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Civic sense of Pakistanis – It’s a 360 degrees circle

What you do WILL come back to you. It has to be considered “why” they are doing it and you are not? What made the difference?

It’s a 360 degrees circle

Poetic much? Borderline Rumi-esque? No, this is not Rumi. This is the scribe of this write-up who is frustrated every day at the gross violations of social ethics, but unknowingly might have many a time committed the same violations in less aware days of her life. She may have driven ahead on a red traffic signal, and may have thrown a plastic wrapper on the street, and may have not gone to exercise her right to vote, and may have not closed the unnecessarily running water tap, and may have gone ahead of her place in a queue. The writer of this write-up is a tad bit more “civil” now, because she is more aware about what entails civic sense.

This is why such write-ups are important. This is why we must speak up about these things. But kindly so, because all of us have at some stage in our lives been less civil.

The concept of having civic sense is both simple and ancient. The biblical Golden Rule and the well-known Prophetic tradition in Islam say, in essence, the same thing: do as you would be done by, and do not wish for others what you would not wish for yourself.

So here goes — I’m going to use a list of strong words I don’t usually use, like hate, loathe, detest, etc. I hate the polythene bags that drift in the breeze and gather in front of my gate every evening. I detest the sound of the water suction pump from neighbouring homes that suck away the little water that comes in the waterline for Karachiites, and I hate that we have to keep replacing the no-return valve in the underground water tank to ensure this little water stays in my tank.

I loathe the squirts of reddish brown saliva mixed with paan ka katha which I have to endure on streets, or when climbing up a flight of stairs on government offices. I feel revolted by the carelessness with which young boys on motorcycles crisscross through traffic jams without helmets, and I feel even more revolted when I see a man wearing a helmet on a motorbike, but his family — the pillion riders — sitting behind him with no protection for their skulls. I am unable to stomach the attitude of entitlement that the rich and famous have when they break queues at the bank or at the airport. I feel annoyed when people come too close in public spaces and do not respect proximity. And I despise the fact that people try to justify systemic corruption in governance, and feel it is okay to have political apathy and not exercise their right of casting a vote at the ballot.

Civic sense is one of the most important part of ethics and set of life skills we need to learn and teach. It is important not just because it is the right thing to do, but because it is a 360 degrees circle in society.

Yet, again, I wonder how many times I have been the one others may have hated, loathed, detested or despised. How many times I may have instantaneously become an emblem of civility the moment I landed at a country other than Pakistan where the rule of law, especially laws pertaining to shared spaces and existences, are respected more.

Also read: If everybody is doing it, why can’t we?

Civic sense is one of the most important part of ethics and set of life skills we need to learn and teach. It is important not just because it is the right thing to do, but because it is a 360 degrees circle in society. What you do WILL come back to you. So it may not be enough to just look down at those who are abusing out loud or leaving offal on the road after ritual animal slaughter on Eid-ul-Azha or urinating near the wall. It has to be considered “why” they are doing it and you are not? What made the difference? I think we all know the answer. And in that answer lies the solution.

http://tns.thenews.com.pk/360-degrees-circle/#.XMArcugzbIU

Not enough daycare facilities

The need is real but compared with population increase and urbanisation, there are not enough daycare centres

Not enough daycare facilities

A half of Pakistan’s population is female. An increasing number of females, especially in urban Pakistan, are working professionally as the second earner, and even sometimes the first, whether it is in the formal or informal sector.

Women also are the ones who bear children breastfeed them, and wean them off to solid food. The initial years in particular are the years in which children need constant monitoring and vigilant care. This is where the need for daycare centres comes in.

By law, all organisations across the board in Pakistan are supposed to have daycare arrangements to enable working mothers, and even fathers, to join work after maternity and paternity leave, but very few abide by the laws.

Farhat Parveen, Executive Director at National Organisation for Working Communities (NOWCommunities), explains how the provision for a nursery or daycare for children in law has been there since long in the Factories Act 1934 (now the Act of 2018).

This provision should be there for children as young as infants to the age of six years. “While things are getting better and some public educational institutes like Karachi University and some private organisations like Aga Khan University (AKU), PILER, HANDS, and many corporate organisations have some facilities in this regard, it is not enough,” says Parveen.

With not enough daycare facilities available in-house in organisations, the centres in the private sector are most sought after. Ayesha Amin, a working mother of a four-year-old, has had a good experience with them and has utilised these facilities, especially for summer camps, but regrets that in Pakistan there aren’t enough daycare facilities, especially in urban areas. “There are not enough options for lower income groups from what I know; but then there may be more family support in joint family systems. The more affluent the grandparents and family are, the busier and more social they are too.”

In less affluent areas, working mothers are not less in number, whether they go out to work as salesperson or domestic house help. In the absence of any proper daycare centres, women in these localities leave their children with relatives or neighbours who can keep an eye on the children till they come back from work, and pay them agreed upon sums as remuneration. Others bring back teenage siblings or cousins from villages for a few months, giving them food, lodging and some pocket money to see over their children.

In Amin’s opinion, there is a greater need for in-house daycares which Pakistani organisations lack. “If they really want women to work, then it is pretty inconvenient for a parent to first drop a child to a school and go to their own workplace, pick the child from school and then drop to daycare and collect again in the evening, especially in a city like Karachi where commute and traffic is a huge factor in planning anything,” she says, speaking for many working parents.

Fariduddin Siddique, an engineer by training, established “Bright Minds Learning Hub and Daycare,” along with his wife, some two years ago in the upscale Clifton locality of Karachi. They accept children from ages four months to six years. “Me and my wife were both working parents, and we realised the need for centres that provide quality daycare facilities,” he says. In Siddique’s experience, couples in Pakistan usually have support from their families, but that is not always the case.

In less affluent areas, working mothers are not less in number, whether they go out to work as salesperson or domestic house help. In the absence of any proper daycare centres, women in these localities leave their children with relatives or neighbours.

He adds that for a mother to leave her career for an extended period of time creates a gap in her work trajectory which is not good for her career prospects. “The key priorities at daycare centres for children are giving them a hygienic environment, a healthy routine, extreme care and love, as well as opportunities for learning and development according to the child’s age.”.

For Siddiqui and his team, it has been a journey of learning. At this centre, parents have to send food from home. The fee structure is the same for all age groups, and parents have to pay based on whether they leave the child for half a day or full day.

For summer camps, upscale daycare centres charge anywhere between Rs12-18000 a month. A well-known daycare centre (name withheld) charges Rs19000 per month, and this includes a lunch meal, while their hourly rates are Rs350 for the first hour and Rs300 for each subsequent hour.

For parents working in the corporate or business sector, with both husband and wife working, this might be affordable. But for lower income or lower middle income groups, this might be too steep. Prices get steeper depending on the area where the daycare centre is based.

Running since 2007 with three successful branches, Dr Sofia’s Daycare & Learning School charges between rupees eight to ten thousand for a full day and four to six thousand for half day. “Dr Sofia Rahman, the founder, felt an urgent need of a daycare when she herself faced difficulty in raising her kids while doing a job. Her main idea was to help working women so that they could pursue their dreams,” says Hina Fahd from the daycare management. They accept children from age brackets three months to ten years. “The older children usually come to us after having attended school in the morning,” she says, adding that daycares are a better option than leaving children with grandparents as with grandparents children may not be as disciplined in terms of routine and learning reinforcement.

The need for daycare centres is real, and is on its way up, but when compared with population increase and urbanisation, they are simply not enough. Parveen shares that the very government departments in Sindh that are responsible for making sure these facilities exist, like the Labour Department, do not generally have nurseries or facilities for children of employees, and are also ineffective in terms of fulfilling duties of inspection. “The laws are all there, but there is no implementation.”

http://tns.thenews.com.pk/enough-daycare-facilities/#.XKW9EJgzbIU

Millenials vs Us – How weddings in Pakistan have changed

Without over-spending and showing off, one can still have a fun, festive, joyous wedding

Millenials and us

There is always a level of naivety at a young age. The stars in our eyes cloud our vision. Yet today’s generation is smarter in some ways, if not all, than us. For starters, they know that after the “wedding” there is something called “marriage”. Back then, we had one single word for both very different concepts — shaadi.

For us, shaadi meant the rasoomaat (traditional wedding rituals), the dresses, the jahez and bari (yes, we come from that stone age era where jahez was not a bad word and was politically correct, and bari was a given). Our focus was the wedding and not so much the marriage as we set off on our, perhaps, most important journey that was to change the course of our lives.

So here are the pros and cons — on a comparative level — between the age of innocence (or stupidity) and the age of the so-called Generation Y (our smarter counterparts).

The Net Generation knows, for the most part, what it wants out of life. They have definitive goals, and marriage is, for most if not all of them, ONE of their many goals. For us, it was THE most important goal. This is why the wedding hype in our over-dramatic times was emotionally exaggerated. The crying at the time of rukhsati was a given. It’s not that brides today won’t miss their folks but the make-up is a result of either parents or the by-now-earning bride working hard to pay the make-up artist loads of money. Loads are always relative, of course. Today’s bride cannot afford to faint in sadness at rukhsati time. She knows that some 20k went just into her dupatta fixing and jewellery setting. She got the appointment a year in advance. It’s not worth it to get the mascara to flow. Besides, crying can be done on another day.

The millenials are also very clear in terms of who they want present on the wedding. Their “friends” are key. It’s ok upto phuphichachimaami and khala. And cousins are always good fun. But they don’t want distant relatives or neighbours of an area the parents left 20 years ago. They want smaller but “classier” weddings. They’d rather spend on the flowers than on people who don’t mean much.

The brides today are also smarter in that they are not big on gold jewellery because prices of gold have skyrocketed. So they are smart enough to use silver that is gold-plated. They also wear one carefully selected set. ONE. As opposed to brides of my generation wearing like 5 necklaces on any given shaadi.

The brides today are decidedly more elegant. The groom is more well-groomed, really. The couple portraits are more picturesque at smartly chosen locations. Their invitees are more select. They know that weddings lead to marriage. They are simply smarter. Or are they?

While the weddings of millenials are smarter, the old world charm has been lost in some aspects. Just take the excessively choreographed mehndis for one that seem more for Instagram and snapchat and less for the simple joy of unrehearsed celebration that came out of spontaneous luddi and singing tappay. The dholkis have everything but a dholak.

While smaller weddings are a great idea, they would truly be great only if they are less ostentatious and lighter on the pocket. We invite less people but end up spending more money. The event management, flowers and elaborate menus from upper tier caterers are a huge burden on the families. Even if one can afford it all, is it a must that we spend not lacs but millions? Also, there was a certain warmth in inviting relatives and old neighbours. One can and may limit the number of people, but why leave out those who have been a part of the lives of these families? The rasoomaat are debatable for many reasons — religious, cultural or due to social evolution. But the joy of sharing this momentous occasion is a pre-requisite.

While we laud the weddings of today on account of some smarter choices, are these choices really pragmatic, or has our extravagance simply changed forms? The jewellery may now be gold-plated silver, and it may be a single set the bride wears, but what about the wedding dress that takes years to plan and order, and costs a fortune, and is so heavily full of work that it provides no visual relief, yet is something we don’t seem to mind.

Earlier it was jahez. Now it is expensive wedding dresses by designers and elaborate wedding events. Have we actually had a paradigm shift socially? Look closely and nothing has really changed. Weddings are a pricier affair than ever.

And while the millenials are smarter in their life choices, they are sometimes so smart that leave alone wedding, they doubt if even marriage is a good idea, because it has simply too many strings attached, and is too much commitment.

The wedding is a special occasion. It opens the door to a new and special journey. But our society is sitting on the crux of change. As families and as a country, can we afford such extravagance? Without over-spending and showing off, one can still have a fun, festive, joyous wedding. The money one saves can help so many others. If no one else, it can help the couple settle in life.

Time to re-think weddings.

http://tns.thenews.com.pk/millenials-us/#.XKW3p5gzbIU

King of Sweets – Gulab Jamun is now Pakistan’s National Sweet

A perfect gulab jamun, not hard at the core, not mushy and soft to break down, is now Pakistan’s national sweet

King of sweets
In the midst of macabre headline news, Pakistan’s favourite comfort food made it big. The nayi government of naya Pakistan ran a poll on Twitter as the naya saal (New Year) ushered in: “Which should be the National Sweet of Pakistan?” There were three options: jalebi, gulab jamun, and barfi. More than 15,000 people voted, and gulab jamun won with 47 percent votes.

The poll I subsequently run on my facebook page had just two options: gulab jamun contended only by barfi. Gulab jamun won by a whopping 79 percent votes.

However, are polls on social media enough to decipher what is Pakistan’s favourite indulgence when it comes to a sweet tooth? There has been an uproar among social media users who complain that there was no national consultation in this important existential debate. However, at grassroots level, gulab jamun does seem to have tugged at the nation’s heartstrings. Mithai sellers and caterers confirm that gulab jamun is indeed the hottest selling item [pun intended] as they taste best when warm, bordering on hot.

The historical origins of gullus, as gulab jamuns are often fondly called, are often traced back to the times of Mughal emperors, particularly Shah Jahan. Folklore has it that Shah Jahan’s royal chef accidentally fused elements and by a stroke of fate, a sweet from heaven found its way on earth. Other food historians claim that its origins are Turkish or Persian. As diverse as the language in which its name is taken, which is Urdu, gulab jamun seems to be wrapped in layers of culture and history. Whatever its trajectory may have been, it is part of the very essence of happiness in the subcontinent.

Gulab jamuns are like all good thing in life. It has to be just right, and one mistake can be unforgiving. A perfect gulab jamun requires technique, skill, precision, accuracy, and above all patience. They cannot afford to be hard at the core, but also cannot be so mushy and soft that they break down — just like a well-rounded person [pun again intended]. The reduced milk — khoya — which forms the basic ingredient of the dough of the tempting dessert, is derived after painstakingly cooking milk till it evaporates, leaving behind khoya. Once these dough balls are fried and are light brown, or blackish if it is a kala jamun, they are then soaked in sugar syrup. The syrup was originally rose-flavoured, which gives it the suffix “gulab”.

Now, the rose essence is optional. But the sugar syrup or “sheera” as we Pakistanis lovingly call it, is a must. As an avid gulab jamun fan said when asked why she loves, “the sheera drips into my soul… it makes everything seem alright”. Warm it a bit and it melts in the mouth. Put it in zarda (sweet saffron rice) and a bite with tiny gulab jamun makes you thank God for the good life. Have it after dinner or compliment it with chai. Gulab jamuns allure you. It is perhaps these enchanting qualities of the gulab jamun that make it the popular choice.

As a barfi lover, it is not easy for me to accept the supremacy of this King of Mithai. But one has to accept that gulab jamun has a more comforting and satisfying feel to it.

Gulab jamun being crowned as Pakistan’s national sweet has led to debates across borders. Nations across the subcontinent — India, Nepal, Bangladesh, and of course Pakistan — are claiming that it belongs to them. The debates on social media are often divisive. Everyone wants to establish that the home of the gulab jamun is their country. The gulab jamun smiles on, basking in its golden glory, while its lovers’ squabble like the “raqeeb” (adversary) in Urdu love poetry of yore would fight for a claim to the beloved.

Fact remains that Pakistan has taken the lead and gulab jamun is now, officially or semi-officially, Pakistan’s national sweet. But looking at the glass half full, here’s what is great about this phenomenon: If in nothing else, Pakistan and India may find themselves on the same page, for once, when it comes to the love of gulab jamun. When all else may have failed to build bridges, this gastronomic delight may do the trick. How sweet!

http://tns.thenews.com.pk/king-sweets/#.XDxKp7hS81k

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

No time to sensationalise – How Media Reports Suicide

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

No time to sensationalise

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Treatment for viral diseases is leading to drug-resistant infections

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

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

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

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

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

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

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

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

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

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

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

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

4.Multidrug resistant Typhoid, effecting all ages

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

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

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

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

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

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

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

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