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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.

NON-FICTION: THE AESTHETIC MYSTIC

Updated August 04, 2019
A photo by Joseph Hoyt and calligraphy by Ziaur Rehman Khan and Ali Alam | Images from the book
A photo by Joseph Hoyt and calligraphy by Ziaur Rehman Khan and Ali Alam | Images from the book

Mirza Asadullah Khan Ghalib and Allama Muhammad Iqbal in a more regional context, and William Shakespeare in a more global one, would be turning in their graves in this era of social media. So many of the couplets and verses attributed to them were never written by them. But more than any of these greats, it is the words of Rumi — or not, actually, the words of Rumi — that are shared callously and confidently. Translations of alleged excerpts from the Masnavi-i-Masnavi of the 13th century poet, jurist, Islamic scholar, theologian and Sufi mystic Jalaluddin Muhammad Rumi — often called Maulana when mentioned with a term of endearment — have been popularised to the point that, today, it is difficult to decipher which of the quotes in social media artworks and in coffee table books actually originated from Rumi’s pen and heart, and which are mere ambitious and fictitious attributions to him. However, when Coleman Barks, one of the most famous Western interpreters of Rumi, says that a couplet is Rumi’s, it probably is.

The works of Barks, complimenting some of the choicest images taken by photographer Joseph Hoyt, constitute The Mystery of Things: Interpretations of Rumi. Hardbound, visually delightful, and an easy and satisfying skim-through on a day when one is looking for nuggets of spiritual wisdom to answer deeper existential questions, the book touches just the right chords with today’s lover of Rumi’s works.

Hoyt’s earlier book, Afghanistan 1970-1975: Images from an Era of Peace, published in 2008, was when his photographs — based on the time he spent in Afghanistan — transitioned from being in exhibitions to taking form as a book. The Mystery of Things also started from being photographs on exhibit and are complemented by Barks’s writings based on Rumi’s verses.

Khalid Hosseini, author of the famed The Kite Runner, and Hoyt have had a long connection. Half of the proceeds from Hoyt’s first book went toward supporting The Khaled Hosseini Foundation to help with providing humanitarian assistance to communities in Afghanistan that needed it. It is thus befitting that the foreword of this book is written by Hosseini. In the foreword, he explains why photographs taken in Afghanistan are a suitable backdrop for Rumi’s verses: “Rumi’s soul was in the Afghan wind. It was in the air, in the water. You could hear it in the blind crooner’s song at a crowded street corner, in the extra beat he held the sorrowful notes, in the elegiac tremble of his voice. Rumi was everywhere. It is hardly surprising. Afghanistan is, after all, the birthplace of the great poet.” Hosseini goes on to call this book the perfect marriage between words and images.

The 44 images from Afghanistan in this book are simultaneously timeless in their human quality and nostalgic in the fact that they were captured by Hoyt’s lens in the 1970s, and thus remind one of an Afghanistan that has changed and evolved in many ways, owing to the many storms the country and the nation has weathered.

Perhaps that is something Rumi’s poetry also highlights in the human race. There is so much that is intransient in humans, owing to their inherent connection with the Divine. Yet the identity of humans keeps evolving. In this, there is much that is lasting and much that is fleeting and ever changing in humanity.

The selections of poetry are careful, and stirring, which is a quality archetypical to Rumi’s poems. Such as this quatrain:

Burning with longing fire
Wanting to sleep with my head on your doorsill
My living is composed only of this trying
To be in your presence

Another one, juxtaposed against a spectacular photograph of an amber-hued sunset — or sunrise — sky reflecting in still waters, is this classic piece of mystic poetry:

I keep asking, Who gives my soul
This increasing delight in what it does?
Who gave me life in the first place?
Sometimes I feel covered
Like a falcon mewed
Waiting inside its hood
Other times I can see
Then I get released into the sky

The art in the book is not limited to Hoyt’s photography. The sections are divided by selected verses from Rumi’s Persian poetry, calligraphed with a flow that is almost poetic, merging seamlessly into the philosophy that Maulana’s poetry offers. For this, calligraphers Ziaur Rehman Khan and Ali Alam deserve a special mention.

In Pakistan, the book has been published by the Bookgroup and the editors are Rakhshee Niazi and Sami Mustafa. The paper quality, layout and the touch and feel of the book, as well as the careful selection of the colour palette of black-and-white with greys, does justice to the content. It is a sensitively designed and printed book, with a gentle and aesthetic feel to it and not once does it overstep the boundaries of being in the periphery of Rumi’s mystic ideology. It is then safe to say that this is a layered book, in that it uses various media such as mystic poetry, calligraphy and impactful photography.

Yet another layer that may interest the Rumi aficionado is the fact that it is none other than Coleman Barks whose translations have been used as the main textual content of the book. To many, Barks’s work on Rumi has been the means to get introduced to the great sage’s poetry. To others, Barks’s work remains a debatable means for this introduction. For starters, Barks — according to some experts — is not known for his prowess of Persian, but rather as one who interprets existing translations of Rumi’s work, thus being the interpreter rather than the translator. But even if he is established as the translator as well as the interpreter, who is the target audience of Barks’s interpretations of Rumi’s work? The way Barks interprets Rumi’s poetry makes Rumi sound simply a mystic, and the image he paints of Rumi is what many have critically called a ‘non-Islamic Rumi’, whereas history has it clearly that Rumi — in addition to being a spiritual master and mystic poet — was a theologian, a scholar and a jurist of Islamic law as well. It is almost as if the mention of Rumi as a Muslim scholar has been erasedfrom his works. Perhaps today’s human craves answers to the bigger questions in poems that are connecting him or her with the Divine as the Beloved, but does not wish to alter his or her lifestyle in accordance with Islamic jurisprudence. Thus, the Rumi described in Barks’s interpretation of him is one whose only creed is love. While this is very enticing to today’s audience, how close to reality it is remains debatable.

Nevertheless, Barks’s contribution to popularising and propagating the works of Rumi cannot be taken away. This book, thus, remains an important and refreshing addition to aesthetic printed renditions of the works of Rumi.

The reviewer is a Karachi-based journalist, editor and media trainer; human-centric feature stories and long form write-ups are her niche

The Mystery of Things:
Interpretations of Rumi
Translations by Coleman
Barks
Photography by Joseph Hoyt
Bookgroup, Karachi
ISBN: 978-9695503683
120pp.

Published in Dawn, Books & Authors, August 4th, 2019

https://www.dawn.com/news/1497975?fbclid=IwAR3mgJnawPNEbV5jCUc3dnMdbjDxZUx4pJUulypP6Y7UGzlVcv_Tl5XFTxU

“If you ask me who I am, I will say I am a storyteller” – Reza Aslan

Interview with Dr Reza Aslan

“If you ask me who I am, I will say I am a storyteller”

Dr Reza Aslan’s journey has been long and winding. From a young Shia Muslim migrant from Iran to USA, to a converted Christian at the age of 15, to again a Muslim a few years later, Aslan’s journey is the quintessential journey of discovering one’s self and one’s religion. Perhaps this is why he resonates with his audiences and readers. Faith, however, has remained a constant with him. Answering a question from the audience at a packed auditorium at Habib University Karachi where he delivered a Yohsin Lecture on the topic ‘Why Do We Believe’ on June 13, Aslan distinguished between faith and religion with the help of a metaphor. According to him, when we dig wells, the wells may be different but the water under the earth’s surface is all the same. Similarly, the water is faith and the wells are religions — they are all the different paths to faith, he says.

In this exclusive interview for The News on Sunday, Aslan begins by talking about how he gets away with presenting opposing and often offbeat points of view. “When you are talking about issues of religion and politics, you are talking about things that are very deeply embedded into people’s identities, and sometimes will react if they feel their identity is under attack. My relative success has been predicated on having respect for people who disagree with me, and taking faith and religion seriously even when I disagree with it. Recognising that my arguments are always going to be founded upon reason and history and fact has, for the most part, inoculated me a little bit, but I still get into trouble all the time, both personally and professionally.”

As a person of faith, and one with a keen and critical eye on world history and politics, Aslan’s take on the role of religion in public life is unique. “I always make a clear distinction between Secularism and Secularisation,” he says, further explaining the two concepts. “Secularism is a political ideology that says religion should have no place in public life. I understand where that argument comes from but it doesn’t make any sense in a modern constitutional democracy if the entire point of a democratic system is to allow people to find representatives who share their values, their ideas, and their worldview. Religion becomes a very easy shorthand for those complicated notions. So it’s ridiculous to say that religion should have no role in politics and in the public realm. Of course it should.”

Pakistan has an extraordinarily unique history. “This country defined itself from the very beginning in terms that are impossible to actually live out. When you call yourself an Islamic state, you need to figure out what that exactly means.”

He goes on to add that Secularisation is about making sure that religion doesn’t have political authority, and that religious institutions are distinct from the governing bodies and the political authorities — that authority itself over the state should rest not in the hands of religious leaders but in the hands of political leaders. “Secularisation is very important when it comes to modern constitutional state because, particularly in countries where vast majorities share a single religious tradition, religion can very easily become authoritarian where those who disagree with the religion, those who have no religion and those who have a different religion become second class citizens. That is not a democracy.

“That’s what I think is important. Secularism is not the key to a functioning democratic state. Secularisation is the key to that, because Secularisation is about pluralism, about rights of all citizens regardless of their religion,” he says. In Aslan’s opinion, Secularism is based on the forceful removal of religion from the public realm which is anti-democratic. “It’s anti-democratic when France does it. It’s anti-democratic when Turkey used to do it. It’s anti-democratic when Egypt does it.”

Commenting on Pakistan’s historical journey and the role of religion in it, Aslan says that it is important to recognise that Pakistan has an extraordinarily unique history. “This country defined itself from the very beginning in terms that are impossible to actually live out. When you call yourself an Islamic state, you need to figure out what that exactly means. Does that mean it’s a state for a majority Muslim population or does it mean that it’s a state founded upon Islamic ideology or does it mean that it’s a state that is run according to Islam? I think the problem is that it was never explicitly defined; it becomes difficult to have these kinds of ideological conversations about the nature of the state when you have no choice but to build the state. That of course had to do with the fact that it was created in the midst of the single largest mass migration in human history to this day.”

According to him, that more than anything explains the tumultuous history of Pakistan going from a secular democracy to a military dictatorship to being a religious-inspired state, then back to being a secular democracy and then a military dictatorship and then a religious-inspired state. “What the experience of Pakistan shows — and that is precisely why it is so unique — is the difficulty of trying to define a nation state in religious terms,” he says, mentioning Israel as a cautionary tale, “a country that is disintegrating from within”.

Fiercely and openly critical of Modi, Netanyahu, and Trump, Aslan says that it has been a very long time that Pakistan has had a Modi or a Trump. “We cannot say that there can never be the rise of a demagogue in Pakistan. But for the most part, I think the (political) trends are moving in a positive direction,” he says. Commenting further on the kind of political leadership he is wary of, he says that a global-wide identity crisis has created the vacuum for authoritarian demagogues to step in and provide an easy way for citizens of these states to define themselves according to religion or race or ethnicity etc.

“There’s nothing about India or about Hinduism that explains Modi, for example. What is happening in India and Israel and USA is a global phenomenon; it is not just about these individual countries.”

To Aslan, while religion is a potential tool for social stability, and collective identity, he feels that like any tool, it can be wielded in positive and negative ways. “It’s all about the person wielding it. I cannot say religion is a force for good or force for evil, or that it causes peace or causes violence. Religion doesn’t do any of those things. People do those things. Religion is a means for them to achieve those ends.”

When asked what he enjoys most — teaching, public speaking or writing books, his answer is simple. “It’s all storytelling. Stories are how we define ourselves and communicate our ideas to the world. The platform doesn’t matter. If you ask me who I am, I will say I am a storyteller.”

http://tns.thenews.com.pk/ask-will-say-storyteller/#.XRMmmugzbIU

A packed December – When Non-Resident Pakistanis Flock to Pakistan

A month of homecoming, packed with weddings and socialising, can be overwhelming for the visitors and the hosts

A packed December

Pakistan is living with a big hole in its heart. That hole in its heart is Pakistanis who have left for greener or richer pastures, grazing in the economically lucrative lands in Europe, USA, the Middle East, or even down under. With each person who leaves, this hole widens. Rarely do you come across a Pakistani family that is still “whole’. At the hands of this exodus, we have missed out on our best.

Fragmented families suffice with Whatsapp calls and Facetime connections. Most of our friends of school and college are somewhere far away. Every other home has children who have left for better education and exposure, with parents very aware that once they go, they might make new homes in faraway lands. Yet we are making these choices, every day, seeing this migration as the chance at better lives and better futures.

Yes, Pakistan is indeed living with a big hole in its heart.

But come December and that hole starts to fill up — unnaturally and temporarily.

Birds, mammals, fish — the animal kingdom is full of examples of seasonal migrations. Humans have a history of doing it too — for agricultural harvesting, for grazing their cattle, for finding summer or winter jobs.

But what is happening in urban Pakistan is unprecedented. December is the month that non-resident Pakistanis choose collectively to visit their birthland. This includes our children who are studying in universities abroad or offspring who are working abroad — they get their winter break in December. While this should mean a time for families spending time together and re-bonding, it often does not end up being so, as social commitments seem to multiply by a hundred, if not a thousand, in December.

On an average December weekend, people are invited to anywhere between two to four weddings a day. With weddings come preceding or subsequent shopping sprees. The fact that Pakistanis who are now used to cooler climates request that relatives in Pakistan keep weddings in winters, and want to visit a city like Karachi not when it is 40 degrees Celsius but a milder 15 degrees is understandable. And so it is.

Overcrowded shopping malls and eateries, breakfasts, brunches, lunches and dinners. Traffic on the streets. Late nights. On the peripheries there are the day trips to beaches, farmhouses, or even the occasional trip to a village or a smaller town, because we love to romanticise villages, poverty, and the ‘colourful culture of small towns’. Even Karachi’s infamous viral fevers, cough and flu cannot deter the incomers nor their hosts.

What does this mean for us the resident Pakistanis? Put in simple words, we have to put our lives on hold. While we continue going to work or running everyday errands, we have to accommodate a lot more and wish that each day was not 24 but 48 hours.

As Pakistanis, our most important and unavoidable way of showing affection is feeding people. The stomachs of our guests from abroad go into culture shocks as instead of soups, salads, sandwiches, less spicy and less oily food, they are offered nothing less than nihari, qorma and katakat, dripping in oil and followed by halwas in desi ghee. No amount of antibiotics they may have taken in precaution helps. It is tough on the tummies, but saying no is difficult to the overzealous resident Pakistanis. But it is not really anyone’s fault. This is our way, as a nation, that we show love and care — we feed people. Also, if we don’t offer a meal or go to meet our guests, it will be said “yeh log buhut badal gaye hain” (they have changed).

There are, you see, dynamics of Pakistanis who live abroad. If they left Pakistan 30 years ago, they have an image of Pakistan frozen in time. Their relatives who were young teenagers listening to George Michael and Madonna when they left are now gray-haired and popping blood thinners into their system, parenting children who are millenials. Of course Pakistan has changed, and yes the people have changed, because societies are fluid and not static. But there is an unsaid pressure on those still living in Pakistan to pretend that we are still the same.

It is also not easy for those visiting Pakistan. Too many people to visit, to meet, to give gifts, to stay connected with. Too many obligations. And at times, if not always, the pressure to pretend that they are still connected to these people in terms of culture, whereas the reality is that exposure and life experiences change us. We evolve.

While this December influx of people means an air of festivity and excitement, more money coming into Pakistani economy, and lots of feasting and meeting-up, it can be overwhelming for both the visitors and the hosts. Why not have weddings in March or September? Or visits to Pakistan in February or October? Too much of a good thing dilutes the effect. Let’s space it out, shall we?

PS: Relatives, siblings and friends visiting Pakistan in December, please don’t write me off after reading this, and believe me when I say I love you all visiting. Promise.

http://tns.thenews.com.pk/packed-december/#.XDxJpbhS81k

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

Treatment for viral diseases is leading to drug-resistant infections

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

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

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

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

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

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

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

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

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

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

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

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

4.Multidrug resistant Typhoid, effecting all ages

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

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

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

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

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

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

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

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Wearing second hat as family’s sole breadwinner

November 12, 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Imran Khan: The human-centric Prime Minister

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

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

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

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

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


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

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