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Don’t give up hope – Caring for the elderly

Farhanaz Zahidi September 11, 2016



As people age, what can we do to improve their quality of life?
“With the bam of a motorcycle I suddenly became the head of the family,” says Junaid Ahmed Qazi. While caring for the elderly is seen primarily as something that women are expected do, Qazi is defying the norms because life left him no choice. As an only child, life changed for him some 20 months ago when his father, a healthy man in his early 70s, became victim of a hit-and-run case.
“Ten days before the accident we had both climbed five flights of stairs together.” What followed was a brain surgery, weeks in the ICU, and a nosocomial (hospital-acquired) infection his father caught, that left him invalid. “We believe he recognises us and has emotions. He wants to talk but cannot,” says Qazi.
For him the sound of his father’s voice is a far-fetched dream. Yet the optimist in him refuses to give up.
Qazi’s troubles are not unusual. The number of elderly people has risen globally with life expectancy having gone up due to advanced medical interventions. So has the corresponding number of their caregivers. The average life expectancy at birth of the global population in 2015 has risen to 71.4 years according to the WHO’s Global Health Observatory (GHO). HelpAge, a global network of organisations working with and for older people, predicts that by 2050 one in five South Asians will be over 60. The network states that South Asia is growing older faster than any other country in the world.
While HelpAge’s Global AgeWatch Index 2015, that ranks countries by how well their older populations are faring, rates Pakistan at 92 out of 96 countries, healthcare professionals and doctors feel the close-knit family structure in Pakistan mitigates cases of neglect and abandonment of the elderly.
“Caregivers are the unsung heroes when it comes to geriatric care. They are also underappreciated. When Parkinson’s disease or Alzheimer’s strikes a patient, the entire family is affected,” says Dr Nadir Ali Syed, a neurologist at Karachi’s South City Hospital who has been treating elderly people for 25 years. In his experience, if the quality of life of old people in countries like the US and Pakistan is compared, the elderly in Pakistan are much better off, provided their families are taking care of them. “The family is vital for elderly people. Generally, our elderly are not subject to neglect.”
With an increase in urbanisation and more Pakistani women joining the workforce, old homes and healthcare centres for the elderly is a discussion that is expected to come up more and more in the years to come. The need for geriatric medical care and for doctors specialising in the field has also gone up, and related challenges are multilayered.
“There is a lack of awareness and an acknowledgement of geriatrics as a unique specialty with special needs, health issues and care requirements. This exists both at the level of physicians, and at the governmental level. Caregivers often do not understand the needs of their aged family members and the stresses involved in caring for the elderly,” says Dr Saniya Sabzwari who specialises in geriatric care at the Aga Khan University Hospital in Karachi.
“Caregivers are the unsung heroes when it comes to geriatric care. They are also underappreciated. When Parkinson’s disease or Alzheimer’s strikes a patient, the entire family is affected,” says Dr Nadir Ali Syed, a neurologist at Karachi’s South City Hospital who has been treating elderly people for 25 years.
The patience and endurance of caregivers are put to the test in more than one way and, practically, providing satisfactory healthcare to the elderly is an expensive proposition. “The biggest challenge is financial. Nursing care and attendants at home cost a lot. For those who cannot afford to hire professional healthcare at home, the challenge is even more daunting. It becomes physically difficult to look after an invalid person,” says Asma Nazeer, who requested that her real name not be shared.
Nazeer does not want people to know that she served her mother who had Parkinson’s and related dementia for 10 years, since she feels that it will take away from her award. “I was the only one, as all my siblings are abroad, so they sent help in the form of finances and sporadic visits but basically it was just me for 10 years.”
Nursing care at home for the elderly who suffer from a lack of mobility is expensive. Yet more and more people are opting for it. “The biggest determinant for better geriatric care is affordability — to be able to pay for quality healthcare,” affirms Dr Syed.
Two round-the-clock certified nurses take care of Qazi’s father who, he shares, are pampered by him so that he does not have to go through the process of changing nurses and teaching them the ropes repeatedly. The price of nursing care at home is exorbitant but it still costs him less than the hospital would. His father’s room is now nothing less than the Intensive Care Unit of any hospital emanating the smell of medicines and sterilising liquids. Oxygen cylinders and the feeding tube through which liquefied food is transferred to his father’s stomach, like most elderly patients who are no longer able to eat by mouth due to multiple reasons, are maintained by nurses.
On average, depending on the level of expertise and seriousness of the patient’s illness, a certified nurse for a 12-hour shift costs anywhere between Rs1,200 to 1,800 or more, and are hired through an agency. The monthly cost can run into more than Rs100,000 if two staff nurses and two attendants are hired. “Many nurses are now turning towards attending to bedridden elderly patients at home because it pays well,” says 24-years-old Zaiba Kiran, a staff nurse who has been caring for elderly patients who are mostly bedridden. “We go through agents because it suits both the family of the patient and the nurse in case the nurse needs a day off or either of the parties has any complaints.”
Just like it is tough for caregivers, caring for debilitated elderly patients is not easy for nurses either. “With an elderly patient we have to be extra careful. They are very fragile. They can choke easily. We have to keep a constant watch over their vitals. Anything can happen at any time. It also takes more energy and time to learn how to deal with an elderly patient; they are often impatient like children.”
But perhaps the biggest side effect of seeing your loved parent become a shadow of who they used to be is psychological. “We saw the stages where my mother would hallucinate and there were behavioural changes. But the most painful was the stage when she could not even lift her finger. For the last three years of her life she was fed through a nasal tube,” reminisces Nazeer.
One of the jolts a family may receive is when they are told their loved one is now on what is called palliative or end-of-life care, a concept that is often not fully understood. The term does not mean that these are the final hours or days of the patient’s life. It means that the patient suffers from a terminal disease, and there is no hope of a cure. However the dying process may take years.
“With patients of Alzheimer’s the process may take seven to 12 years,” says Dr Syed. The aim of doctors and family, at this stage, is that the quality of life be improved and the patient be made comfortable. “In Pakistan you get drugs like heroine everywhere but intravenous morphine is not available to a dying patient to help relieve a dying patient’s suffering,” says Dr Syed, explaining the obstacles.
The goal, as Dr Sabzwari explains, is not longevity of life, unlike what families or patients want. “Most important is the quality of life.”
To see a loved one in pain takes its toll. “Till my father had the accident, I was a carefree guy. I can safely say I aged at least 10 years within days. I have lost a lot of hair ever since. I do feel depressed inside at times but I cannot afford the luxury to sit and cry because the responsibility of my family is on me,” says Qazi.
Luckily for him, his supportive wife has been his biggest strength. Even families of the elderly are psychologically impacted. “My six-year-old daughter is affected as well; she can’t understand why dada won’t play with her anymore.” Yet, Qazi refuses to give up on giving the best possible care to his father. “My father didn’t stop caring for me when I was a child and was totally dependent on him. How can I stop taking care of him?”
In Dr Syed’s opinion, one must not give up on the treatment and care of the elderly because a lot can be done to improve their quality of life. “A few years ago dementia was considered incurable and some of the treatments available now were not available then. Now, we can drastically improve the patient’s quality of life as well as slow down the dementia.”
The biggest challenge, then, is to not give up hope.

Being a mother – How breastfeeding can save lives of Pakistan’s infants

breastfeeding pic
By Farahnaz Zahidi

August 7, 2016

The myth that just mother’s milk does not suffice has caught on, and this trend is an imminent danger to the lives of Pakistani infants

Her fifth child is due any day. Nazeer Bibi lives in a shanty part of Qayyumabad, Karachi, and has already decided that she will feed her baby formula milk.
“I work in three houses as a domestic help to support my family. I leave at 8 am after dropping my older children to school and return by 4 pm, and the baby will have to be at home. What option do I have? Besides, dabbay ka doodh (formula milk) makes babies healthier. I want my baby to be healthy like the babies in advertisements.”
Nazeer’s baby will be one of the 62 per cent Pakistani infants who are not exclusively breastfed. Only 38 per cent of infants under the age of six months are exclusively breastfed, according to the Pakistan Demographic and Health Survey (PDHS) 2012-13. The rates are the lowest in South Asia.
The myth that just mother’s milk does not suffice has caught on, and this trend is an imminent danger to the lives of Pakistani infants, a danger that is not talked about often enough. As the World Breastfeeding Week is celebrated globally from August 1-7, the conversation around breastfeeding needs to be more audible and frequent in Pakistan. But bringing up the topic inevitably initiates parallel discourse regarding how lives of infants are less safer till formula milk is promoted as a choice. “From tobacco, to sugar, to formula milk, the most vulnerable suffer when commercial interests collide with public health,” says an editorial in medical journal The Lancet.
“Formula milk should only be given when there is a medical reason for it,” says Dr Azra Ahsan, an expert in mother and child health. “The baby gets complete nutrition through breastfeeding. The mother passes on her protective antibodies to prevent common illnesses in the baby. As no water is required to prepare it, unlike how formula milk is prepared, the chances of diarrohea and vomiting are minimised.”
According to the World Health Organisation (WHO), breastfeeding has the potential to prevent about 800,000 under-five deaths per year globally if all children 0-23 months were optimally breastfed. Pakistan has one of the highest infant mortality rates in the region, all the more reason that breastfeeding must be encouraged, especially among the lower income strata.
The PDHS 2012-13 findings also show increase in bottle feeding rates in Pakistan.
“Babies who are born to mothers from the lower income strata are more at danger if they are not exclusively breastfed. The water these mothers use to prepare the formula is unhygienic, and the bottles are not sterilized. Also, formula milk is not cheap. Once they start the baby on it, they start diluting the milk over time so that the formula powder lasts longer; as a result, the baby becomes malnourished,” says Neha Mankani who works as a community health midwife at a hospital in Karachi.
According to the World Health Organisation (WHO), breastfeeding has the potential to prevent about 800,000 under-five deaths per year globally if all children 0-23 months were optimally breastfed.
Once the baby is started off on top feed, the unaffording or unaware mother, over time, starts substituting it with unboiled cow’s milk or low quality tea whitening milk powder which is unsuited for an infant. “We can try and convince the mothers but only till they are in the hospital. Also, Community Health Workers (CHWs) have no access to women who deliver at home,” says Mankani, adding that she and her colleagues try to convince mothers to breastfeed.
However, part of the problem could be that healthcare providers are not doing enough to raise awareness. “Healthcare professionals are the main culprits. Instead of advising new mothers to breastfeed, they help perpetuate the trend of using formula milk. They are given incentives by formula milk companies. Research shows that children delivered in hospitals are more frequently formula fed,” says Dr DS Akram, Founder, Health, Education & Literacy Programme (HELP).
The laws protecting the right of the infant to health and nutrition are there. Lawyer Summaiya Zaidi says that the primary focus of laws like the Protection of Breast-Feeding and Child Nutrition Ordinance 2002 is to protect the nutrition of the child and promote breastfeeding as a primary source of nutrition. After the devolution, each province developed its own Acts for the purpose.
“The Sindh 2013 Act stresses that manufacturing, advertising and sale of alternate sources of child nutrition cannot be promoted as better than mothers’ milk or even compared to it. This stresses the primacy of breast milk as the best source of nutrition for a growing baby, and only when the mother is unable to provide the same to her child should alternatives be made available. It basically controls the manufacture and advertising of child nutrition products by placing certain legal limits on promotion of the same,” says Zaidi.
Yet, the tussle between public health experts and forces of consumerism continue. Companies producing or distributing formula milk refused to give any statement regarding how they justify the tempting advertising campaigns.
At the 69th World Health Assembly earlier this year, a resolution welcomed WHO’s guidance on ending the inappropriate promotion of foods for infants and young children. The guidance states that in order to protect, promote and support breastfeeding, the marketing of “follow-up formula” and “growing-up milks should be regulated. This recommendation is in line with the International Code of Marketing of Breast-milk Substitutes.
“The laws are there, but the implementation is a distant dream. Formula companies continue to particularly tantalise urban markets,” says Dr Akram, adding that the government does not seem interested in this cause. Dr Akram and her team run the Baby-friendly Hospital Initiative (BFHI) of WHO and UNICEF successfully in Pakistan for a few years. “When external funding stopped, the government was not interested in investing in it,” she says, adding that companies that produce formula milk mainly target the urban market to tantalise consumers.
“For the poor population in rural areas, breastfeeding is mostly the only available option. The urban social landscape is more challenging when it comes to breastfeeding. More mothers are working mothers; more options for top feed are available here; more people can afford to buy formula milk. Awareness is needed in both rural and urban areas,” says Dr Sara Salman of WHO Sindh.
According to Mankani, despite trying to raise awareness, most mothers follow popular myths. “They feel the baby is healthier if fed formula, owing to the aggressive marketing of formula milk.”
The biggest challenge for exclusive breastfeeding is the perception that mothers are not producing enough milk and should supplement with formula because the baby cries, says Meredith Jackson-deGraffenried from Helen Keller International. “This perception is driven by the misunderstanding that if the mother is undernourished and poor, she must be incapable of adequately nourishing her baby.”
“We try to teach these women basics about expressing their own milk and how to store it. Mother’s milk stays fine for up to three days in a refrigerator, and up to six hours at room temperature. It’s an economical and healthier option. But myths are hard to fight,” says Mankani.
Despite proven benefits like the mother who breastfeeds return to her pre-pregnancy state much earlier, and the incidence of breast cancer in women who breastfeed being much lower, as Dr Ahsan says, the myths seem to be winning.
“Socially, breastfeeding proves a challenge as well. There are usually no crèche or nursing rooms at work. That’s one reason working mothers stop breastfeeding,” says Dr Ahsan.

Originally published here:

Why is Pakistan’s affluent class so ashamed of getting extra food packed at a restaurant?

Published: February 13, 2016

We associate affluence with wastage; wastage that is criminal in a country where 61 million people are food insecure and malnutrition and stunting are common. PHOTO: REUTERS

“You are embarrassing me!”

Said the husband, upset over the fact that his wife asked the restaurant staff to pack the left overs which included one kabab, three-fourths of a naan and a bit of chicken karhai.

“But it will be wasted,”

She smiled and even carried the large mineral water bottle that was almost untouched with resolve.

It was a delightful dinner my family and I were invited to and this conversation between our host couple was all too familiar. There is the “what will people think” attitude associated with carrying home leftovers and in doing so we forget that edible, clean and fresh food will be thrown away simply because we over-ordered. We associate affluence with wastage; wastage that is criminal in a country where 61 million people are food insecure and malnutrition and stunting are common.

The numbers clash and vary, but all surveys and reports point in the direction that millions of Pakistanis live below the poverty line, with a 2015 World Bank report citing that the number is as high as over 50 per cent of Pakistan’s population. Women giving birth suffer from anemia, get too little protein and give birth to weak and often premature children.

On the other side of the social see-saw, privileged Pakistanis continue to pile their plates with food at weddings and buffets or order more than they can consume and end up wasting food, an offence that should be made a criminal offence.

But this criminal offence is not Pakistan specific. According to data released by the Food and Agriculture Organisation (FAO) of the United Nations, a total of 793 million people world over are estimated to be suffering from chronic hunger, regularly not getting enough food to conduct an active life. Of these, 791 million live in developing regions.

Meanwhile, in every other Hollywood movie, we see people getting up in the middle of the meal saying “I’m done” and emptying half of their plates into the trash bin.

Why did they heap so much food in their plates in the first place? And what precedent are they setting?

The perpetrators of food wastage do so both at an individual as well as at a colossal collective level. Supermarkets and franchise eateries throw away clean food items, even though most items stay okay for a while after the expiry date is over.

A very promising initiative in this regard is Lahore’s Robin Hood Army (RHA). The campaign intelligently used social media to mobilise volunteers and motivate food catering companies and restaurants to bring un-used food to those who needed to be fed.

But is that enough?

Can Pakistan learn from the recent initiative taken by France at the state level?

Recently, France became the first nation in the world that came up with a law that bans supermarkets from wasting food. French grocery stores will now have to donate unsold food to charities. As a result, millions more in need of food will be fed. The law is expected to spill over into all of the European Union eventually.

Yet here we are, Pakistan’s thankless, skimming over pictures of malnourished children with big bellies in Tharparkar dying of hunger, doing the customary “tsk tsk”, and moving on wasting the crust of the pizza slice or throwing away half the meal because it does not taste well. The scourge of hunger is not just limited to districts like Tharparkar.

Adjacent to Karachi’s affluent localities of Defence and Clifton, go visit the kitchens of your domestic help. Stories of malnourished underprivileged children abound. We follow international trends and become vegetarians and vegans for health reasons, but very few are ready to become freegans, or understand how freeganism can help feed more people use consumable food that needs to be reclaimed. We are environment friendly, or so we think, but are okay with writing off good fresh food just because the taste is not up to the mark. Maybe Pakistan needs a Tristram Stuart who comes and gives us a talk on food wastage repeatedly till we get brainwashed into respecting the food on our table.

Our lopsided food choices and unnecessary nakhray (tantrums) are also responsible for this trend of food hemorrhaging. We, as a nation, are getting more and more inclined towards eating more meat. Thus, because of the imbalanced food choices of the privileged, the demand for these food groups increases. This results in a lot of good crops going into fattening livestock to provide more food from the dairy and meat groups. When the balance is lost, the entire food chain equilibrium is lost, with more humans going hungry.

We can’t feed them all, but we can feed some. That packet of leftover food at the restaurant or café can be given to the kids at the signals. We can be more vigilant about giving away and sharing food items in our fridge and pantry before they are no longer edible. Small things will make a difference. But above all, we have to get rid of the ungrateful attitude towards food. We are the blessed ones. Let us be thankful till God is giving us enough food for the fill and share the blessing.

Emergency Contraceptive Pills: The misunderstood savior for Pakistan?

02/01/2016 01:07 pm ET | Updated 10 hours ago

  • Farahnaz Zahidi Writer, editor, media trainer and communications expert.


It does not work by means of abortion, has no effect on future fertility, does not increase risk of diseases like cancer or stroke, and will not harm a fetus or cause birth defects if a woman already happens to be pregnant. Yet, while the conventional 21 to 28 day contraceptive pill has found a degree of acceptance in Pakistan and most developing countries, the ECP (Emergency Contraceptive Pill) continues to be shadowed by myths.

Most people still confuse it for something that terminates a potential pregnancy, and thus confuse it with abortion. The facts could not be further from the truth. It is ironic that in Pakistan a lot of people avoid the ECP thinking that it translates into an abortion. Out of the 2.4 million unwanted pregnancies in Pakistan in 2002, some 900,000 were terminated by induced abortions (Studies in Family Planning 2007). These unsafe abortions that often claim the woman’s life due to resulting complications can be avoided with the use of an ECP.
This method of contraception can be used after unprotected sex when another form of contraception is unavailable or has failed. It can be used to prevent pregnancy for up to 120 hours (five days) after. Again, it acts as a preemptive measure, and does not cause abortions. The sooner it is taken, the better is the efficacy.

Why choose ECPs in Pakistan?
In Pakistan, it is available over the counter and unlike many other countries where it is a pricey contraceptive choice, it is economical. And it is safe. What is needed, then, is a more aware understanding about this excellent option.

As concerned world leaders, philanthropists, media persons and health care persons came together for the fourth International Conference on Family Planningheld in Bali, Indonesia, from 25 to 28 January, 2016, the ECP was discussed in depth. For the world’s sixth most populous nation even if the registered number of Pakistani citizens is considered, which stands at 199,085,847 in July 2015, as per the CIA Fact book, understanding contraceptive methods is vital.

In Pakistan, many organizations and pharmaceuticals, including Green Star andMarie Stopes facilitate the availability of and understanding about the ECPs. A section on emergency contraception in the Manual of National Standards for Family Planning Services, a document developed by the Family Advancement for Life and Health (FALAH) project, includes the EC and related policy. While the document recognizes that there is a lack of awareness among health care providers regarding ECPs, it also mentions certain stipulations about when it should be used and who should prescribe or dispense it. The possibility of it being used without misconception or difficulty, then, depends on how aware both the users and the health care providers are.

Representatives of the International Consortium for Emergency Contraception (ICEC) shed light on the subject during the ICFP. In over 140 countries women can buy emergency contraception and the ECP is readily available over the counter in 60 countries including Pakistan.

When the ECP is the best choice – in rape and other cases

While using a regular, ongoing method is recommended as the most effective way to prevent a pregnancy, in certain cases the ECP is the better choice. In cases of rape, it makes perfect sense. In 2013, the 57th Session of the United Nations Commission on the Status of Women stated that all Member States must require first responders to include EC provision in post-rape care. The ECP, thus, needs to be included as a regular post-rape treatment.

But the usage of the ECP should not be limited to cases of rape. It is also ideal in cases where the couple may not have regular sexual activity.

Most importantly, it bails out the couple, and especially the woman, in case of an “accident”. If she decides that this might not be the best time to have a child, the pill empowers her to use that discretion.

It is a safe, economical and effective method of contraception. It has very few side-effects and can be used more than once with the consultation of a doctor but should not be used as a regular contraceptive. To gain maximum benefits, people need to know more about what is often called the morning after pill. Above all, it need not be discussed in hushed tones. Contraception is a careful choice and Pakistanis need to make informed decisions regarding FP. Better to be more informed about the ECP and be safe than sorry.

So who should talk to the 20-somethings about contraception?

Published: January 27, 2016

The world is realising that due to cultural norms, adolescents and young people often do not discuss contraception with their elders or family members. PHOTO AFP

They can curse in each other’s presence, break traffic signals in unison and smoke together, and they may at times act macho and show off their romantic escapades. But young men, like their elders, do not readily open up about reproductive issues. Parents or teachers do not discuss subjects of a sensitive nature with them. While it is the same with adolescent and young women, they are comparatively more open to confiding in each other and getting guidance.

But it seems the world may be in for a change in attitude. Young men, all over the world, are stepping up to take part in reproductive discourse.

One such young man is Hamza Moghari. He is still reeling from the long journey from Deir El-Balah in Gaza, Palestine, to Bali, Indonesia. And the reason why he is there is that he has the guts to talk to his peers about difficult subjects like contraceptive choices and reproductive health. Hamza has seen more violence and difficulty than he deserved to in his tender age of 22 years. Coming to the International Family Planning Conference (ICFP) 2016 is a dream come true for him.

“This is the first time I sat on an airplane. I nearly never came,” he says, sharing the long journey of how he first reached Jordan from his home in Gaza.

He explained that he was sent away and told to go back due to lack of a no objection document, but he stayed near the border and went back the next morning, and was finally let into Jordan from where he flew to Bali.

A tad bit shy by nature, he confesses that the most difficult subject to talk about with boys his age is sexuality. Yet it seems that the world is realising that due to cultural norms, adolescents and young people often do not discuss these issues with their elders or family members. With their own age group, if they feel safe enough, they can talk about the typically hushed topics too. Y-PEER, a youth network of young people from more than 700 non-profit organisations and government agencies in more than 50 countries initiated by the United Nations Fund for Population Activities (UNFPA), uses an integrated approach to work with young people on subjects like gender, contraception and reproductive health. This year the thrust of all the discussions at ICFP was how to involve youth in the process. Half of the world’s population today, which is over 3.5 billion people, is under 30, mostly living in developing countries. They need guidance on these matters and silence may not be feasible anymore.

“If you’re not on the table you’re on the menu. How do we bring the youth on the table to talk about family planning?”

This question was put forth by Katja Iversen, CEO of Women Deliver, at the ICFP.

Pakistan is currently the world’s seventh most populous nation, according to the registered number of Pakistani, 199,085,847 in July 2015, as per the CIA FactbookContraception is thus an important subject that should be included in the nation’s narrative at all levels. In Pakistan too, this working via youth strategy has found a foothold.

One such initiative is Chanan Development Association (CDA). What started as a small theatre group is now an organisation that is youth-led and works for the youth.

Muhammad Shahzad, the executive director, has in tow young leaders wherever he goes. At the ICFP, too, he is watching out for and introducing proudly bright young people from Pakistan. One of them is 24-year-old Qaisar Roonjha, who says working with and for people his age is something he just has to do. His organisation, WANG (Welfare Association for Young Generation), is youth-led, and its primary focus is to struggle for a fairer society. Important buzz words like Youth Development, Women Empowerment, Mother and Child Health, Young Girls Education, Gender justice, Peace Promotion, Youth Development and livelihood security are all highlighted on the WANG website. From Lasbela in the perilous province of Balochistan, Qaisar has come a long way.

“I have met at least 40,000 young people all over Pakistan in the last five years,” he says with pride.

He shares that the toughest subject to tackle while talking to young people in Pakistan is gender equality.

“They still seem ready to discuss contraception. At least the married ones do. But seeing women as equal partners is difficult,” adds Shahzad.

Qaisar, whose video was selected for a competition held by organisers of the ICFP, attended the high profile conference in Bali as a moderator.

Ayesha Memon, an MBA student and youth leader from Hyderabad, also won the same recognition for her video, and addressed groups of interested activists and experts at the ICFP.

“Young people need to come out of their boxes; we should not assume things can’t change.”

Sharaf Boborakhimov is no novice at engaging with his peers on some of the trickiest subjects, which especially boys never openly talk about. Originally hailing from Tajikistan, he currently lives in Sofia, Bulgaria. This graduate in International Economy joined Y-Peer in 2011.

“What we do is provide safe spaces to youth where they can talk about sensitive subjects to people their own age. The peer-to-peer methodology works in tackling these subjects. We choose each word very carefully. We have to memorise manuals to know what to say and what not to and how to approach a subject.”

He has a close eye on the Syrian crisis, has Syrian friends, and has worked in Jordan closely with Syrian refugees who have made the Zaatari Camp their permanent home.

“We specially trained couples so that they could go back in the camps and train others. The refugees are just like any other couple. All they want is peace. They are depressed and frustrated no doubt. But in them I see a vision and a hope for a better tomorrow. They need guidance about contraception too.”

Theatre-based peer education, in Sharaf’s view is most effective for youth, whether they are refugees or not, the same strategy Chanan begun with.

“Since 2009, we have recruited some 50,000 young people for Y-Peer who work with us to educate their peers in important matters like sexual and reproductive health rights and also contraception,” Shahzad shares, adding that Pakistan was the first country in Asia Pacific that introduced UNFPA’s Y-Peer program in the region in 2009.

They are working with youth across 135 districts spread all over Pakistan including its toughest regions. In Pakistan, 65 per cent of the population is under 29, and 40 per cent fall into the even narrower age bracket of 10 to 24 years, says Shahzad.

“A big focus of our work is to engage with policymakers,” he says, sharing that Chanan was part of the National Task Force of 2009 for youth policy development, and is hosting the National Secretariat for Y-Peer in Pakistan.

For Hamza, the journey started by working for a local Palestinian organisation called Palestinian Family Planning and Protection Association (PFPPA). He is studying to get a degree in nursing.

“There are two million people in Gaza. The blockade is continuing since two years. Aid and medical help is almost impossible. Unemployment in my people is 70 per cent; among the youth it is 55 per cent. The healthcare system is fragmented. Very few people are able to reach the government-run healthcare centres.”

“In shelters that he has worked in, two to three thousand people were staying in one school. That meant each classroom was housing at least 50 people. Men, women and children, all strangers for each other, crammed into one room. With no food and water at least for the initial days till help started trickling in. Do you think family planning is a priority for them on a hungry stomach?”

In difficult situations and at such a young age, to be taken seriously and sensitise people about contraception is an uphill task. But these young people have realised that their generation’s reproductive choices will shape future demographic trends. They are thus helping their peers make informed decisions.

Miracle milk – The Camel Milk Diaries
Pakistan experiences a boost in sale of camel milk, hailed as an elixir of health. PHOTOS : FARAHNAZ ZAHIDI

Pakistan experiences a boost in sale of camel milk, hailed as an elixir of health. PHOTOS : FARAHNAZ ZAHIDI

A few yards short of the very busy Korangi crossing in Karachi, a series of makeshift settlements set up by nomadic clans is attracting a lot of attention. The family profile of these matriarchal clans is almost identical. Headed by a woman, they comprise of one or two men, children and a few camels with their calves. Their main source of income is the sale of camel milk. People stop their cars, motorbikes and bicycles and form queues to buy this nutritious milk, which has recently gained popularity in Pakistan.

The most sought-after property in camel’s milk is freshness. Cynical buyers, therefore, insist that the camel be milked in front of them. The technique is simple. Calves are brought close to the mother’s udders and when they begin to nudge her to be fed, milk starts flowing into the udders. At that moment, calves are harshly pulled away and their share of milk is taken out by skilled hands into stainless steel buckets or in a thermos or utensil provided by the more hygiene-conscious buyers.

But hygiene, in most cases, is less than satisfactory. These families, living in the open, lack proper facilities of sanitation. While the milk has no impurities, their hands and utensils are often not clean. And with the common belief that one must never boil camel’s milk, the bacteria transferred from unwashed utensils remain alive. “We don’t boil camel’s milk. It should never be boiled. I buy it every week for my wife who complains of lethargy, weakness, aches and pains,” says a regular buyer, who almost walked away empty-handed when he saw a girl adulterate the milk with water.

A matter of preference

Within the last few years, camel milk patrons are increasing in number. Despite having a thin consistency, salty taste and slight odour, the milk has created a market for itself in the country due to its potential medicinal benefits. The imported version, bottled with preservatives, is commonly available in high-end grocery store chillers.

But street vendors continue to present an appealing option to consumers who want the satisfaction of purchasing organic milk. Nusrat Ahmed, who works at Adeela Camel Milk, however, does not approve of the practice. “These camel herders are unfair to the calves. They pull the calf away from the mother and they do not get enough milk. Also, how do their camels produce so much milk on a daily basis? It is possible that they inject hormones into the animal,” he says. Camel milk is not a food product, it is a medicine, vouches Ahmed, and warns that the milk should not be boiled. “If you boil it, camel milk will still be nutritious, but will no longer be a medicine. It has certain natural ingredients that fight disease and they perish once you boil it.”

Many rural families have moved to cities to sell camel milk. PHOTOS : FARAHNAZ ZAHIDI

From virility in males to obesity control, the benefits of camel milk as a form of treatment are many. Wali Muhammad Akhtar, one of the most senior staff members at Dawakhana Hakeem Ajmal Khan in Saddar, Karachi, confirms that camel milk is beneficial for health. “It is Sunnah of the Prophet (pbuh). How can it not be beneficial?” he says. “It has less fat content so we use it in medicines to cure obesity. It is also the main ingredient of a popular herbal product called Labub Kabir Ajmali (an aphrodisiac for men),” says Akhtar, adding that the medicine’s recommended dose is half a teaspoon before breakfast. While assessing the product in light of the Avicennian alternative branch of medicine, commonly known as hikmat, Hakeem Ajmal, named after his great grandfather, confirms that camel’s milk is used in some of the Dawakhana’s 350 plus products. According to him, the ingredient is used in its original form instead of an extract or essence. “Camel milk is hot and dry in temperament,” explains Ajmal, referring to Avicenna’s theory of humours.

There is mass consensus among health practitioners regarding the potential health benefits of camel milk. Nutritionist Tayyaba Khan says that the milk is nutritionally very rich. “It has Vitamin C which helps boost immunity. It is also rich in iron and Vitamin B. It helps with diabetes management and is fortified with minerals.” Diabetics are therefore leaning towards camel milk as a possible course of treatment with no side effects. According to reports, camel milk has about a quart of insulin in each litre, making it a potential treatment option for diabetics. India’s Bikaner Diabetes Care Research Center conducted a study on the effects of camel milk on type 1 diabetes, determining that consuming camel milk significantly reduces insulin doses required to maintain long-term glycemic or blood sugar levels. Zahida, a 50-year-old diabetic, has just begun using camel milk as a form of alternative therapy. When asked who prescribed it to her, she says, “Suna hai logon se (I have heard about it from people),” and feels that since it has no harm if no benefits, then why not give it a try. But according to Akhtar, to reap those benefits, one should first boil camel milk.

Future demand

With proven benefits, it is hard to determine why camel milk is still not a common or popular choice and has a growing, but niche market. One of the reasons could be an inherent social prejudice against the animal which is associated with low economic value and underdevelopment, herded by the Bedouins and nomads. There seems to be a social hierarchy in animals as well: The camel is a symbol of the working class while a horse represents grandeur and status. Mules and donkeys rank even lower on the social ladder, although donkey’s milk has been used since centuries as a beauty product, especially an anti-aging agent, with tales of Cleopatra bathing in it. “We buy camel milk for Rs40 per kg. We don’t drink camel milk commonly despite its easy availability in Rohi (Cholistan Desert). We just use it to make kheer,” says Nazeeran Bibi, who lives in a village near Bahawalpur.

Ali Raza takes great care of his camel named baby as the animal is his family’s main source of income.  PHOTOS : FARAHNAZ ZAHIDI

Despite the milk’s low price, as confirmed by Dr Ghulam Ahmed, a field operations manager for Engro Foods Limited, Bahawalpur, it is not popular. Ghulam is actively involved with the company’s milk collection and animal farming projects, which contributes to the supply of camel milk throughout Pakistan. “After May, supply becomes limited, so, the price is raised slightly, starting at Rs45,” says Ghulam, adding that it will still always be cheaper than cow’s milk. “Camel milk will be more readily available in the calving and the rainy season when more fodder is available for the animal.”

In urban centres, however, prices are expectedly higher, and online sellers have cropped up to meet the increasing demand. “We have camel milk which is very suitable for hepatitis, cancer, sugar and liver disease,” claims a Karachi-based website for camel milk that offers door-to-door delivery service.

With the emergence of a new market for camel milk, further urbanisation of families like that of Goshi, in her late 40s, who has moved to Karachi from Jhang, Punjab, is expected. Unlike others who claim that they have borrowed their camels for a period of four months from camel farmers, Goshi says that she owns the animals. Her nine-year-old son, Ali Raza, plays with a calf and kisses it affectionately. “His name is Baby. He is one month old.” Ali does not go to school and spends his time herding camels, relying on the sale of the animal’s milk for a livelihood till the season comes to a close.

Farahnaz Zahidi works as a senior subeditor at The Express Tribune.

She tweets @FarahnazZahidi

Published in The Express Tribune, Sunday Magazine, May 31st, 2015.

Pakistani women are neglecting their lung health: World No Tobacco Day

Published: May 31, 2015


“I will break my children’s bones if they ever try to smoke,” says 27-years-old Sana (name changed). She tried her first cigarette at the age of 15 and was hooked onto the habit by the age of 17. Since then, except the one year where she quit, this young female journalist has been addicted. From regular to light, from non-menthol to menthol, from blue packs to green ones, and from cigarettes to sheesha and even electronic cigarettes, she has tried it all, but is unable to give up her reliance on one of the most addictive substances in the world.

Research shows that the gender gap between smokers is narrowing, and while smoking among females is on a decline in the developed world, it is on the rise in developing countries. A change in the traditionally defined gender roles has a correlation here, as do the marketing strategies. Use of coined terms like ‘light’ and ‘menthol’ make it more acceptable to women. Sheesha cafes have also made use of this psyche. Fruity smells and seemingly harmless flavours, such as green apple andpaan mint make the choice seem more aesthetic and less hardcore. Before one knows it, one is hooked.

Socio-economic reasons seem to have a definite influence. The study “Women and Smoking: A Report of the Surgeon General” states that women whose parents have been to college are more likely to have tried a hand at smoking. “The school one goes to has an impact for sure,” says Sana, adding that certain professions attract the habit, especially among females. The study also shows that women with stronger links with religion are more likely to avoid or discontinue smoking.

Globally, incidence of lung cancer and heart disease among women has gone up, and experts are searching its links back to an increase in use of tobacco. Smoking, in women, lowers their estrogen and their high-density lipoproteins that prevent arteries from blockage.

Getting it from the men

“We seem to have a unique tuberculosis (TB) epidemiology whereby young females appear to have the highest incidence of TB, and comprise more than a third of all our patients,” says Dr Asad Zaidi, who has been working on health initiatives to promote lung health and fight TB, and is associated with International Research and Development (IRD). The Sehatmand Zindagi Centre is the lunghealth and diabetes initiative established through Community Health Solutions (CHS), a social enterprise, in partnership with IRD, with which Zaidi is involved. Working in the peri-urban areas of Karachi, observation of these experts working for Sehatmand Zindagi reveals a definite trend of young women, aged between 15 and 22 years, having higher incidences of TB. “The exact causes for the high rates of TB amongst young women are poorly understood but we can speculate. We already know that nutritional deficiencies are much more common in girls, including widespread anemia and Vitamin D deficiency, often from a very young age. Stunting is more common in girls, they are less likely to be immunised during childhood or be treated once they fall ill. The high numbers of TB in young women, then, could just be another manifestation of the wider gender inequality plaguing this country,” adds Zaidi.

The connection between smoking and TB cannot be ignored, even though the young women being treated at these centres are from underprivileged backgrounds may not be smokers themselves. “We have a girl under treatment at Indus Hospital Karachi as part of our programme. She got married at the age of 20 to a man much older who already was a patient of TB, and smoked, and she acquired the disease from him. It is a complicated case of multi drug-resistant (MDR) TB, and she is expecting a baby. But she is better in the seventh month of her treatment,” says Sajida Qurban Khan who works as a manager in the Sehatmand Zindagi centres. In most cases, in Khan’s experience, these young girls have acquired the disease from fathers or brothers who were smokers and suffered from TB. “Women are actually more eager to come in for treatment and prove to be cooperative patients. But they also give up treatment midway more readily as they are less likely to be able to sustain the side effects of the medications.”

WHO confirms that TB is one of the major public health problems in Pakistan. Pakistan ranks fifth amongst TB high-burden countries worldwide. Pakistan is also estimated to have the fourth highest prevalence of multidrug-resistant TB (MDR-TB) globally.

Sheesha, social smoking and young ladies

“I don’t remember when I started smoking sheesha; I was very young, maybe 15 or 16. I started it because it was really in so I had to try it out. I thought it would make me look cool,” says Khizra Khan, 21-years-old, an undergrad student in Karachi. She says she now knows the health hazards of smoking sheesha or smoking, but defends the habit. “Everyone knows that sheesha and smoking are equally harmful. But you don’t get addicted to sheesha and you can never smoke sheeshaalone. I can go on for a month without smoking it. Plus it’s a good thing to hang out with friends over; it’s cheap and affordable compared to going out for lunch or dinner,” says Khizra, and shares that her parents hate the idea of sheesha smoking.

Waterpipe tobacco smoking, despite bans, has gained momentum among Pakistani youth. Women who hesitate smoking in public feel no hesitation smoking sheesha in public. “It is more socially acceptable compared to smoking. It’s the one fun thing I can do publicly,” says Sumera (name changed) who says she and her husband bond over sheesha smoking.

A research paper presented by Professor Javaid Khan, Aga Khan University, states that “Besides lung cancer, sheesha use is also linked with increased risk of mouth and urinary bladder cancer. There is also some evidence that sheesha use may also decrease the sperm count in men. Regular sheesha users have lung functions approximately 25 per cent lower than those who do not use this. One study has also shown that sheesha use increases the risk of pulmonary tuberculosis. Children are particularly vulnerable to the harmful effect of the sheesha use”.

According to the World Health Organization (WHO), sheesha, hookah, goza or hubbly bubbly, is indeed addictive and actually might end up being more harmful than smoking. WHO warns that a one-hour sheesha session can throw in as much nicotine in your system as smoking one hundred cigarettes. While a cigarette smoker typically takes between eight and 12 puffs, inhaling 0.5 to 0.6 litres of smoke, a sheesha smoker during an hour-long session may take up to 200 drags of between 0.15 to 1 litre of smoke each. “Reduced concentration of nicotine in the waterpipe smoke may result in smokers inhaling higher amounts of nicotine,” says the WHO report.

“There is already unequivocal evidence linking tobacco smoke, whether through cigarettes or shisha, to increased risk for TB. The rising trend in smoking then, is clearly a big problem. A lot young people out there don’t know that smoking could give them TB, and because smoking reduces our immunity, the infection is that much harder to cure.”

According to a study called “Prevalence of cigarette smoking among young adults in Pakistan” published in the Journal of Pakistan Medical Association, nicotine addiction and stress were the most common reasons given by students for why they smoked (53 per cent and 50 per cent, respectively). Most of the respondents shared that at least one of their five closest friends smoked cigarettes and more than half mentioned that at least one person in their home smoked cigarettes.

“I wish I had never acquired this habit,” says Sana with regret. For her, it might be too little too late. But creating awareness may potentially save lives of many young Pakistanis, especially women.

Tobacco kills up to half of its users

Tobacco kills nearly 6 million people each year, according to the World Heath Organisation. More than five million of those deaths are the result of direct tobacco use while more than 600 000 are the result of non-smokers being exposed to second-hand smoke. Unless urgent action is taken, the annual death toll could rise to more than eight million by 2030.

Nearly 80 per cent of the world’s one billion smokers live in low- and middle-income countries.