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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

Pakistan’s fast changing kitchen-scape

Hiring cooks does not mean women, or men, are not homely any more. It is a social change, one that we must accept, and see cooking as an emerging, respected profession

The fast changing kitchen-scape

Once upon a time I used to cook up things like a mean deg of nihari, loads of bihari kabab, and the genuinely ghutta hua haleem for a dinner for 30 people quite frequently and without panicking. If I had a helper to cut up the onions and vegetables and wash the meat and do the dishes, I was good to go, taking smugly all the compliments that came my way.

But somewhere along the road, priorities changed. It was not just the fact that I became more invested in my profession. It was also not just me. The emergence of “cooks” came to the fore.

No, these were not the live-in Khan-e-Samaan breed of cooks that our mothers and grandmothers had who used to manage the entire kitchen and cater to all food-based needs of big families. These are part-timers. A few hours a day or a week. Neatly stacked storage boxes of salan and kabab split into portions in the fridge and freezer, also labelled for convenience. This is what the modern-day cooks on urban Pakistan are like.

Often one doesn’t have one but actually many. I have one in my list of contacts in my phone that is for usual day-to-day cooking — the chawal, daal, sabzi, qeema type of stuff. Then there’s the one you call when there is a dinner at home — biryani, kabab, qorma and the likes of these. But then there’s the super fancy one — the CV or intro says, “can make Chinese, Thai and oriental food”. I have not utilised services of all but there is a comfort in knowing they are there.

In a fast-changing social landscape, the larger joint families have been replaced by nuclear families. In these urban families crunching under inflation, the woman no longer has time to deliberate about the daily menu, then cook it, and then serve it. She is as much an earning member of the household as her husband. Many a times, even the children, once they are young adults, are working part-time.

The good thing that has come out of this is that unnatural expectations from women to focus their lives only around the kitchen and its periphery are decreasing. But that also means cooks are an integral part of life. However, full-time cooks are expensive in more ways than one. Not only is it the salary, but it is also the unsaid pressure to get food cooked daily in order to justify why you have that full-time cook.

It is an expensive proposition to house domestic staff. Thus, part-time cooks seem like a great option — both for the employer and the employee. For the employee as being able to work in more than one house allows him or her more flexibility of timings, and is mostly a more lucrative option.

The good thing that has come out of this is that unnatural expectations from women to focus their lives only around the kitchen and its periphery are decreasing. But that also means cooks are an integral part of life.

A faster-paced lifestyle also means we are less discerning about many things — we don’t get our masalas pounded at home; we are ready to buy ‘heat and eat’ items, and we use a lot of easy-to-cook meat options, mainly poultry. Fried onion packets have found a way in our homes, as have frozen chopped vegetables. Plus we eat out way more than our counterparts a few generations ago.

Pakistanis are serious about their food so it is not that cooking has taken a back seat. However, other more pressing things have taken precedence. We still cook, but now it is more sporadic, and limited to certain specialties to remind our families and ourselves that we still have not forgotten how to make food. Hiring cooks does not mean women, or men, are not homely any more. It is a social change, one that we must accept, and see cooking as an emerging, respected profession.

http://tns.thenews.com.pk/fast-changing-kitchen-scape/?fbclid=IwAR164tl3DjPcZGwjGbfv9XCe6Cp6k8fkmpwmFfbRDZZ9CCDSbphQ1zCj-BA#.XAJZic1oQ1l

As the door opens to guests…

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

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

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

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

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

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

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

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

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

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

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

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

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

Read also: Eid with Maria

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

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

http://tns.thenews.com.pk/door-opens-guests/#.W3UwzegzbIV

Why must women get an ID card?

The reasons for women lagging behind men in the race to get registered as citizens are many, and in rural areas the factors multiply

Why get an ID card?

“Traditionally, in our village, people didn’t feel it was necessary for a woman to have a national identity card (NIC),” she says. Men are the ones who traditionally own property, get preference in education, and have ambitions to be financially independent, not women. But some ten years ago, Kaneez found an incentive to rush to get her NIC made — the Benazir Income Support Programme (BISP) that gave her the hope of a monthly stipend.

Today, at the age of 41, Kaneez is thankful she got the NIC, as none of the employers in Karachi want to hire her as house help till she shows them her NIC. “Once we moved to Karachi, I realised that to get my daughters admitted in school I needed to get their B Forms made.”

The reasons for women lagging behind men in the race to get registered as citizens are many, and in rural areas the factors multiply.

If women do not have an identity card, they lose out on everything, says Maliha Zia Lari, lawyer and gender activist. “Without it they are not recognised by law; they officially do not exist. It has a massive impact on the personal, the social and the institutional levels.”

Without the NIC, women cannot reach out for any legal protection, their ability do anything on their own is curtailed; they cannot hope for independence. They cannot own or inherit property, and also cannot hope for insurance or be the beneficiary of any welfare initiative, as Lari explains. “Nadra requires a family certificate now for everything, so even the husband not having an ID card poses a problem if and when the wife and children want to get registered. Child marriage cannot be mitigated if a girl without an ID card is married off as she may be a minor for all we know.”

The reasons for women lagging behind men in the race to get registered as citizens are many, and in rural areas the factors multiply. “One of the issues is fulfilling the legal requirements and documentation required for getting the CNIC. Women in rural areas often don’t have means to readily get to the towns, are illiterate, have restrictions on mobility due to traditional customs and cannot travel alone [due to security reasons or family restrictions], and male members of their families don’t always support them to get to offices of the National Database & Registration Authority (Nadra),” says Ali Akbar from the Association for Water, Applied Education & Renewable Energy (AWARE) in district Tharparkar.

Read also: The cultural blockade

Akbar shares instances where women who did not have NICs were exploited and robbed of their rights. “Brothers and fathers who were not willing to give the rightful share of wealth to a sister or a daughter would, to close the revenue department’s record, get the tehsildar to record the statement of a couple of villagers mentioning that Mr so and so has no sister/daughters or that she has died or she is not claiming her right, and thus this male member of the family has the right to hold this property. But now the Nadra record is computerised and the woman has to be present and her statement recorded before the magistrate or registrar for any change in the legal ownership of property. The NIC, then, is a basic pillar for the empowerment of any woman.”

However, the awareness about the importance of being a registered citizen is growing among Pakistani women. Mahnaz Rahman, Director, Sindh chapter of the Aurat Foundation, says the projects by AF aim to incentivise it in many ways for women. “For example, we tell Muslim women that you need it to go for Hajj otherwise you cannot get a passport to travel for the pilgrimage. There is increased realisation about this among the lower income and middle income strata as well where the women are working to support their families,” she says.

Currently, AF is working on a project aimed at women from non-Muslim communities, encouraging them to get CNICs and in turn to exercise their right to cast the vote.

The BISP has had a positive impact in encouraging women like Kaneez to apply for NICs. “Our surveys show that numbers of women who have registered for the NIC has increased exponentially,” says Hasrat Prakash, Field Supervisor, BISP, in Mithi and Chachro, district Tharparkar, who adds that women are not just going for the ID card but are actually opting for the Smart National Identity Card (SNIC), Pakistan’s first national electronic identity card. The SNIC contains a data chip and many security features.

“BISP now requires biometric verification, which incentivised making of these SNICs. The incentive, of course, is the money stipend. The best part is that more women are now included in the voters’ list, and that more people are registering daughters at birth for the B Form, especially the eldest daughter of each family,” says Prakash.

As mobility still remains a real issue for women, facilitation efforts are being made by various organisations to help them get registered. “If in any locality we find one hundred or more women who need to get registered, Nadra’s mobile van comes there to help us and register women on the spot. There are holistic efforts by the civil society, aid agencies, Nadra and BISP among others, and the situation is comparatively better,” says Rahman, but also adds that more campaigns and efforts are needed for social mobilisation.

“Registering can be a tiresome process and if the people are not highly motivated why would they give up on a week’s daily wages to get an identity card?” says Lari, adding that “the most important thing that needs to be done is make the registration free as well as easier.”

http://tns.thenews.com.pk/get-id-card/#.Wi-XQt-WbIU

Truck art for education

An initiative that spreads pro-girls’ education slogans via truck art is hoping to change mindsets in Kohistan and around the country

Truck art for education

“It’s an initiative that I am so proud of because the local community has owned it,” says documentary filmmaker and rights activist Samar Minallah who developed the concept of a culturally relevant advocacy initiative through truck art. “The brightly painted trucks are like moving billboards that amplify a message from one part of Pakistan to another. My visit to Kohistan further reinforced my belief in using art and traditional motifs and designs for raising awareness,” says Minallah. Kohistan, according to the Alif Ailaan Pakistan Education District ranking 2015, is the worst performing district educationally in KP.

According to local teachers, children of primary schools of Pattan look forward to attending their newly painted classrooms decorated with bright indigenous symbols from Kohistan.

Using indigenous sensitivities and art in mind, Minallah interviewed local people for their opinion and collected local embroidery motifs created by village women as the preparatory research for the project, to incorporate in the final drawings and paintings. “The aim was to not only raise awareness about the importance of education for girls but also to honour local art and crafts, and develop a sense of ownership for the local community members,” she says. The total number of trucks that have been painted till now with these messages is 30.

“The feedback has been great because indigenous art and tools were used to convince local communities about the importance of education for girls, so it found acceptance and appreciation,” said Dr Ziaur Rehman Faruqi who is Head of Programmes at National Integrated Development Association (NIDA), and is actively involved with the project ‘Girls Right to Education’ in collaboration with UNESCO and both the federal and provincial governments. In the spirit of collaborative efforts, Faruqi shared that they have brought on board not just local leaders and parents but also the religious clergy and the political leadership for what he called a “holistic approach”. “This could not have been achieved otherwise as Kohistan had multiple issues like ghost schools and teachers.”

IMG_0010

School children of Kohistan took part in interactive painting activities .

According to local teachers, children of primary schools of Pattan look forward to attending their newly painted classrooms decorated with bright indigenous symbols from Kohistan, shares Minallah, adding that truck owners from Punjab have reached out to the artists to have their trucks painted with similar images and messages. “One of the local mosque imams asked if his mosque’s name could also be added on the newly painted bridge along with the pro-education empowering messages,” she says. Local people take selfies and photos from their mobile phones in front of these bridges of Sholgara, Dubair and Bisham adorned with important messages such as

Bhai aur behen mil kar school jaain, Zindagi main ilm se roshni jalaain (Both brother and sister should go to school and bring to life the light of knowledge) and Apni aulaad ko taleem ka tohfa daen (Give your children the gift of education).

Atif Khan, Minister for Education, KP, shares how education of girls is now being seen as a priority. “We are especially working on education for girls. Examples are that 70 per cent of all new schools we are 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,” he says. As an incentive, female education managers in backward districts like Kohistan are being paid 50 per cent extra. Lauding the initiative to sensitize communities towards the right of education for girls through truck art, the minister said that traditions don’t change overnight. “Just constructing schools and passing bills is not enough. It is the mindsets that have to be worked on.”

“Work on this project has made me happy. It made the girls and their teachers happy. The classrooms looked beautiful. The girls would join in painting with me,” said Shaukat Khan, the painter who has till now painted these positive messages with colourful drawings on three bridges and eight classrooms in far-flung parts of Kohistan. “Initially the locals resisted. They were even upset. But once they saw the finished work, they began to like the idea. Change is starting to happen,” said Khan. Khan, a father of four daughters and one son, is an artist from Swat, who has made sure his daughters are going to school “because girls must get an education”.

http://tns.thenews.com.pk/truck-art-education/#.Wh–5UqWbIU

Old age matters – What being a caregiver to my mother & her passing taught me

Caring for the elderly is not just an act of love. It is a skill that one acquires over time, whether you are family or a paid caregiver. It is an upward learning curve, and the only way out is through

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Two months ago, I lost my mother after her ten years’ long battle with the debilitating and progressive disease called dementia. On that first night after she passed, I got a message from a friend saying, “As you settle down to spend the first night without her in this world….” These words struck a chord with me. As people poured in to condole, and said, “you must have been prepared,” I honestly didn’t know if I was actually prepared, even though I knew it was inevitable. You’re never really prepared for the emptiness the loss of a loved one leaves. Yet, awareness helps us deal with this testing time.

For those who can afford to hire help or get their elderly loved one treated by trained healthcare practitioners, the blow is relatively cushioned, and the biggest struggle is the emotional pain one goes through to witness them fading away. This is when you learn the word ‘palliative’ care. “Sadly, less than 1 per cent Pakistanis have access to specialty palliative care,” says Dr Atif Waqar, Geriatrician and Section Head for palliative Care at the Aga Khan University Hospital, Karachi.

Geriatrics and Palliative care, as he explains, are two different sub-sections of medical care. “Geriatrics is care and treatment of the elderly, while palliative care is aimed at relief and prevention of suffering for both the patients as well as their families. Palliative care is not necessarily end of life care; that is a common misconception that sometimes even healthcare providers have,” he explains. Palliative care, then, is a more holistic approach. “It is actually all about living, not death. However, if all treatment options have been tried and exhausted, then palliative care does involve end of life or hospice care.

“Geriatrics is care and treatment of the elderly while Palliative care is aimed at relief and prevention of suffering for both the patients as well as their families. Palliative care is not necessarily end of life care; that is a common misconception that sometimes even healthcare providers have,” says Dr Atif Waqar.

Thus, we can say that all end-of-life care does come under palliative care but all palliative care is not end of life care.” Palliative care is a shift in focus where medical practitioners try to palliate the symptoms. Studies show that terminally ill patients actually live longer with holistic palliative care rather than with aggressive treatment.

As a son and caregiver, Afaq Ahmed, who lost his mother a few years earlier and his father just six weeks ago, has had to make some tough choices along with his siblings. He describes the painful experience of seeing his father, who loved to eat, refusing to eat due to dementia. “He would purse his lips tightly, and even if we managed to put something in his mouth, he kept the food in for a long time,” he says. The disease progressed, and he shares that it was a very tough decision when they decided that they wouldn’t use [aggressive] means to prolong his agony.

“Doctors and physicians are trained to save lives, which is why sometimes they use invasive means to keep the patient alive, but end up prolonging their suffering,” says Dr Waqar, and shares the questions that palliative care doctors put in front of the patients’ families. “Questions like ‘What would your loved one have wanted? Would they have wanted to live with this quality of life in a state of complete dependency? Would they have liked to be on a ventilator or someone pumping on their chest for CPR when it’s of no benefit? Would they rather choose to pass with dignity?’” What is often seen as defeat, then, by caregivers or physicians, is actually an informed choice.

“Doctors told us to consider if this is the kind of life our father would have wanted. My parents repeatedly used to say that they would not want a life of dependency and they were ready for the transition. We based our decision on the honest answer to that,” says Ahmed. He and his siblings decided to not force feed their father, neither by mouth nor through means such as a nasogastric (NG) tube.

Read also: Care for the caregivers

However this does not imply that all medications and treatment is discontinued. According to Waqar, intravenous fluids and antibiotics are actually therapeutic and if they help alleviate symptoms they should be continued till the end. Pain relieving medicines, like Morphine, are an option at this stage.

“Morphine is on WHO’s List of Essential Medicines that should be available because it is everyone’s right to be relieved of pain. But in Pakistan limited hospitals are given very specific and limited quotas. We strongly urge the concerned drug regulatory and health authorities to make it available to trained medical practitioners,” says Dr Waqar.

Ahmed and the family did use last resort pain relieving medications to ease his father’s pain in the last few days. “These medicines are not easily available but you can get them through the hospital or doctor under whose treatment your loved one is.”

It is not, however, easy to predict when it is time to let go. “Prognostication, or an estimation of survival, varies from illness to illness. It is both a science and an art. The variables differ from person to person. Doctors run tests to determine the actual situation,” says Dr Waqar. In his opinion, estimation is much easier in terminal stage cancer, for example, but not so easy in neurodegenerative diseases like dementia.

“Sometimes end stage patients surprise you and bounce back. There are dips, plateaus and peaks in their condition. However, when we see a steady decline in these four areas — functional, clinical, nutritional and cognitive — we know that the patient is approaching the end.” You see your loved one becoming increasingly dependent for even small chores, from being on the wheelchair to being bed-bound, and sleeping most of the day.

“They eventually stop eating; it starts with a decrease in taking solids but goes onto difficulty in even swallowing liquids. This is a natural process towards ‘transition’ which we commonly know as death. When the organs begin to shut down, the caloric requirement becomes lesser and lesser,” explains the doctor, adding that the family often thinks they are starving, which actually they are not; they no longer need that much nutrition. Caregivers attempt to force feed them which does more harm than good as the food ends up going in the lungs and aspiration pneumonia can develop.

In a lot of cases, the patient suddenly begins to show improvement or a burst of energy in the last few weeks or months. “That is actually the calm before the storm. This burst of energy helps them finish unfinished business. These facts are scientifically proven and are not hocus pocus,” Dr Waqar says. In his opinion, people in their end stage have very strong awareness about the upcoming transition. Patients are known to experience visitations of their loved ones who have already passed on and are now beckoning them. Near Death Awareness (NDA) is part of the dying process but caregivers often confuse it with delirium. Some patients who can articulate their experiences communicate what they are going through; others, like patients of advanced dementia, may not be able to.

The role of the caregivers, whether they are family members or paid staff, is one that is both painstaking and rewarding. Zaiba Emanuelle, a certified nurse in Karachi, works with elderly patients and has seen a surge in the number of nurses being employed in homes for the elderly. In her experience, patients are easier to handle compared to families of the patients. “The family keeps interrogating us. I understand that they have to do it, but it’s not easy dealing with them,” says Zaiba. “I have learnt that to deal with elderly patients, you have to understand them, and treat them with as much gentleness as one would treat children. It’s all about patience and flexibility.”

As a caregiver, I have learnt tremendously about life and death because of this sojourn on the path of dementia with my mother. I have learnt about what it means to be an elderly person in the twilight years of life, or to be a caregiver. Caring for the elderly is not just an act of love. It is a skill that one acquires over time, whether you are family or a paid caregiver. It is an upward learning curve, and the only way out is through.

When senior citizens are not a priority

Expecting specialised geriatric care might be too ambitious for the average Pakistani who sometimes does not even have a comfortable home or a devoted caregiver. “The numbers of neglected and abandoned senior citizens have escalated, and the reasons are many,” says Faisal Edhi of the Edhi Foundation that has been taking care of abandoned and underprivileged elderly since inception.

He feels that the dismantling of the joint family system, urbanisation, the thrust on industries, and the increase in population — all this has left families with little time to care for their elderly. “The government needs to face this reality and think of setting up old-age homes in peri-urban areas and outskirts of cities; this would be a much more economical option compared to hospitals. But senior citizens are not the priority in an already failing service sector,” he says.

In 2014, both Khyber-Pakhtunkhwa (KP) and Sindh provincial assemblies came up with laws guarding interests of the elderly. The laws are ambitious. Sindh Senior Citizen Welfare Act, 2014, aims at lodging establishments, free geriatric and medical services, 25 per cent concession in all private medical centres and 25 per cent discount on purchase of essential commodities to name a few. However, what is missing is the implementation. Quality care for the elderly requires a steady stream of money, something not many Pakistani families can afford.

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