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Monthly Archives: August 2018

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This is the doctor who has now disappeared, is missed by many with yearning and nostalgia, and has been replaced by different ‘specialists’ for every part of the body.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

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.”

As the door opens to guests…

While much remains the same when it comes to traditions of eid, there is a lot that has changed

As the door opens to guests…
A wave of nostalgia grips most of us when we reminisce about eid of bygone years.

The countdown to eid would begin the day the Ramzan moon was sighted. As children, we would go out in the garden or on the roof and try to catch a glimpse of the moon on chand raat. Thereon the preparations would begin.

The sewaiyyan, the sheer khorma, the mehndi, the glass bangles, the trolley set for guests, the giddy excitement whenever the bell rung, the eidee…eid was festivity at its best.

Eid is the highlight of the year for so many of us. Or is it? While much remains the same when it comes to traditions of eid, there is much that has changed.

For starters, on eid one could just go and ring a relative or neighbour’s bell, go in for a treat, and enjoy. There was an excitement in the anticipation of who would come to visit. However, over time the concept of “Open House” was introduced. There is now a specific time on which the doors open to guests. If you miss that time window, it is unlikely that you will get a chance to go there again.

Faster times. A faster world. Another thing that has changed is the practicality. If we have met someone on the first day of eid as they visited you or met you at your grandmother’s, we no longer want to meet the same people again by visiting them, unlike the earlier culture of exchange visits, where if someone visited you, it was a must that you also visited them.

There are also lesser of the big, gigantic eid get-togethers at the homes of the elders of the family, simply because families have grown and multiplied, house help is less readily available or affordable, and quite frankly it’s too much work for the overworked daughters-in-law or daughters who used to be doing the tough work of pulling off lunches for 80 people every eid. Yes, our societal dynamics are in flux, if not completely altered.

Some 20 years ago, girls were so conditioned to put mehndi on their hands for eid that it never even occurred to them that eid could be without mehndi. From the crushed raw henna leaves era to the chemical-filled henna cone era, and now to the glitter-filled henna tattoos — henna still remains a part of the eid tradition. But many no longer choose to have it applied. Some find it itchy, others don’t like the smell, and yet others feel it looks very unprofessional to go to office the 4th day of eid with henna peeling off one’s palms.

There are also lesser of the big, gigantic eid get-togethers at the homes of the elders of the family, simply because families have grown and multiplied, house help is less readily available or affordable, and quite frankly it’s too much work for the overworked daughters-in-law or daughters.

Some things may have changed for the better, though. While a majority of women still don’t get why they should also go to the mosque for eid prayers, mainly because their men still don’t get it, there is a growing number of Pakistani women at least in the major cities that do go for eid namaz. I happen to be one of them and I can say safely that it is a beautiful experience that acts like a bridge between Ramzan and the rest of the year.

In the absence of going for eid namaz, the spirituality and the connection with the Creator one has inched towards in Ramzan is suddenly lost on eid morning, and eid becomes just another day, barring the eating and meeting and dressing up.

As for eidee, it still remains an intrinsic part of eid, and children (they could be in their 40s for all you know) look up to their elders in the hope of that coveted envelope. However, in earlier times one would give eidee to any and every younger person one met. Now parents have become smarter and more calculative. They have separate lifafas (envelopes) for those who give to their children generously, compared to those who give smaller sums.

Read also: Eid with Maria

But perhaps the most obvious change is that so many of us use eid holidays for vacationing. With the number of Pakistani expatriates increasing by the minute, and a few family members travelling on eid for vacationing, there is that void that not having one family member leaves for the rest, especially on happy occasions. Add to it that many parents can be seen complaining that their children sleep it out on the eid day.

But there are some beautiful traditions of eid that continue to date. Giving (starting with the fitranah), feeding (the sewaiyyan above all), sharing (eidee is sharing money, isn’t it), reconnecting with relatives, looking good, feeling good, and celebrating having gotten the opportunity of another Ramzan. It is hoped that this — the real spirit of eid — will survive the test of time.

In Pakistan, restaurants only care if you fast, but not if you pray

 Published: June 8, 2018


Muslim women activists pray the Maghrib sunset prayer before Iftar outside Trump Tower in New York, US, on June 1, 2017. PHOTO: REUTERS

“Fast, pray, feast!”

This attractive marketing tagline, alongside tempting pictures of food, is being circulated by a well-known eatery this Ramazan, as is the case every year. Not only is the food tempting, but also the deals. And why not? When one opens their fast at sunset in this most special month for Muslims, delicious food is but a must.

But there is one issue. While they openly marketed the “pray” bit, there is no place for praying if you go to said eatery for an iftar deal. A young girl I spoke with who went there with her friend said the staff looked shocked when she asked where she could pray.

“They said we have no arrangements, because no one wants to pray generally, barring very few people. I told them I am from those very few and you must help me; I need a very tiny corner for just five minutes. At my insistence, they made me stand between tables crowded with people. It was a very uncomfortable experience. Not going there again in Ramazan.”

This is not just about one restaurant or café. Except a few places, you can literally count on your fingers how a majority of restaurants milk the blessings of Ramazan by introducing dealswhich help increase their sales, but do not have the sensitivity towards those customers who want to pray.

This has been a topic of discussion on social media and otherwise since years, but nothing seems to come out of it. I have prayed on dusty floors, with music playing and people passing in front of me, whenever I dared to go for an iftar meal. The problem for women is even more pronounced, because men can go for prayers to a nearby mosque if need be, but except for limited mosques that allow women to pray, there is no concept of mosques as public spaces for women.

Ironically, many mosques allow women to come for Taraweeh prayers in Ramazan, a voluntary prayer, but will not open their doors to women for the obligatory five prayers.

As someone who has been trying to bring this issue to the attention of the owners and the management of restaurants for years, their responses on social media have been less than empathetic.

“Why do you need to go and eat out in Ramazan if you are so religious? Do your iftar at home. Can’t you live without eating out?”

These, and other stronger reactions, are normal now. It is as if people who want to pray in Ramazan are not welcome to mingle in society and go out to eat, and are meant to stay in bubbles or at home.

Sure, one can do iftar mostly at home. But there are times you are invited to go out. And there are times you feel like going out to eat. The reverse discrimination against people who attempt at being practicing Muslims in the Islamic Republic of Pakistan is real. On the other hand, I have experienced refreshing cooperation from non-Muslim friends and from strangers while traveling abroad whenever I needed to pray.

This issue is not just specific to Ramazan. However, in other months of the year, one can plan to go out to eat at a time when prayers are not disturbed. But when fasting, this is not a possibility.

There are many possible solutions to this, and some select restaurants have employed these solutions. For example, a well-known oriental restaurant in Clifton has made arrangements not just for their own customers to pray, but also welcomes customers of nearby eateries. At other places, they request you to pray quickly and by turn, but have the good sense to at least keep prayer mats. But such restaurants are numbered.

So here’s sincerely requesting restaurants: the next time you use the Ramazan tagline to boost your sales, have enough empathy to reserve a small corner of your restaurant for 15 minutes so that those who want to pray can do so with ease. If for nothing else, then in the spirit of the compassion that Ramazan is all about.

Ralli-ing together

A traditional art form has become an unlikely symbol of women empowerment and inter-generational love

Ralli-ing together
Ralli-making (also known as Rilli) comes from the word “ral” which means to mingle. This traditional art form provides women an activity that transforms their homes into women-friendly spaces where women gather and sew bits and pieces of fabric into a quilt. It is a test of creativity, turning whatever pieces life has left them into a thing of beauty and utility – from nothing into something. Even today, if you go to interior Sindh, the lady of the house will spread out her best Ralli on the charpoy and motion you to make yourself comfortable.

The art of quilt-making is, thus, metaphorical in many ways. Women create homes out of small and big things gathered and assembled together as a labour of love. It requires accuracy, patience and hard work. Making a quilt is similar.

When Samiah Ahsan Zia and Samina Qureshi co-founded a group for women in 2008 with a passion for quilting, little did they know that more than a dozen passionate quilters would join hands with them. “The Piecemakers’ Guild”, as the group is named, recently held its 4th exhibition in Karachi. With quilts on display and on sale, the work of these women is nothing short of art.

The love for quilting took time to grow on Zeba Rehman, one of the group’s earliest members. Her eye-catching quilt with shades of white and indigo is on display. “I now spend days sitting near the window in the sunlight, sewing each piece carefully, with my glasses on. When I am working on a quilt, I can go on working non-stop for hours,” adds Rehman.

“We are 16 members, all very committed, who meet every fortnight. Senior quilters train new quilters. We use varied techniques,” says Samina Qureshi. Her piece was the winner of the Mughal Art Challenge this year, in which she has used many mediums like applique, block-printing, sequence and thread embroidery, and even printing. “I find quilt-making therapeutic; it has a calming effect,” adds Qureshi.

Samiah Ahsan Zia echoes Qureshi’s sentiment. “It keeps the mind and hands busy and offers an avenue to express one’s creativity. Patchwork and quilting has been practiced world over since time immemorial. Modern tools have added new dimensions to it,” she says.

The art of quilt-making is metaphorical in many ways. Women create homes out of small and big things gathered and assembled together as a labour of love.

For Nida Huq, another member of the Guild, the inspiration came from her mother who has passed away. “It was my way of remembering my mother as she used to sew,” she says. Huq finds the activity very effective for stress management. For her, the most rewarding piece has been the raffle quilt which has been completed by the team to fund-raise for a good cause.

“The money from the raffle quilt will be donated to the Child Aid Association which operates from the National Institute of Child Health and treats children suffering from cancer. We treat quilting not just as a hobby but try to use it for social activism for causes close to our hearts,” says Zia.

The group was also invited to participate in the Karachi Biennale 2017, and challenged to convert a discarded electric cable reel into an art installation. “Our reel, titled ‘Heroines not victims’ was designed to be a tribute to Pakistani women and their resilient spirit, highlighting their achievements despite immense socioeconomic challenges and rampant misogyny,” says Zia. The group has also intermittently worked with groups of women from interior Sindh to help hone the skills of rural women in the art of ralli-making. “We hope that while staying true to their age-old craft, their work would become more contemporary and hence more marketable.”

For Rehman, a mother of two sons, the aim is “to leave one quilt each for my two future daughters-in-law as a personalized family heirloom”.