mean women, or men, are not homely any more. It is a social change, one that we must accept, and see cooking as an emerging, respected profession.

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Age of the specialist – Where is the family doctor?

In search of a doctor who treats us as a whole — the one-stop shop for all ailments, both physical or mental

Age of the specialist

We all had that one family doctor. The one who always had time. The one who was always accessible. The one who had given one the first shots as a baby. The one who knew the medical history of the grandparents, the parents, the sons and daughters, and perhaps the grandchildren if the doctor lived through it all. This family doctor was the one stop shop for all ailments, both physical and mental. This doctor treated everything from arthritis to diabetes to heart disease, as well as common complains like the flu or an upset stomach.

This is the doctor who has now disappeared, is missed by many with yearning and nostalgia, and has been replaced by different ‘specialists’ for every part of the body.

The specialists’ option is both more time consuming as well as more expensive, yet it seems this is curveball advancement in healthcare thrown at patients. With more awareness and emergence of newer classifications of illnesses, it seems avoiding specialists is something impossible.

“Going to an ENT specialist for sore throat and to a cardiologist for high blood pressure may feel like getting the best care, and often it is, but the overall health is then overlooked with each specialist focusing only on their area and not the person as a whole. A well-trained family physician is capable of dealing with 90 per cent of common health problems of the individual and his/her family, and appropriately referring to specialist if needed,” says Dr Saniya Sabzwari, Geriatric Specialist at AKU.

Doctors like Dr Mohsin Ali Mustafa agree that the role of the GP is irreplaceable. “Primary care especially in the context of a patient, that is, the role of a family physician is the backbone of a healthy and functioning community. Lack of quality and mistrust of ‘GP Clinics’ in Pakistan has led to people approaching consultants as their first stop for medical needs,” he says. Dr Mustafa is the co-founder of Clinic5.

Clinic5 was established with the aim of reducing the burden of disease by providing primary care in communities, at a cost that the average Pakistani can afford. “A good family physician can treat most common ailments and even some complicated medical cases because they have a good command over not just your medical ailment but also the social and family context. This dual understanding is often missing with a specialist,” he adds.

Yasmin Elahi, a writer, is one of those patients who are not in favour of this trend of reaching out to specialists before the GP. “Doctors these days consider patients not a person but a combination of systems and organs. At 65 plus, I have some chronic health problems. Visiting a dermatologist, ENT, a pulmonologist and a rheumatologist separately, is both time and money-consuming and I often put the less pressing problem in the back seat,” she says, and points to an important and perilous side-effect of this trend: self-medication and seeking over-the-counter advice from pharmacists instead of doctors, which more and more patients have begun opting for, just to avoid the expenses as well as the long wait involved in getting an appointment with specialists.

“Nowadays specialists are not ready to listen to any complaint other than what falls in their own field. Family physicians don’t charge a lot whereas with specialists you have to pay an exorbitant amount.”

A popular career choice these days when it comes to healthcare is being a physician’s assistant (PA), world over. Its popularity is perhaps the outcome of the void being felt by patients due to a sharp recession in the importance and presence of family physicians.

Daniyal Ahmed, a 2nd year student in the US in the PA programme, sheds light on the issue. “The primary care provider (PCP), or general practitioner (GP), is meant to be the first point of contact for a patient. If you are sick, you visit your PCP; if they deem it is beyond their scope of practice, they refer you to a specialist. By eliminating that role, a large gap in patient care has been created — it puts an unreasonable burden on specialists, who are now effectively serving as PCPs in addition to their subspecialty,” he says.

In the US, according to Ahmed, a huge part of the role of PAs is in primary care. “There’s a chronic physician shortage in primary care and family medicine, largely because it doesn’t pay as well as specialties and is a relatively thankless job. PAs and NPs (Nurse Practitioners) are often hired to fill those roles that we don’t have enough physicians for.”

Dr Ambreen Iqbal’s family mostly doesn’t need to see specialists, as she is a family physician who advises them about their basic health problems. “I think family physicians are like gatekeepers who direct one to the right doctor. They have a holistic approach to patient care. Nowadays specialists are not ready to listen to any complaint other than what falls in their own field. Also, family physicians don’t charge a lot whereas with specialists you have to pay an exorbitant amount.”

“In the past, specialists were few and GPS were many. Specialists would come into the picture only when people were referred to them by their GPs; the culture of going on your own to a specialist was simply not there,” says Pervez Muslim, a Chartered Accountant who has observed closely the pros and cons of GPs and specialists as he has been treated by both, in Pakistan as well as abroad. He feels that as more and more doctors started to go abroad for specialisation and began to return to the country to practice, and due to increased awareness, people started to rely more on specialists.

“Affluence in a certain social strata further cultivated the culture of going directly to specialists. Development of better hospitals in the country made it easy for people to go to such hospitals where only specialists practice. Hence, the tide turned,” he says.

Muslim adds that in this day and age, specialisation is the name of the game in every field and profession. “Jacks of all trades are fading with the passage of time.  Their use is now restricted to those who cannot afford to pay to specialists. Unfortunately, this has also become a status symbol.”

The sentiments expressed against specialists, then, seem to be a result of two factors: Firstly, treatment from specialists is a pricier option, and often involves a battery of laboratory tests that patients who are used to GPs find hard to grapple with. The second grievance comes in the form of what seems a lack of empathy. The more a specialist is trained to treat a certain genre of illness, the more disconnected he or she seems with the other illnesses.

“I don’t believe it’s necessarily the specialists themselves who lack empathy or understanding of patients; they are meant to deal with very specific health problems,” says Ahmed.

Dr Mustafa feels that the need of the hour is for standardisation of quality at existing GP clinics and an uplift of their infrastructure so that people can trust the care being dispensed at these centres. “This makes both clinical and economic sense.”

While Dr Sabzwari agrees that the specialist mindset has fragmented care of individuals and families, she adds that it is unavoidable. “The need for specialists will always remain for complicated problems, difficult diagnoses and ailments requiring complex management.”

Thus, varied opinions notwithstanding, and much as patients may resist to the idea, it seems specialists are here to stay.

http://tns.thenews.com.pk/age-specialist/#.W3Uym-gzbIU

One against twenty – The only differently-abled candidate in Elections 2018

Differently-abled Raza Shah is contesting elections from PS-103, and probably he is the only such candidate

One against twenty
He dreams of climbing the K-2 one day. But contesting against 20 heavyweight contestants in Karachi’s thickly populated and ethnically diverse constituency PS-103 is possibly tougher than climbing a mountain, especially if one is an independent candidate who does not have the backing of the affluent.

For Raza Shah, the fact that he is one of the few, or possibly Pakistan’s only differently-abled contestant for the upcoming general elections 2018, his being a polio survivor is not his biggest limitation. “We live in a world where political parties politicise everything to win the elections. If there were other differently-abled contestants, they would have been highlighted by the big parties by now for sure,” says 36-years-old Shah.

For everyone in their lives, there is one moment of epiphany. So it was for Shah who, witnessing the issues people like him faced and the fact that they had no one to solve the problems, realised he must step up. “For every problem, one had to either contact political bigwigs through networks and contacts, or through giving money. The people who were our points of contact knew nothing about our problems. I thought to myself ‘why can’t I be that point of contact?’.”

From 8am to 3am, Shah and his core group of supporters knock door to door in their constituency for the Sindh Assembly seat PS-103. Gradually, people are getting convinced, and the response is very positive, according to Shah, because he is one of them. But it hasn’t been easy. “Har party ke hissay kee gaaliyan bhi mein ne khayi hain (I have been hearing abuses in place of the other political parties),” he laughs and says, because when he goes to convince people, they ask what can he do if those political giants could do nothing, only to be convinced that here is a man who actually has the will to fight the odds and help his community. And the will is perhaps all it takes.

Campaigning has taught him a lot, as interacting one-on-one teaches what hours on the podium giving speeches doesn’t. “I have also learnt that our people are very hospitable and make sure you take chai or cold drinks, but there are no public toilets in Karachi,” he says, pointing out a legitimate issue in the garb of humour.

While newspapers proudly sported the headline given by Election Commission of Pakistan (ECP) that disabled people are being facilitated and are allowed to vote through postal ballot, where is that much-awaited headline that says that differently-abled people are contesting elections? Yes there are reserved seats for them but is that enough? For Shah, his contesting the elections is also about making a point about social inclusion. Parties like Pakistan Tehreek-e-Insaf (PTI) and Pakistan People’s Party (PPP) have sections in their manifesto talking about ensuring rights of the differently-abled.

Campaigning has taught him a lot, as interacting one-on-one teaches what hours on the podium giving speeches doesn’t.

Other major political parties have not even bothered to do that. However, Shah feels that this is all good to the extent of manifestos only, but Pakistan’s differently-abled need more than just job quotas. They need their voices heard. “Practically, no one has fielded differently-abled candidates from their parties, have they?” says Shah who contracted polio at the age of one and a half. “Every day is a fight, living with this [disability]. If I can fight this, I can do more.”

An optimist, Shah feels that more and more independent candidates will come up in elections over time. “Voters will also understand over time that those who spend crores on election campaigns will obviously invest that much to earn it all and more back after the elections. It is independent candidates who are focused on solving people’s problems because they are in it to serve their communities,” he adds. His election symbol is brick. “It is a symbol of constructing something. It reflects the ideology of progress.”

Shah also does not see his disability as his claim to fame. “I tell people that if I can contest elections with limitations like being an independent candidate, putting up a fight against representatives of Pakistan’s biggest political parties, and on top of it being differently-abled, then so can you. I am a reality. I am part of the equation, even though I have limitations. Unless citizens like me stand up for themselves, and gain the strength to help their communities, no one is going to help us.”

http://tns.thenews.com.pk/one-twenty/#.W3Uw2ugzbIU