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Women should leave the hospital with a contraceptive

Pakistan must ensure that women are included in the family planning process

 Published: September 26, 2019

An Internally Displaced Pakistan woman from the North Waziristan tribal region carries her sick child. PHOTO: AFP

By Farahnaz Zahidi

Her backache is better, and she is feeling relieved for more than one reason. An hour ago, Azra got an Intrauterine Contraceptive Device (IUCD) which she calls a Challa (ring) inserted, with her own free will; the IUCD will potentially give her a break of five years from conceiving a child. This 30-plus years old mother of three, who does not know even her own exact age, knows well now that to remain healthy to look after her three children, and to possibly give birth to healthy children in the future, her body needs a break. Azra had come to the Naudero Rural Health Centre (RHC), District Larkana, Sindh, complaining of bleeding since eight days. This was her second miscarriage. The medical staff, after an ultrasound, told her she had been pregnant since nine weeks and her pregnancy could no longer be sustained. As her dilation and curettage (D&C) was performed, she also got the IUCD inserted. “My husband did not want me to use a permanent method of contraception as we may want to have children after a gap of some years,” she said. Muhammad Panjal, her husband, and Azra herself, mutually decided to go for a long-term contraceptive, an IUCD in their case. “One of our focuses presently is to encourage women to go for long-term contraceptives, like we did for Azra,” says Naghma, working for Pathfinder as a Technical Supervisor for the district of Larkana for Family Planning (FP) related initiatives. Azra is all praise for the staff at RHC who made her understand what was best for her and her family. “We counsel the patients mostly during the antenatal visits; this gives us enough time inform them about the various choices of contraceptives, their benefits, as well as side-effects if any. The decision, then, remains with the patient; she chooses, after discussing with her family, the FP method best suited for her,” says Dr Erum Siyal, working at RHC Naudero.

Dr Siyal explains why Post-partum family planning (PPFP) is a key focus for FP in areas like Naudero. “Once they leave the hospital after delivery, they rarely come back. Reasons are many. Lack of mobility, lack of resources to pay for transport to reach the hospital, lack of awareness – these are all deterrents,” she says.

Dr Azra Ahsan, a gynecologist and obstetrician with a special focus on family planning and maternal health, terms the focus on PPFP as being “extremely important’, adding that it is all the more important because the Contraceptive Prevalence Rate (CPR) is insufficient for effective family planning, which means people are not using enough FP methods. “The silver lining, however, is that women are coming to health facilities to have their babies in increasing numbers. This is a moment to seize and an opportunity not to be missed,” says Ahsan.

Grass root level initiatives like Naya Qadam, implemented by Pathfinder International, have an increased focus on access to post pregnancy family planning. Naya Qadam is a consortium of six organizations – Pathfinder, Aahung, Greenstar Social Marketing (GSM), National Committee on Maternal and Neonatal Health (NCMNH), IPAS and Shirkat Gah – working in six districts of Punjab and Sindh provinces. The objective is to increase access to high quality PPFP with a focus on young women (age 15-24) in Sindh and Punjab. Naya Qadam is introducing a multi-sectoral, counseling-centered, integrated life cycle approach to post-pregnancy service delivery. It aims to lessen the widening gap between service availability and unmet need by upgrading lady health workers, community midwives, and lady health visitors’ (LHVs) capacity to offer services through redesigning antenatal care as a lever for taking full advantage of the postpartum moment to offer FP.

Women like Azra go back to their villages after getting contraception, and become informal activists of FP, convincing their female friends and relatives to do the same. According to Dr Siyal “the awareness has increased and continues increasing at a fast pace”.

57-years-old Salma John from Jamshed Town, Garden East Karachi, has been working as a Lady Health Worker (LHW) since 2003. “Contraception should be carried out within 24 to 48 hours after delivery or DNC, and within ten minutes after the placenta is expelled. That is the best time to do it, otherwise most women do not come back for follow up.” John shares that condoms and pills still remain the most popular methods of contraception. Examples of modern methods include the pill, intrauterine devices, implants, injectables, and condoms. “With the help of Naya Qadam’s training sessions, we learn something new every time,” says, John, explaining how LHWs stay abreast with the latest developments in the field of FP. Each LHW, in John’s area, covers a population of 1000, which means she has to visit 100 to 150 houses. “Attitudes vary greatly across ethnicities and demographics matter a lot,” says John.

Experts predict that by 2030, Pakistan’s population will swell up 245 million, making it the 4th most populous nation in the world. According to the latest Pakistan Demographic and Health Survey (PDHS) 2017-18, 17 per cent of currently married women have an unmet need for family planning. If all married women who want to space or limit their children were to use a family planning method, the contraceptive prevalence rate (CPR) would increase from 34 percent to 52 percent. Only 34 percent of currently married women are using a contraceptive method either to space or to limit births.

Zahida Parveen, an LHW for District Okara, Punjab, sounds very hopeful. “Over 20 years as an LHW, I have visited thousands of houses, often visiting 15 houses a day. And I have seen how the awareness about family planning has grown exponentially. Initially people were so skeptical of LHWs visiting and counseling them, especially about FP, that they would not even touch the Paracetamol we sometimes gave them for pain or fever. The mother-in-laws in particular felt we are part of some sinister scheme to stop their daughters-in-law from having children, and want to stop their future generations from coming into this world,” she says. Now, she happily reports, even long-term contraceptives like IUCD are accepted as a choice by many women. The training she and other LHWs are receiving by Naya Qadam has taught them about newer forms of contraception too, like Levonorgestrel Implants – implantable subcutaneous contraceptive capsules – sold under brand names like Norplant and Jadelle. “It has taken years to win over the trust of these families; now they are open to the counseling services we provide for them,” says Parveen.

Social attitudes and changing mindsets remains one of the biggest challenges. Based on her experience of more than 15 years, John feels that attitudes towards FP have improved. “Now women are becoming aware enough to themselves giving permission to get contraceptives. However male involvement is still deep-rooted, as are the pressures of in-laws. One of the biggest tasks of LHWs is counseling the families,” she says.

“Women are raised in the community to accept patriarchy and gender inequality, letting go off their rights to choose for themselves. This further empowers men and other household figures, like mothers-in-law, to decide about potential size of families,” says Tabinda Sarosh, a women’s rights and reproductive health advocate, and currently the Country Director of Pathfinder International. In many families, desire to have sons results in increase in family size, and men make most decisions on health, economics and rights of family members, yet do not take responsibility for contraception, she explains. As someone who is running projects with the Government of Pakistan for quality services of FP, Sarosh feels that the most important solution to the problem is re-construction of the existing social and gender norms, by working from policy to communities, through multi-level and multi-sectoral interventions. “Combining health, education, gender, and micro-finance interventions to create an enabling environment for women to get equal opportunities in education, employment and health related decisions” is the baseline solution in her opinion.

Provincial governments are showing an upward swing, and the thrust on FP seems to have started to show improvement.

Minister for Health, Punjab, Dr Yasmin Rashid, is focusing especially on two areas as priority – Maternal Health and Child Health – says Dr Akhtar Rasheed, who works as Technical Lead for Family Planning and Nutrition, government of Punjab, assistant the province’s Minister for Health as Adviser. “We want family planning to become a means for improving maternal health by ensuring that women have a gap of at least three years between having children,” he says. 1195 basic health units are working 24/7 in Punjab, in addition RHCs, DHQ hospitals, and tehsil-level hospitals. “Our focus is on facilitating antenatal care and visits, and use this opportunity to counsel the women to go for long-term family planning,” says Rasheed.

Focal person of the Sindh FP2020 and Technical Adviser of the Costed Implementation Plan’s (CIP), Dr Talib Lashari, says that the CIP’s implementation in the province of Sindh is underway at a fast pace. The province of Sindh became the first province to come up with a roadmap, the CIP, for achieving FP2020 goals. “Our focus is on increasing and enhancing existing services. We have 72 Reproductive Health Service A Centres (RHS-A) located in DHQs that supply a full range of all kinds of contraceptive methods. A new choice among contraceptives that has been approved is an easy-to-use subcutaneous contraceptive injection that women can give to themselves to prevent pregnancies for short term like 3-months; it is called Sayana Press. This has been introduced in 17 districts already and will be introduced in another 12 districts by December. Our aim is to increase the CPR to 45% by 2020. Post the release of the latest PDHS, research conducted by departments under the CIP Secretariat shows that the CPR has already reached 34%. But to reach our target, we will have to work two fold,” says Lashari.

Both the Sindh government and Punjab government provide contraceptives free of cost. In Punjab, the government even gives women the facility of free pick up to reach the hospital for deliver free of cost to encourage them to deliver at proper health facilities.

What is a fresh spin on the strategy for FP is that to increase the contraceptive prevalence rate (CPR), the government of Sindh is now focusing on urban migratory population and slums. “For this the Karachi Urban Plan is being made. Part of the efforts is to counsel migratory communities in their own language. We are focusing on PPFP, and 1758 doctors are being trained across Sindh for it. Tertiary hospitals are also being looped in for FP efforts. Trainings are also being conducted for helping insert devices that release levonorgestrel for birth control,” says Lashari.  He adds that in Sindh the political commitment is a hundred percent. However, he accepts that while there are opportunities, there are challenges too, and much needs to be done. “We have a window of optimism due to the above steps being taken.”

“When a woman goes through the often traumatic experience of a miscarriage, an abortion, or childbirth, and especially if her pregnancy was not a desired one, she is more receptive to the idea of getting PPFP. By PPFP, I mean both post-partum family planning and post-pregnancy family planning. That is the best time to make sure she goes home with a contraceptive,” says Rasheed.

While modern methods are being introduced and both public and private sectors are working on increasing awareness about FP as well as working on supply of contraceptives, there is little that can be done to bring women back to the hospital once they leave. Thus, post pregnancy family planning remains the key. “The women should not only leave the hospital with a baby, but with a contraceptive too,” says Ahsan.

An abridged version of this article was published in The Express Tribune here.

Let us talk numbers – Contraception in Pakistan

For Pakistan to climb the ladder of development indicators, the issue of family planning needs urgent attention

Let us talk numbers
Only 34 percent of married women are using a contraceptive method.

While we are at it, let us talk more numbers. According to the latest Pakistan Demographic and Health Survey (PDHS) 2017-18, 52 percent of currently married women age 15-49 in Pakistan have a demand for family planning (FP), 19 percent for spacing births, and 33 percent for limiting births. Only 34 percent of currently married women are using a contraceptive method either to space or to limit births, and therefore have fulfilled their need. However, 17 percent of currently married women have an unmet need for family planning — 10 percent want to space and 8 percent desire to limit births but are currently not using any contraception. If all married women who want to space or limit their children were to use a family planning method, the contraceptive prevalence rate (CPR) would increase from 34 percent to 52 percent.

Humans require developed ecosystems to survive and thrive, something that we are unable to provide to more than 220 million people. Of the 17 Sustainable Development Goals (SDGs), Pakistan is lagging behind at most. According to UNICEF, 23 million children between the ages of 5 and 16 are out of school in Pakistan, a whopping 44 percent of the total population in this age group. There are some five million children between the ages of 5 to 9 who are not in school, making it the world’s second-highest number of out-of-school children (OOSC) at the primary level. Not just this but also that gender-wise, boys outnumber girls at every stage of education. In Balochistan alone, 78 percent of girls are out of school. For every 10.7 million boys that are enrolled at the primary level, 8.6 million girls are enrolled, and dropouts of female students remain high. Health experts say that over 44 percent of Pakistani children under five years are stunted due to chronic malnutrition.

It is not that Pakistan is not working on these issues. Yes, clearly, the work is not enough, but there is something more to the failing state of our social indicators. That is, perhaps, the missing link we do not see enough work being done on — family planning. The strapping Pakistani youth in such high numbers could be Pakistan’s asset; they are, instead, Pakistan’s Achilles heel. The nation has to not just feed the 220 million plus people. It also has to provide opportunities for growth and development so that Pakistani people can tap into their potential for economic prosperity of themselves and of the country.

The dots have been joined. Why, then, are we failing at it?

Lack of political will, and perhaps realisation among the upper echelons of power regarding the importance of mitigating this increase in population has been a consistent issue. Earlier this year, the Ministry of Health formulated an action plan for population control. The draft shows that the government is aiming at obtaining universal productive health services by 2025. The buck stops at the National Task Force on Population Control, headed by Prime Minister Imran Khan. But the real test is not just the approval of such action plans, but actually the implementation. The plans have been multiple but the implementation has clearly not been enough. When a country’s biggest issue has been its national security, followed if not preceded by layered and debilitating economic crises, family planning seems to be a lesser important challenge. In reality, it is one of the biggest ones.

What the proposed law is doing is updating an old piece of legislation with some new principles of human and women’s rights and ensuring that processes are made easier and more streamlined and that the suffering of a significant number of people in their country is reduced.

Healthcare persons and experts working at the grass root level cite many potential issues. While antenatal care and visits from a skilled healthcare provider may have improved, there is still much to be done. Midwives and lady health visitors can play an imperative role in this, and it is these programmes that need to be strengthened through their training and capacity-building. Perhaps this is why modern contraceptive use by married women has stagnated over the last 5 years, with 26 percent of women using a modern method in 2012-13 and 25 percent in 2017-18, according to the PDHS. Lady health workers play a major role in dispensing injectables, oral pills, and condoms to women, 18 percent, 26 percent, and 15 percent respectively.

Modern methods include injectables, intrauterine devices (IUDs), contraceptive pills, implants, male condoms, the standard days method, lactational amenorrhoea method, and emergency contraception.

69 percent of unplanned pregnancies end in induced abortion in Pakistan, states a recent study by Guttmacher Institute titled “Adding It Up: Costs and Benefits of Meeting the Contraceptive and Maternal and Newborn Health Needs of Women in Pakistan”. The study further informs that fully meeting married women’s need for contraception would lead to an estimated reduction of nearly 1,000 maternal deaths annually.

Contraceptive discontinuation, myths surrounding use of modern contraceptives, fear of side effects, lack of awareness, an absence of decisions made mutually by the couple without interference of mothers-in-law and societal dictates — the reasons are multiple.

World Contraception Day falls on the 26th of September. It is a reminder that for Pakistan’s well-being, much needed impetus for the issue of family planning is the solution. It is only then that Pakistan can hope to climb the rungs on the ladder of development indicators.

http://tns.thenews.com.pk/let-us-talk-numbers/#.XZGtB0YzbIU

 

Different strokes for different rozaydaars

Times have changed and so have the food choices of those observing the fast

Different strokes for different rozaydaars

The idea, back then, was that you need to stuff yourself with such food at sehri that will help you not feel hungry, nor thirsty till Iftar. While that never actually happened, nutritious and filling foods like khajlapheni, and qeema  or aloo parathas kept one full enough at least till mid-day. And then we topped it off with jugs of water, and lay there on a couch later, panting with over-eating, filling up our bellies in the hope that the holy month would suddenly give us the capacity of a camel to store food and fluids.

That was the era where we didn’t care about good cholesterol or bad cholesterol, and it didn’t really matter if, instead of losing weight, Ramzan meant gaining a few pounds. Ramzan is about self-control, starting with food. It actually has been interpreted by a foodie nation as being just the opposite — about indulgence in food. But with awareness about healthier food choices, all of this may have begun to change, at least in urban Pakistan.

One thing is for sure: the health-conscious fasting person now focuses more on sehri than on iftar, particularly, if the said person also wants to pray peacefully at night, at home or at the masjid. For such people, they have a completely altered routine in Ramzan. Heavy, oily food, and an overload of beans and chickpeas can cause bloating and digestive issues, even though the latter two are very good sources of nutrition and should be taken in moderation.

The one change that we see is that unlike earlier when people used to first have iftar, then dinner a few hours later, and then sehri, the more conscientious eater is eating just two meals a day, with in-between healthy snacking if needed.

For many of us, the parathas and khajlas made of white flour and laden with fats have been replaced by porridge, oatmeal, brown bread, chapatis made of whole-wheat flour, and even brown rice. However, some things still remain indispensable for sehri, like eggs. Eggs have earned that spot as a favourite for good reason. Eggs provide 13 essential vitamins and minerals (vitamin D, riboflavin, selenium), antioxidants Lutein and zeaxanthin, and high-quality protein, all needed for one who is fasting.

The new entrants are the health-benefit items that once were seen as medicinal, but are now seen as “snacks”.

Dates, traditionally seen as the thing to open one’s fast with, have now made their way to the sehri meal as well. They are not just high in antioxidants, fiber, and potassium, but also provide essential nutrients, such as vitamin B-6 and iron. Bananas, an essential component of the fruit chaat, is now being eaten by the health-conscious rozaydaar as part of the morning pre-fast meal as well, as they provide fiber, potassium, vitamin B6, vitamin C, and various antioxidants and phytonutrients.

One of the things a person fasting in summers goes through is possible dehydration, or an electrolyte imbalance. Bananas, known as the leader among fruits and vegetables containing potassium, help control muscles and blood pressure. Thus bananas replenish electrolytes.

While restaurants offer attractive deals, the regular and more cautious people who observe fasting are being seen avoiding the eating out experience. “Unless it is unavoidable, me and my family have stopped eating out to eat at iftar,” says a regular fast-keeper. “The food in restaurants, no matter how tasty, will be always more oily, more rich in spices, and probably less hygienically prepared compared to home-cooked food.”

“When the fast is broken after almost 15 hours, it takes the body time to adjust to eating and drinking. It’s not a good idea to suddenly overload your system after a break from eating for a long time. The food’s not going anywhere! Why not have it in breaks, going gentle on your system?”

Also read: Oh, this makes sense

The new entrants are the health-benefit items that once were seen as medicinal items, but are now seen as “snacks”. You might see a particularly health-aware friend munching on iceberg lettuce with pine nuts topped with chia seeds as a post-iftar snack. Another relative might be having a combo of flaxseed, pumpkin seeds, and prunes with yogurt at sehri. And yet another one might be seen sprinkling moringa leaves powder on top of a sugar-free fruit chaat.

Different strokes for different rozaydaars.

Yes, times have changed and so have the food choices of those observing fast. Many of these changes are positive. Perhaps people have begun to realise that Ramzan and fasting do not remind us of stuffing our mouths with food on tables laden with 20 items, but in fact this month is a reminder of the joys of simple, wholesome, healthy food that is a blessing from the Creator. Abundance is, then, perhaps, in our attitude towards food, not in the quantity. It is the month of gratitude. Good health calls for gratitude, and practical gratitude demands taking care of your health.

Happy fasting and healthy feasting.

http://tns.thenews.com.pk/different-strokes-different-rozaydaars/#.XRMjE-gzbIU

No time to sensationalise – How Media Reports Suicide

The journalists reporting on suicide in Pakistan are not really trained to do so. They are learning as they go along by trial and error

No time to sensationalise

Death induced by suicide is a life cut short by self-directed violence. It finds its way in the newspapers and news TV channel segments readily. Often mediapersons reporting it do not know what an important part of the equation they are: With every suicide, there is an unfortunate but important duty laid on the shoulders of the mediaperson working on that news story. Will this opportunity be used to raise awareness, and perhaps help save lives from a similar fate? Or will it be just another sensationalised bit of news?

The choice is ours. We, the journalists, have important work to do in society as relayers of information. This must be done carefully, consciously, and sincerely.

But when it comes to mental health issues, particularly suicide, is it really the fault of the journalist, when he or she has never been trained in the subject?

Journalists have “beats” to report on; health is an important beat — public health, sexual and reproductive health, maternal and child health, and other sub-specialties under the health beat.

However, there has been no formal training of Pakistani journalists to date on how to have mental health as a beat, and how to report on it. If a journalist has organically acquired a certain sensitivity to report on delicate issues, then he or she will apply it when reporting on suicide as well. Yet journalists may often get lost in the quagmire of details when reporting on a suicide. Details like the where, when and how. The opportunity of raising awareness on the issue is often lost in such reporting.

This year in June, fashion designer Kate Spade and celebrity chef Anthony Bourdain died by suicide just days apart. There have been relatively well known Pakistanis who died after committing suicide. This has shed media light on the subject. A study on ‘Newspaper Coverage of Suicide‘ done at Sindh University by Mahesar RA states that “One person, after every 16 minutes, dies not merely because of accident or any other disease but intentionally because of suicide [sic]”.

However, the journalists reporting on it in Pakistan are not really trained to do so. They are learning as they go along by trial and error. The subject of “suicide” — and mental health on the macro level — is staring at us in the face as an unavoidable news beat. But the lack of training leaves means we are making mistakes.

Reporting on suicide, and mental health issues, is a huge responsibility, as well as an opportunity to make a difference. These are not stories to be sensationalised. These are not lifestyle or entertainment stories.

One of the most common mistakes is extreme positions taken by the media when reporting on suicide. One extreme is stigmatising and re-stigmatising both the person who committed suicide as well as the family. The sad music while reporting on suicide on tv, the hackneyed jargon, the nuanced but audible judgment in the news report — it all shows a lack of objectivity.

However, the other dangerous extreme is romanticising the act of suicide — of glorifying it, and instead of presenting facts about this act of extreme self-directed violence, perpetuating myths about it and calling it a “choice.” With the suicides of the aforementioned celebrities (Spade and Bourdain) experts began talking about the risk of triggering what is called the “Suicide Contagion.”

Experts of mental health affirm that suicide (of one or multiple well-known people), can lead to an increase in suicidal behaviour among people who are already at a risk of it. Thus, it is important that these news reports do not just mull over details and allude to it as a heroic act, but present the fact, which is that suicide is, in a majority of cases, linked to mental health issues.

Suicide almost always is not something that happens suddenly out of the blue. It has been considered by the person earlier. There may have been warning signs which people close to the person may have missed. An article published by International Journalists Network titled, Guidelines for Reporting about Suicide, aptly suggests to journalists that they must not suggest that a suicide was caused by a single event. “Suicide is complex, and is often the outcome of different causes, including mental illness — whether recognised and treated or not,” says the article.

Giving details of the method employed for the suicide may also contribute to the suicide contagion. Graphic details and photographs are not only disrespectful and insensitive to the deceased and the bereaved family, but also end up giving ideas to those who may be thinking on the same lines.

Care must be exercised even when writing an obituary for the person who left this world — whether as a journalist on a news platform or as a friend or peer on the many social media platforms. Be careful of the language you use. And most importantly, focus objectively on that person’s life instead of the methodology of death.

Pakistan Tehreek-e-Insaf’s then presidential nominee, Arif Alvi, had publicly suggested a readily available 24/7 psychiatric helpline in September 2018. In November 2018, the President, while addressing the 22nd International Psychiatric Conference organised by Pakistan Psychiatric Society (PPS) said that everyone should play his role for establishing a healthier society in the country. The government can and must play its role too in this regard, and the media can play its role by reminding policymakers and those in positions of power to recognise that mental health must be put on the forefront of the list of priorities when it comes to public health.

WHO’s 2014 report, “Preventing suicide: a global imperative” estimates that for every suicide there are at least 10–20 acts of Deliberate Self Harm (DSH). By this estimate, there may be between 130,000 to 270,000 acts of DSH in Pakistan annually. This means that there are signs before the actual act of suicide is completed. Journalists must include then, after consulting a mental health doctor or therapist, some points about how to recognise the signs that a person may be inching towards suicide, and what can be done to help such a person. The reader can also be directed towards Suicide Prevention Helplines.

Reporting on suicide, and mental health issues, is a huge responsibility, as well as an opportunity to make a difference. These are not stories to be sensationalised. These are not lifestyle or entertainment stories. These are stories that come under the beat of “health”. Once journalists recognise this, the reporting will become more responsible. Most importantly, out of these dark and seemingly hopeless news stories, there can emerge a ray of hope — the hope that if reporting is done intelligently and carefully, it may help spread much needed awareness. It may help someone out there. It may help save a life.

http://tns.thenews.com.pk/time-sensationalise/#.XDxIJbhS81k

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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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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Me and my Hashimoto’s – Living with an Autoimmune condition

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If a person has one autoimmune disorder, there are chances that he or she is susceptible to getting another one

Me and my Hashimoto’s

I am a journalist, and there is this thing with journalists – they have this insatiable need to inform others about what they learn. Journalists are people who relay information, even if it is information about an autoimmune disorder they are suffering from.

I have been wanting to write about an autoimmune disorder that I have been suffering from. In turn, I wanted to write about autoimmune disorders – a wretched group of diseases that very many people suffer from, but often do not know what it actually is that is making them feel unwell.

I started asking people who I knew had different autoimmune disorders. Many of them agreed to speak to me for the write-up but requested anonymity. Others refused to speak about their disorder. It is understandable as it is not easy to announce to the world that you have something that makes you feel unwell so often.

But autoimmune disorders need to be spoken about and written about because they are more common than we realise. We also need to speak about what we go through because it is a means of helping those who are going through something similar. Suffering from a disease or a disorder is not something that should embarrass or demean us. It is what it is. All we need to do is manage it the best we can, and for that we need awareness. Write-ups like this one are aimed at just that one goal — creating awareness that might tell someone else reading it that “you are not alone”.

For me, it started with just feeling down and listless and unusually cold, very cold. I saw people around me sitting comfortably in air-conditioned rooms with fans on in Karachi summers, but I felt spears of cold entering my ribs and my back. Getting up in the morning became a struggle. There were aches and pains and just feeling down, with no energy. I started realising that I could no longer lose nor maintain my weight that easily. But I knew it was time for an SOS when out of nowhere I would break out into rashes — rashes that would come out of nowhere and disappear without any medication as well.

I googled all my symptoms. My google search findings remained inconclusive. Not knowing what is going on inside your body is one of the scariest feelings because you cannot do much about what you don’t know.

Awareness about my Hashimoto’s Thyroditis has led me to understand better things like where my constant fatigue stemmed from, and why insomnia keeps making surprise visits to me, and also why unexplained aches and pains keep coming and going.

My symptoms led me to knock on the doors of many genres of doctors — general physicians, skin specialists, orthopedic specialists, homeopathic doctors, and even a psychiatrist, as google kept bringing up the suggestion that perhaps this was nothing but depression. It was finally an allergy specialist who, luckily for me, was extra cautious, and advised me to get my tests done, including one for autoimmune thyroditis. The result was clear. I finally had a diagnosis. I have what is called “Hashimoto’s Thyroditis”, and it is an autoimmune disease. It is an annoying disorder to put it simply and honestly, because it makes life a drudge. The good news is that for the most part, it is not an extremely dangerous condition. Yet, living with an ongoing condition is a test of patience — both physically and emotionally.

To put it simply, autoimmune diseases are when the cops who have the job of catching the bad guys start harming the good guys. It is when the body starts getting attacked by its own immune system, and instead of attacking infections and anything that harms us, the immune system starts attacking the normal body tissues.

Why do certain people get them and others don’t is a question medical science is still trying to answer. It can be one of many reasons. For starters, more women get afflicted by these disorders than men do, and one reason experts give is the female hormones, particularly estrogen, that may lead to a predisposition to autoimmune diseases. Another reason could be hidden in our genetic pool. Certain families report higher incidences of illnesses like Multiple Sclerosis and Lupus, but there is no way of telling why some people in these families get them and others don’t.

Are autoimmune diseases on the rise? Many medical experts believe yes they are, and they feel environmental factors like ready use of chemicals and solvents, unhealthy environments, and infections could be the culprits. But others feel that these diseases have always been there but we are just getting better at diagnosing them. Some suspect the increased use of fats, sugar, and processed foods. Unhealthy food choices lead to inflammation that leads to an overactive immune response in the body. Another hypothesis is that use of sanitisers, antiseptics, vaccines and keeping one’s self in overly sterile environments leads to a lack of exposure to germs, and resultantly sometimes our immune system overreacts as a result and goes into autoimmune mode. And maybe, just maybe, stress and emotional trauma triggers these disorders.

Some common autoimmune disorders are Rheumatoid arthritis (RA), Psoriasis, Multiple Sclerosis, Systemic Lupus Erythematosus (Lupus), Inflammatory Bowel Disease, and even Type 1 Diabetes. Some of these like Lupus can lead to serious complications if not managed with care.

If a person has one autoimmune disorder, there are chances that he or she is susceptible to getting another one.

Awareness about my Hashimoto’s Thyroditis has led me to understand better things like where my constant fatigue stemmed from, and why insomnia keeps making surprise visits to me, and also why unexplained aches and pains keep coming and going. I have understood that I have to regularly visit a doctor for follow-ups, and keep a check on my thyroid levels. I have understood that taking medicines regularly is a lifeline. And I have understood that a healthy lifestyle –healthier eating, exercise, yoga, sleep, faith in God – will help me in this fight against this disorder.

I have also come to understand that one needs to be more sensitive to what other people are going through, because we often do not know what is causing that person to feel a certain way. Why do certain people feel down more than others? Why do some people put on weight more than others? Why do some sleep like babies while others struggle to even get a few hours’ snooze? Why do some people feel so hot and others feel so cold? Who knows who among us is going through an invisible but debilitating condition?

Autoimmune disorders are not all bad, then, are they? Maybe they make us a better person.

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The writer is a freelance journalist with a focus on human rights, gender and peace-building. She works in the field of Corporate Communications.