Problem of Problems!

Once you have read everything in a Magazine then you come to a realization of ‘what’ to read, similar to the fact that once you have lived your life then you comes to a realization of ‘how’ to live. Having done so, one comes to a point where one feels like reaching out to people. This afterthought is an insight of varied paths which lie in front of us all; a canvas of possibilities on which we could paint varied pictures – a reality – emanating from our subjective consciousness. Taking this journey of introspection, one reaches the shores of internal realms where words and images blend in to eternal ‘Cause’.
Wise among us have taken that journey in order to discover the essence of all things. It is reassuring to know that where our efforts end, an everlasting will extend, in order to perpetuate our just cause. It is, as if, divine cause works to have our cause fulfilled. It is to give us mortar to create an eternal abode. Time loses its relativity and meaning in this journey of introspection, where there are no cycles of sun and moon, therefore, the rules are ever constant. However in this realm, observer as much influences the environment as much environment influences the observer. However, these influences are discreet. A desire will bring home what is cherished, moments become easy, creativity enhanced – one can bring in to existence his reality – based on past and current influence. However material world works against persons will – slowing it, denying it, asking him to strive more and more until he actualizes himself. Thus these, so called problems, shape his spirit and soul.
Those in the domain of counseling would attest to the fact that most of our problems are self manufactured. In general, the way we habitually think and feel about issues determine the way we approach a problem. The dark remorse and chains of regrets contribute too much heartache; it does not serve any one anything. It is best to close the doors on problems of the past and move on with the purpose of living. In fact, the very label ‘problem’ leads to dejection and disappointment. Relabeling them as an ‘opportunity’ or ‘challenge’ would impel us to muster all of the power towards a stimulus. It is like a laser beam (of concentrated effort) which can cut through thickest of steel-sheet. It is our choice to be like steel which is forged by a hammering of life’s problems or be like a glass which is shattered by a single blow. The determining factor in individual’s life is how he/she handles problems.
Then, there are circumstances which are beyond the control of mortals and which can very well be regarded as a problem. The death of a parent, wife, brother or any other significant other which seemed nothing but alienation, somewhat assumes the aspect of a guide. This may bring in a revolution in our way of life, terminating a period of dependency waiting to be closed. This may brings in a new era of growth, or formation of new acquaintances and reception of new influences which would herald in a new era of development. In the words of Ralph Waldo Emerson ‘ the man or women who would have remained a sunny garden flower, with no room for its roots and too much sunshine for its head, by the falling of the walls and the neglect of the gardener, is made the banyan of the forest, yielding shade and fruit to wide neighborhoods of men’.
Problems are growth-stimulators. It is through problems that human spirit is forged in to greatness, of one sort or another. Those without problems are relegated to deep waters of failure. In embracing the problems, one realizes the true meaning and zest of life; this entails growth and self actualization through deep study, earnest and sustained effort towards a cherished goal in life. However this only happens when one realizes the necessity of problems in one’s life, thereby encouraging a constant stream of difficulties. One would argue that this would lead to masochism of sort. Answer is: Highly unlikely. In fact this would ensure a steady growth and maturity.
In conclusion within every problem there are seeds of equal, if not more, benefits. Realization of these facts makes us cognizant of the necessity of problems. We welcome them for what new message they bring for us. Take out a paper and draw a line in the middle. Write problem on one side and opportunity on the other; subsequently make a sustained effort in converting these so-called problem in to an opportunities. Keeps this paper with yourself, for you will be astonished in few years time, how things have turned out!

Terrorism, Health and Responsibility of Intellectuals?

In contemporary times, the loss of skilled staff to incidences of terrorism is a matter of concern. The prime example of this tragedy is death of Surgeon General, Pakistan, Gen Mukhtar Ahmed Baig, in an incidence involving Suicide Bombing1. Suicide bombing is a strategy in which perpetrator intends to inflict harm on his victim with no exit strategy in mind. No place is immune to such incidences; acts of terrorism and suicide bombing have been carried out in Hospitals, private clinics and places of worships. The incidence of such gastly acts has increased since induction of Pakistan as a front line state in the War on Terror. One would argue this is a heavy price to pay. In this write-up we will examine the health related variables of terrorism.

Pakistan has seen a steady rise in the incidence of suicide bombing. Although accurate statistics are not available but according to one estimate 927 people have been killed in the acts of terrorism involving 71 suicide attacks in 2007, alone2. Subsequent years have seen a rapid rise in the incidence of Suicide bombings. Though there may be no virtue in counting the dead, lessons can be learned in order to rectify the mistakes. There are various determinants of this rising extremism in the country. A discussion on the political reasons is beyond the scope of this write-up; however, some would be sighted as a background to our main discussion.

Pakistan is a country with an Agrarian economy. The health related indices read a sorry picture; the neonatal mortality of 57 per 1000 live births and infant mortality rate (under one) of 78 per 1000 live births is a source of persistent concern3. We are beleaguered by a double burden of Infectious and Non-communicable diseases. There are those who are inflicted with cardiovascular diseases, obesity – much like western countries – due to affluence while the rest suffer from poverty, malnutrition and scarcity of clean water supply. In terms of economic resources we are classified as a Low- Middle Income Country while health related variables may be at par with Sub-Saharan Low Income Countries4. Community based studies site Prevalence estimates of common mental disorders (Depression and Anxiety) to be around 30%, which is double the figures from the industrialized western countries5. Conflicts and wars lead to migration of population, foremost to erosion of protective factors for mental health. Post Traumatic Stress Disorder (PTSD) is a common disorder under these conditions. Though there are no representative figures, of 1020 Afghan refugees presenting to a psychiatric clinic in Peshawar, North West Frontier Province, Pakistan, 76.1% (n=776) met DSM-III-R diagnostic criteria of PTSD6.

In a periodical, scientific American, Susser et al. writes ‘Terror does not always come out of the barrel of a gun or in the shape of a bomb or grenade. Intimidation, harassment, threat of violence or the creation of an environment of imminent violence can be enough to paralyzed civil life and kill enterprise and creativity. Such tactics can also lead to violent retaliation by those oppressed.’7 Lack of education and poverty are a breeding ground for extremist ideologies, duly funded by external Agencies and Governments. Armed conflicts lead to alienation of marginalized communities. In Pakistan, Study of Sociology and Anthropology are relegated to those with no options. In this context the policy-decisions are not informed with Research evidence.

Suicide bombing is not an outcome of religious extremism alone. It has various social, psychological and various geo-political determinants. Lack of development and economic opportunities are a breeding ground for extremist ideologies. Fighting terrorism with force is an exercise in futility. Suicide bombing is a symptom of a disorder. There is a dire need to treat the cause rather than control the symptoms, alone. The rise in religious extremism has affected health related initiatives in many ways. In immunization program, the refusals of polio vaccines have been a recent source of concern. Self-styled clerics in North West Frontier Province of Pakistan have claimed that the vaccines have been donated by ‘Western’ countries, with the aim to affect the ‘Faith’ of their future generation. It is of prime importance that Government initiates a dialogue with these religious leaders in order to find an impasse8.

Another important, yet neglected issue which is fallout of War on terror is Drug Use disorders. Heroin as a drug of abuse was virtually unknown in Pakistan prior to 1979. With Heroin addiction reaching epidemic proportion, over the past 40 years, Pakistan has become embroiled in a growing, complex and multi faceted narcotic menace. This has affected nearly all socio-economic groups. According to the 5th and last National Survey on Drug Abuse (N.S.D.A.) conducted in 1993 by the Pakistan Narcotic Control Board, there were nearly 3 million drug addicts in Pakistan with 51% of them being heroin addicts9. United Nation’s Anti-narcotics chief warned that Afghanistan burgeoning opium production was leading to the emergence of new “Golden Triangle” of lawlessness on the country’s borders with Pakistan, Iran and Turkmenistan. “Illegality is very pervasive and trafficking (is) going on,” said Antonio Maria Costa, executive director of the UN’s Office on Drugs and Crime. Recent reports show that Afghanistan saw a record harvest of 8,200 metric tons of opium in 2007, a 34% increase over 2006. The export value of the country’s opium is estimated at $4 billion (Euro 2.73 billion), up 29% on last year and equal to more than half of Afghanistan’s legal gross domestic product. The mountain terrain in the North Western Frontier Province of Pakistan has provided trade route to goods across the Afghanistan and central Asia for centuries. This has resulted in rising sale of hard drugs in Pakistan10.

Suicide bombing and terrorist activities are particularly more devastating in the context of restricted Medical resources of a Pakistan – a developing country11. Unfortunately, an organized Emergency Medical Services does not exist in Pakistan. The initial help to such trauma victims is usually provided by people at the scene of the terrorist activity, which mostly is nothing more than sending the victims to the nearby hospital in whatever form of available transportation. Transportation of these victims to the hospitals is also delayed by the traffic congestion; though the situation has improved in major cities due to the combined efforts of government and NGOs. In-hospital care for suicide bombing victims is also not very effective. The doctors and paramedical staff in the emergency department across the country, even in tertiary care hospitals, are not well trained for the care of suicide bombing victims. The situation of medical services is even worse in tribal areas of Pakistan, which have been badly hit by such incidents lately.

The gravest issue with terrorism is that it impedes development in all facets of life. Health care sector in no exception to this problem; damage to infrastructure, loss of skilled work-force, accessibility to centers and teaching and training opportunities are compromised. Terrorism affects the mental health of the masses direct as well indirectly. The stress of uncertainty leads to state of compromised functioning among those who are vulnerable.

In a larger frame of reference, the lack of development – in terms of human capital – is the biggest loss inflicted by terrorism. In the twenty first century, when stem cell research has opened the avenues for unveiling scientific mysteries, we cannot afford relegation to deep waters of ignorance. We need to initiate dialogue on issues confronting the masses. Universities should play their part in bringing together all stakeholders. Leadership in Academia should step out of their traditional roles and confront the bigger issues, courageously. Noam Chomsky, the famous American Cognitive scientist, linguist and Philosopher in his famed essay, ‘The Responsibility of the Intellectuals’, commented on the prevailing situation after the Second World War: ‘Let me finally return to Dwight Macdonald and the responsibility of intellectuals. Macdonald quotes an interview with a death-camp paymaster who burst into tears when told that the Russians would hang him. “Why should they? What have I done?” he asked. Macdonald concludes: “Only those who are willing to resist authority themselves when it conflicts too intolerably with their personal moral code, only they have the right to condemn the death-camp paymaster.” The question, “What have I done?” is one that we may well ask ourselves, as we read each day of fresh atrocities in Vietnam—as we create, or mouth, or tolerate the deceptions that will be used to justify the next defense of freedom’.11 The same question confronts many intellectuals in this country beleaguered by war and terrorism.

Pathways to Care: Experience from Pakistan

In order to recover from disease and improve health, patients choose different forms of treatment and care. A delay at any stage could be detrimental, leading to psychological, social or medical complications.

Research form the West has shown that general practitioners (GP) are the gatekeepers to specialised psychiatric services. This is similar to a model constructed by Goldberg and Huxley, proposing that patients have to pass through three filters in order to reach specialised mental health care (community-GP-psychiatric care).

In Pakistan, there are three main mental health service providers: the specialists in private sector, the government and traditional healers. Most of the government run mental health facilities are urban, mismanaged, poorly resourced and understaffed with irregular provision of medications. Generally, the poorest sections of the society visit these hospitals since they have no other options available. The rest prefer treatment from private medical specialists.

But even that has its own problems. It is unregulated while monetary exploitation and abuse of patients is not uncommon. This is particularly so in patients with schizophrenia, which leads to delay, thereby increasing the psychosocial morbidity and burden of illness. This is further compounded by the extreme dearth of psychiatrists and other mental health professionals in the country. For example, it is estimated that there are only 360 psychiatrists for a population of 160 million.

According to the World Health Organization (WHO), mental healthcare services should be integrated with general health services and provided in a decentralised manner. It is also beleived that trained health professionals are scarce in developing countries. If proper health care is to be brought within reach of the masses, primary healthcare physicians must work in collaboration with specialised personnel.

Research from the West and developing countries shows that about a quarter to half of the patients in primary care have mental health needs that have not been addressed. Due to poor awareness and resources, primary care staff has not been trained to treat and manage mental illness, thereby fulfilling the need-supply gap. This model was conceived by psychiatrists in the western countries with administrative convenience and well-established primary healthcare system.

In Pakistan, primary health is poorly developed with weak referral chain from primary to secondary to tertiary care services. Most patients by-pass the primary care services and access services at secondary and tertiary care centres directly. The main reason is the poor quality of services offered. Additionally, in the absence of any kind of health insurance, most patients pay out of their own pockets.

Studies on integration of mental health services in primary care centres in Pakistan are inconclusive. The issues involved are related to the perception of government-run primary health care services as well as the costs involved, knowledge of services, stigma, pathways to care and design issues.

A few years ago WHO and Pakistan medical and research council (PMRC) did a survey in order to study the reasons behind the poor utilisation of available BHU services. Low numbers and attendance rate of doctors (63.8 per cent), non-availability of medicines (22 per cent), geographic inaccessibility and low quality of services were some of the major factors. Public sector tertiary care hospitals (TCH) are a major recipient of government budgetary allocation, leaving little resources for improvement in the available primary health care infrastructure. Employees’ salary comprise 55 to 66 per cent of the budget, leaving little room for technological advancement, equipment and medicines.

Integration of mental healthcare in ailing primary care system is a difficult issue which may seem feasible for countries with well-established primary healthcare system. Nearly half a decade of research on pathways to psychiatric care in Pakistan has shown different, yet interesting trends.

For example, a pathway to psychiatric care study from a tertiary care hospital demonstrates that among 96 patients, only 2.8 pre cent were referred by primary care physician as opposed to 20 per cent referral from specialists in other fields of medicine. In this study 63 per cent cases were self/family referred. Only 17 per cent patients had a primary care physician. Clearly, the expected model of primary to tertiary referral care appears to be lacking at a practical level. In this study the principal referral path in Pakistan appeared to be word-of-mouth rather than primary care.

A substantial time period is lost before initiation of treatment in schizophrenia, which is labelled as duration of untreated psychosis (DUP). In the absence of a well-developed primary healthcare system, a majority of patients visit psychiatrists as their first contact. Time is lost due to non-recognition of prodromal symptoms and subsequently, inadequate treatment. Primary care system, which is competent and motivated, needs to be created while specialists must play their role in training and supervising this mass of generalists.

The prevalent apathy in public and private sector is primarily because of lack of awareness and the stigma related to mental illnesses; a perception which needs to be changed. An active public-private partnership could be a workable solution for mental health service provision. This requires a unified agenda and commitment from both tiers. Any lasting solution must address the deep rooted inequities, ethical misconducts and macroeconomic issues.

Workplace Romance!

 

By Syed Ali Wasif

Philosophers and social scientists have tried to define human being. Definition, as we are told is known to captures the distinguishing essentials.  Many definitions are current. ‘Man is a social animal.’; ‘Man is a rational animal.’; ‘Man is a thinking animal.’ etc. Great many definitions suggest one thing: none captures what man is in totality and reflects a specific frame of mind of the definer. Question is what motivates one to do ‘A’ and not ‘B’ at particular point of time and what is it that pushes him to go for ‘A’ rather than ‘B”. Human being is a highly complex thing, indeed. Man’s unfathomable complexity suggests highly complicated environment through which he has come through. Be that as it may, animals very rarely show animal-ness between themselves while man when in animal mood destroys the very fabric of social life of which he is said to be an animal.

  

From this general description of human behaviour, let us move to a more specific example; two colleagues, taking break in the lunch time, hand in hand together – no body should object – after all they are adults. However work place ethics demands certain restrains and boundaries. Just as it is unprofessional to meddle in other people’s affairs, so much so it is unacceptable to put a hand in some one else’s blouse – at least in public – without marital vows. But we are not talking about acceptable moral behavior for spouses, what we are acutely inflamed about is relationship at work place. Baring voyeurs’ and nymphomaniacs of certain type, every body would object to such behaviour.  

 

Well there are allegiances and relationship that are fall out of normal human behavior. However, there are emotions which do not quite fit the bounds of aforementioned categories. What does one do in such circumstances?

 

A damsel of a co-worker comes in to your office, closes the door-shut, with a shallow breath and a husky voice, asks you to be more active in a discourse, involving mere letter to the vendors. After all one is also human, run by same hormones as Adam and Eve. It helps to keep a picture of your spouse, in circumstances like these. There are equally obnoxious bosses who insist on re-doing the letter, all the while gazing certain cleavage – literally reading between the lines. Then the third casualty is a by-stander; a colleague oblivious to the work-environment, engrossed in his work, incidentally opens the store room to find two co-workers  (of opposite gender) engaged in a certain behaviour, which cannot be described in these lines, keeping in view the discretion required for young and tender minds.

 

A colleague of mine argues that this all important aspect of life is essential for optimum functioning at work. Off course, his actions, supplement the theory. I am not quite sure this is the way I would want to develop the focus of my work.  I am quite content to live with the label of ‘sexually repressed’ rather then give in to hedonic impulses. Otherwise the unresolved Oedipus complex is also quite a heinous label to carry.

 

Logical next question is; what are the determinants of such behaviour? Some believe that such relationship gives them some sort of an advantage, over other colleagues or perhaps a job-surety of some sort. Some look to find solace, due to their unhappy home situation. A stale, untendered relationship at home gives way to such work place Romanticizing. Then there are those middle ages men and women, lacking wisdom, who are keen to seek assurance that despite passing years, sagging and wrinkled skin, they are still in demand. Some have no reason; they are just habitual offenders, looking to fill their spare time with some color(s). Anyways when the (work-place) honey moon ends, each end up complaining how they were cheated and tricked, knowingly well that they allowed this manipulation. 

 

The central issue in this problem is personal and societal conflict around love. Love while considered as feeling appeals to every one; being in love with love rather then the person himself. When considered as a verb, it entails lot of thoughtful introspection. In former, one works to improve one’s social appeal; men aims to acquire money, fame and authority, while women work to improve their looks, dressing and social manners. While there may be no harm in pursuing these factors, problem lies when they become an end in themselves. If the focus changes from being loved to that of loving – of one’s capacity to love – then a state of maturity is attained from relatedness.

 

 During my internship years, I remember a supervisor, notorious for his highhanded disciplinary attitude. He use to come down hard on any individual involved in ‘affairs’ other then work. He was particularly concerned about work place attitudes. His advice still echoes in my ear ‘You can take her out, that is not my concern, but the day I see any one of you, sitting around with any chick, that would be your last day’. I would object to his choice of words, but his advice was indeed helpful in shaping my relationships at work.

 

Organizations do intervene if this state of ‘affair’ goes out of hand. It begins to look at the performance and output indicators. After all this is a distraction, albeit whatever line of work you are in, from photography to practice of Medicine

 

 

River of Life

Civilization has advanced at such a pace, over the course of century that it has put man out of touch with himself. We see countless, running hither and thither, trying to achieve peace of mind and spending millions in the process. However, this is of no Vail. 

 

Annals of History reports that Siddhartha, the enlightened Buddha was meditating besides a river when he achieved Nirvana. He came to sudden realization that water is one continuous being; one that has passed on, while the one that is yet to come is one – so is rest of the life force. All emanates from a fountain of infinite life. Off course, years of search and earnest yearning preceded this insight.

 

River teaches us lesson of constant growth and movement towards life’s maturity; to remain still is to stagnate. This incessant struggle towards its objective is some thing which inspires human beings towards self-actualization. Streams have different flow in different areas; as if stones infuriate them by pinching and pricking. However water flows through them with greater fervor. The water that emerges through is brighter, clearer and frothy white – displaying its true nature. At other places it flows leisurely, with sobering calmness and at peace with its surrounding.

 

Obstacles towards one’s objectives should be handled similarly to river; to bypass minor objects without much fuss, while tearing down any thing which stands in its way. Fools and ignorant are similar to small stones in the path of river, to be ignored and passed with compassion. Bigger blocks are to be passed by changing one’s tactics and movement. Only the biggest one are worth the fight, for river is a creative life force, replenishing all that is good and essential. It must fight the good fight with courage and wisdom[1].

 

Stones also seem to have distinctive shapes, exemplifying human character and personalities; sharp one, flat one, big one, small one. All seem to have a place in scheme of things. Some sit on the way side, as if waiting for the destiny to lay bare the course of their path. My soul seems to whisper, ‘wait for your destiny to unfold according to God’s plan’.

 

If city life is about alliances for mutual interests, then wise among men build it on wisdom and forthrightness. Small brooks, rivulets flowing leisurely with melodious sound, chirping of birds, abundance of crops in the fields, shadowy clouds and towering mountain peeks, all speaks of God’s mercy.

 

Cameras and photographs cannot behold the panoramic view; human mind and spirit is the true witness to His magnificence. Rivers and mountains serve to build the spirit within, redefining purpose and meaning. If one observes a towering mountain peak, embraced by silky clouds, romanticizing with the sunlight, giving a panoramic view for all to enjoy; soul take newness from such surroundings. Majesty Mountains bow down in obedience in front of Him. None had the vibrancy to be the witness of his grace, beauty and might – except the creature called Man. It is with ignorance as well as insight that he beckons these thought in his mind and soul.

 

He teaches each towards wholeness, through different means. For some ever flowing river, pine tress rather a chorus of pine trees, placed in an orderly manner, as if carpeting the rugged mountains, in love and awe for a divine guest, are a beckon towards His grace.  Just as tree grows so does human understanding; dyadic thoughts, laden with fruits of wisdom. To be the tallest in the forest, one has to be a beckon of hope. To bear all things, be the farthest in the forest, also takes time and understanding. 

 

There is no conflict in the nature, the beauty of all things, basking under the loving Sun. Similarly there is no denying the presence of omnipresent God. The more one accommodates this belief, the more orderly one’s life grows. Individual life is supported by an infinite spirit, which is constantly replenishing it. To open one self to this spirit of infinite peace, power, wisdom is to have abundant life. To close one self to this spirit is to have stunted, self serving life, which is un-gratifying.

 

We see number of people, spending millions, trying to attain peace of mind. If peace is to be found, it is within. In recognizing the oneness with this spirit of infinite life and opening oneself to its flow, one becomes whole.

In the words of enlightened Emerson ‘Place yourself in the middle of the stream of power and wisdom which animates all whom it floats, and you are without effort impelled to truth, to right, and a perfect contentment’.

 

Every thing in the material has a counterpart in the spiritual domain; former is the effect while later is the cause. The flagrant beauty of a lake, giving way to beautiful rivers is just one metaphor of life emanating from the God – the omnipresent. Realization of these facts, a fundamental change in the world view, leads towards greater satisfaction in life.  

 

 

 

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[1] By the bank of River Kunhar, Kaghan.

Technology Addiction

Addiction to technology is on the rise, with race for electronic communication-gadgets taking an unprecedented pace. Recently, I saw a married couple. It appeared that the wife was married to her Cell phone(s). She constantly fiddled with her Nokia set – sending and receiving SMS messages. Husband also appeared oblivious to his surroundings. He seemed to be immersed in his laptop diary. The much veneered syndrome, now-a-days, is SMS Affair. Though this is yet to enter a text book of clinical psychiatry, one can see the cases in every day practice. The prevalence estimates is estimated to be quite high, so called Illness, running a chronic course, leading to accumulation of cases. 

 

Tell tale, cardinal symptoms of this syndrome are ‘obsessive’ preoccupation with sending messages. A house wife reported that her husband is having such a syndrome. He is having an affair with an anonymous lover. She sends him messages, with luring theme, playing fancily with his imagination. He replies back with same zest. This happens many times a day, with a flurry, subsiding late in the night. On most occasions these are messages which are mere forwards rather then senders own feelings. According to her, this seems to have ruined her life. It was not that she was not responsible in some way. Her time and attention was devoted to the arch-devil, television.

 

She would follow soaps, one after another, discussing and dissecting the details subsequently. If this was not enough, she would participate in quiz competitions, sponsored by the T.V channel and a phone company. ‘What veronica would do next – call her lover and confess her love’, ‘take a poison and die’ or none of the above. Send SMS urgently and win a bumper prize, this seems to be telecasted after the drama. Though a sophisticated marketing and promotion technique, what do an average Joe care about it! After all it is just a drama. Not so for our average Lucy. She would argue that dramas depict real life situations. No wonder so many fantasize these figures, trying to find solutions to their problems. If they would only take responsibility of living their own life and building their healthy relations, then it would have been a different story.

 

High band optic communication fibers and efficient servers are supported by an army of technical experts. Emphasis seems to be on increasing the speed of communication, with out knowing what to say. With who is another question? On-line communication blinds the person to the individual on the other side.  Generally people project their wishes and fantasies, not knowing the true character of the other person. Though most are aware of the fraudulent nature of the interaction – not being true to their words – themselves. There seems to be a dating industry, luring culturally diverse individuals, from Russia to Brazil – with all other included in between.  Off course it takes some pathology on part of person to be incited by such a gimmicks.

 

Latest development in this industry is Shadi-on-line. Survey needs to be carried out on outcome of such discourses. Off course, people tend to put there best foot forward, with problems surfacing subsequently. This is true in all circumstances.

 

I have a friend who have to carry his iPod, pager, (another) Mobile phone, lap-top, every day besides his car-keys and wallet. You can very well imagine the spontaneity, which would emerge out of his daily action!

 

A healthy development that has found its utility in modern day practice of neuropsychiatry is Vagus nerve stimulation devices. Vagus nerve is a nerve which carries impulses to and from the brain; one of its braches, distributed in the chest, can be stimulation with a mild current, supplied from a battery, installed in the human body. This is akin to cardiac pace maker. Charging the battery stimulates the afferent (going to brain) nerve, thereby enhancing the stimulation to the mood regulating centers in the brain. This is proven to be effective in the treatment of depressive disorders.

 

Technology has its benefit, if and when, applied constructively. It can be compared to a surgeon’s scalpel, if it is in a proper hand, it saves life. If it is in the hands of common criminal then it can be dangerous. Therefore, individuals have to learn how to use technology. Its constructive use enhances individual performance and creativity. Take micro-soft as an example. It has revolutionized business communication. Similarly software’s like Statistical package for social sciences (SPSS) has revolutionized the quantitative research. Technology is a means towards an end. If the end point is focused towards public good, besides enhancing the quality of life, then it serves the humanity. Otherwise it can be considered like a scalpel in the hand of fools.

 

Education also needs to focus on teaching humanities, social sciences, ethics before individuals go on to learn specific skills. Our Universities and institutes need to be cognizant of this dilemma, so that they can integrate skills with moral – character building – besides churning out technically sounds individuals.  

 

 

Media and Mental Health in Pakistan

Being an able bodied, mentally competent citizen of this country besides being a hard core Nationalist, raised with the undying admiration for Muhammad Ali Jinnah, I feel compelled to write these words. 

 

Writing, for me, has become a means towards sanity, in this maddening chaos and media glare. Talk’s shows are in abundance, telecasting gibberish, all day long. You have mental health experts, sitting along the culinary experts in a show sponsored by cooking oil, as if to provide a recipe for both. Doom and gloom stories are all around the place, as if land has stopped giving yield, cattle has stopped producing milk, cotton looms are without threads, market is without fruits, Natural Gas reservoirs have depleted, mothers have stopped giving birth to live-new born, God has forsaken us – those who were marginalized and separated on His behalf, from the rest of the continent. Nothing of this sort has happened. Why then we have hue and cries on what is not going write?      

 

Glaring example of this is insensitivity of media towards mental health issue. If one scans a newspaper in the morning, one is struck by the fact that nothing positive is reported. You see the pictures of tortured, charcoaled bodies, set on fire by angry mob. You see rioting youth, raising mayhem on power breakdown.  Why are we fixated on killings, robbery and rape? Are there no news of hope, friendship, sacrifice and love? Why are we so addicted to bad things in life? All this is a cognitive distortion of our community, which journalists seem to share. Collectively, we are the cause of what goes on among us; we should be the impetus of change, too.

 

Those committed to journalism understand the sanctity of written word. After few publications, one becomes well aware of sensitivities required in public domain. Time, maturity and experience teach an individual the finis of self expression. However, the impact of one’s word is proportional to his social-fabric awareness. Oblivion to this background leads to expression of empty words and phrases, which have no impact besides the passing day, a mere ripple in the ocean of words. Most of what is published in our daily news is the same – a ripple of words – an expression of non-entity.

 

Media seems to play a major role in sensationalizing the mental health issues. This is most pronounced in case of suicide. Suicide is a tragic outcome of mental illnesses, which is highlighted in such a way that it seems to have a promotional effect, rather then a deterrent one. This is akin to tarnishing the fabric of society.

 

People with mental illnesses are portrayed as dangerous and unpredictable. This perception is often inflamed by media accounts of crime, although statistics don’t bear out a connection between mental illness and violence. Some people also believe that those with mental illness are less competent, unable to work, should be institutionalized or will never get better.

 

The electronic media, as a reflection of society, has done much to sustain a distorted view of mental illness. Television or movie characters that are aggressive, dangerous and unpredictable can have their behaviour attributed to a mental illness. Mental illness also has not received the sensitive media coverage that other illnesses have been given. We are surrounded by stereotypes, popular movies talk about killers who are “psychos,” and news coverage of mental illness only when it related to violence. These representations and the use of discriminatory language distort the public’s view and reinforce inaccuracies about mental illness.

 

Some mental illnesses are more stigmatized than others. Schizophrenia, for instance, is more highly stigmatized than depression is. It’s routinely mocked and misrepresented and is less likely to generate compassion. Depression, on the other hand, is less often ridiculed, perhaps because of its ubiquitous presence or media advertisement of antidepressant medications has made the disorder more mainstream, thus more acceptable.

 

Almost 60 years have passed since the inception of independent media by the founding father of Nation – Mohammad Ali Jinnah. Instead of passing through years of maturity, media seems to have acquired senescence. Where would it go next?  

 

 

Hospitals

Hospitals are reflective of the collectivistic cultural-values and traditions of any society. A civilization’s way of living their life can be looked, in its entire cycle, through an eye of a hospital. Hospitals are strange place. Few come out of it laughing, while others come out crying. Word hospital have the same root as the word Hospitis – implying host or a place where sick and destitute are well received. Hospice and hospitality are some of the other words derived from the same root. 

 

Hospital can be a memorable place for those who go there for receiving a life. Health care staff can be a beacon of hope. With love and warmth, a mother receives her new born child. A father is showered with lot of blessings. The whole family, who is eagerly waiting for the good news, long faced and worried, is suddenly transformed.

 

Contrarily families get shattered when they are given the news of death. Like, birth, death is also celebrated with its own rituals. Just as in birth, people receive a body and soul wrapped in a white sheet; they receive a body wrapped in white sheet. Families surround the carcass in case of demise of their loved one. One can speak volumes about the deceased, in the manner carcass is handled. Attendants surround the body, refusing to leave it, while others want it to be disposed to the mortuary, at the earliest. Ultimately, it is disposed according to religious tradition of the deceased. 

 

All this happens in hospitals many, many times a day. Doctors and nurses are witness to this interaction – through out their working hours – though rarely paying attention.

 

In hospitals, you see people in pain. Witnessing pain can have paradoxical effect. It can make you more human, empathizing with the pain of other people. Pain can make a person more sensitive to emotion in others. Contrarily witnessing too much pain can also numb you to the point of callousness. All this can happen to people working in hospitals.

 

Generally the reverence we associate with a place like hospital seems to be missing. Some hospitals have become a pick-up point for prostitutes, while others are no less then blethrow house. We hear girls being raped in the hospitals. Similarly hospitals have become a den for thieves, political or other wise. The rich and powerful use their influence to malign the institution of hospital.

 

In our setting, are sick and down trodden people received with the same fervor as the word implies? It is hardly the case. One has to, only, visit any hospital, to see and feel the alienation it conveys. This is representative of the administrations apathy and its neglectful psyche.

 

From the stage of designing, construction and maintenance hospitals are a picture of dismay. They are either constructed on places which do not enable healthiness or slums grow around them, further deteriorating the status of water supply, sewerage, solid waste management. 

 

Consider two major public hospitals, Jinnah Postgraduate medical center (JPMC) and Civil Hospital, Karachi. JPMC having a federal affiliation is expected to cater to the needs of a large section of society. However, its catchments are slums in and around the vicinity. If one visits the hospitals, there are pools of sewerage water lying in and around the emergency department. Emergency department in itself is in the section of the hospital which makes access some what difficult. Problem of car parking and absence of designated space adds to the difficulty of visitors. Similarly there are no good quality, in terms of hygiene, cafeterias to serve the visitors and attendants.

 

Similar problems afflict civil hospital. Karachi. Situated in the crowded vicinity of old Karachi city, there is limited room for expansion. Access to the hospital is made difficult due to gridlock through out the day. In case of emergencies, time can be a critical factor in saving a life. Emergency physician tells us that there is a critical period after an accident, usually an hour, which can be a window of opportunity. Any medical intervention in this hour can be a matter of life and death for the victim. With the traffic situation and the access routes, these hospitals are ill suited to serve the needs of the community.

 

As opposed to these two public hospitals, consider two private sector hospitals in Karachi – Aga Khan University hospital, Karachi and Liaquat National Hospital. Karachi. Though these hospitals are well spaced and designed, they cater to the needs of only those who could afford to pay. This contradicts the charter of health equity. Though, technically, health care provision is a responsibility of the government. People are entitled to care, irrespective of their race, creed or financial status.

 

If one talks to a qualified construction engineer, he would tell us that hospital should be constructed with an earthquake resistant design. Material should also be of a nature which cause least damage in case of such natural calamity. This is due to the reason that hospitals house sick, dependent and vulnerable population, incapable to fending for themselves. In times of recent earthquake in 2005, we have witnessed the pathetic situation in which hospitals crumbled to the ground, proving to be a graveyard for those housing the institution of hospitals.   

 

In general, hospitals have different sections and department. Each has its own unique demands. People working in emergency department are often given to working on the edge. Time can be a critical factor in matter of life and death, therefore early reaction can make a difference. In their lives this, then, becomes there habitual state of affair.

 

Orthopedic surgeons are required to reduce a fracture, applying force to reverse the trauma injury. This is reflected in their behavior and conversation – antagonizing people whom they come in contact. Medical specialists have their unique way of inquiry about the cause and consequences of symptoms. They become thorough to the point of stubborn, detailed discourse on any things and every thing. Psychiatrists, generally, butt of joke for all, shrinks from others, remaining true to the label given to them. These characteristics are seen not only in doctors but nursing staff too.

 

Thus hospitals are not just a visiting place; they house communities which cater to the needs of the society. The better served these individuals are in the hospitals, the higher the quality of rendered care. There is a need to develop sensitivity for these issues in all stakeholders of Hospitals. 

 

Sedatives – kill the pill

LIFE in modern times is fraught with competition and stress. Gone are the days when people had time to gaze upon the stars and ruminate on Tasavor-e-jana(s). Generally speaking, some degree of stress is good for individual performance. However, rush for gold and achievement is bound to catch up with everyone. Further addition to this mayhem comes from the environment, one only has to read the morning newspaper to get stressed out. A friend of mine, has made it a habit to look at the news only in the evening, that too only skimming the headlines. From trigger happy zealots to incompetent structural engineers, all contribute to the stress of a regular Pakistani. Add to it the poor performance of our hockey team and those jockeying in the political arenas. How do people manage their stress? They do it by popping pills – self- prescription of tranquillisers.

Tranquillisers have become an acceptable component in the lives of a large segment of our population. Most of these are available over-the-counter without any medical prescription. These medications are not without hazardous side-effects and should be prescribed judiciously by a qualified health professional and should not be left to the discretion of shopkeepers. Self-prescription of tranquillisers is a multi-factorial problem with economic, social and psychological roots

By a conservative estimate, around seven to 10 million urban dwellers in Pakistan continue to consume tranquillisers regularly. According to one estimate, psychotropic drug sale in Pakistan for a duration of one year (June 2003-4) was worth 2.76 billion; of these tranquillisers and hypnotics were 1.36 billions with a rising trend of 18 per cent and 137 per cent respectively from previous year. General public, impervious to the risks associated with these drugs continue to pop pills.

The most commonly used tranquillisers are pharmacological compounds called benzodiazepines. Not only in Pakistan but around the world benzodiazepines are among the most prescribed and consumed group of medication. The discovery of first benzodiazepine, chlordiacepoxide, in 1957 by Leo Stern Bach was a landmark in modern psychopharmacology. Chlordiacepoxide was soon followed by a large number of similar compounds, which were quickly introduced in clinical practice, becoming among the most successful drugs ever introduced.

Various compounds from the group of benzodiazepine are available in the market. They are marketed with various attractive names and labels; it is not uncommon to see adjectives like tranquility, serenity and relaxation entwined in the names of some compounds. The most important differences among the variety of benzodiazepines are pharmacokinetic ones i.e. elimination half-life, formation of pharmacologically active metabolites. Established indications are anxiety and sleep disorders, seizures, epilepsy, muscle-relaxation, induction of amnesia, pre-medication and sedation in emergency medicine. What people do not know is that these medicines are not the only option available; there is a wide variety of pharmacological and non-pharmacological behavioral interventions that are far safer and effective for the management of these conditions.

The existence of benzodiazepine dependence was described in the early `60s with a very high dose of chlordiazepoxide but it has become a real concern for the medical community since the late `70s with an increasing number of reported withdrawal symptoms.

Individuals taking these drugs for a month or more may develop symptoms of withdrawal, characterised by anxiety, dysphoria, malaise, depersonalisation, and perceptual changes such as hyperacusis and unsteadiness. Sudden withdrawal of these medications can even lead to epileptic seizures. If the medication is stopped abruptly, it may lead to dysphoric withdrawal symptoms while continuation leads to dependence. It is ironic that the very reasons for which the medication was prescribed may return to haunt the individual.

Another hazardous effect of these medications is muscle incordination and delayed time-reactivity. This can prove disastrously fatal if one is driving a vehicle or operating machinery and for housewives, the use of choppers and blenders.

Once a person is habituated to take these medications, tolerance for the substance sets in i.e. the person no longer gets the desired effect for which he was taking the medication. In order to ward off withdrawal symptoms, people generally resort to increasing the number of tablets.

It is not uncommon for people to get concerned after reaching this stage and seek consultation from a physician or mental health professional. Usually, when they are seen in a clinical setting they are hooked on to take 10 to 15 tablets per day. Inter-dose withdrawal is another phenomenon which might impair day-to-day functioning and work performance.

Like other medication, drug-drug interaction is also another issue with benzodiazepines. If mixed with alcohol consumption, the effect of these medications can lead to life threatening conditions; suppression of respiratory centre in brain stem is just one of the concerns. Possibility of getting choked to death cannot be ruled out either if a person reaches an acute stage of intoxication.

Benzodiazepines are the most favoured medication of self-harm. Perhaps this has stemmed from their status as sleeping pills; in an overdose one would expect a person to sleep forever. There lethality index is very high i.e. when taken alone, dose of multiple grams proves to have fatal consequences.

If we look at the research carried out in developed countries, benzodiazepine overdose is the most common way of self-poisoning among the substance induced suicidal attempts, accounting for about 40 per cent of the total. A study done in Germany reports this proportion to be 32 per cent. The study also reveals that 80 per cent of the drugs used in self-poisoning are prescribed by physicians themselves.

In a study carried out in Pakistan, the proportion of benzodiazepine usage in para-suicide is double the figures quoted in the western data i.e. 80 per cent. In 44 per cent of the cases, these drugs have been bought over the counter.

In the context of Pakistan, general physicians prescribe these medications without educating patients about the potential dependence and abuse. In a group of 475 patients, 38 per cent reported current use of one of these compounds; among them 68.3 per cent used them for sleep, 52.2 per cent for stress or anxiety, seven per cent for depression, 0.8 per cent for fits and 10.2 per cent for other reasons.

On inquiry, 85 per cent of the participants reported that these medications were prescribed by physicians at some point in time. Among these Physicians, 60 per cent were general practitioners while 36 per cent were specialists. One can only speculate about the intention of these physicians; whether they do it out of good will, lack of skills pertinent to mental health or have other ulterior motives.

Multinational pharmaceutical companies, driven by economic gains, market these tablets as ‘absolute recipe for peace of mind’. Most physicians act as ‘agents’ for sales and promotion, with their share in the cake. Ultimately it is the patients and their families who have to pay the price. This is obviously done in the guise of science, technology and promotion of ‘robust’ evidence.

During this survey it was discovered that around 80 per cent of people were aware of one or more brands of benzodiazepines – available over the counter. Among these, 67 per cent had some idea that if these medications are used for a longer duration than they can become a liability.

For drug-naïve patients it is best to stay away from these medications. If confronted with problems of sleeplessness (insomnia) or anxiety there are behavioral interventions which can alleviate the problem.

Forging Character

The more one gets to know people in this time and age, more dismayed the heart grows. People have become superficial to the point of being thin as paper – spreading conveniently in social discourses. Inter-personal techniques have replaced the age old values and character-ethics. Truth has become a matter of convenience. Deceptiveness, deceit and lying are sugar coated with diplomacy. City life has become a symbol of hoarding material possessions and filling up the lockers. People are unwilling to share, fearing that giving might replete their supplies.

One serves himself well by going in and around the mountains. Survival in such places is based on mutual reliance and inter-dependence. Characters are forged there, which can withstand the rugged terrains. There are lessons there for those who attend to their soul.

In the wilderness of Bhit, Khirtar Range Mountains, there is a treasure buried deep in to the ground – natural Oil and Gas reserves. Nature has its way with things. It seems that in Bhit land has folded on itself, in order to give a cushion against those vicissitudes of life, which man finds unbearable. In the base of the mountains all find comfort, holy one’s as well as thieves.

Brazen ground, stones and rocks, all have stories to tell. Veiled from external world, people of all sorts find solace here. Now a natural oil field site, it used to be a hideout for outlaws. Isolation is such a paradoxical thing – some raise awareness while other loose it. Phenomenon of life move vividly here, thoughts become clearer as one do away with distraction of modern day living.

These mountains seem to have a majestic presence, circling all around. Wind causes the sand to blow, decreasing the visibility. A mystical haze seems to surround these mammoth mountains. There, you come to realize that sight is so much dependent on things external to the self – out of sight, however does not mean out of mind here. Mountain terrace speaks of God’s presence. Within them they house treasures – spiritual and physical alike. One sees these mountains as a vantage point for any one who wants to test him-self against its vicissitudes.  There are many landmarks, slopes and ridges to give one an identity point.

Plants here seem to have developed reverence for the surroundings. One could see herbs and shrubs, scattered all around. Most of them seem to be dormant, ready to bloom in rainy season. A distinct shade of purple, pale stems gives the whole background an iconic appeal. Though they were small in size, no one could complain of their utility. Few of them are known to produce substances which have anti-venom properties. This place, being a breeding ground for viper snake, seems to carry a panacea of its own – a God’s way of keeping a balance. There were few trees, standing high, resolutely, against the backdrop of wall like mountains. These trees seem to tell a tale of their own, repeating the history season by season and event by event. Their woods is also known to produce finest of the timber.  

Mountains in Bhit and Khadanwari are place where only the rugged and tough ones could survive. Fierce winds seem to move the sand here and there. One could find stones of all shapes and sizes, lying all around, leisurely. Heavy stones seem to be the predominant ones. Same is the case with men, only resolute ones seem to be living there. People with conflicting motives may come here, each serving different reason; from cattle rearing to financial freedom, all have their own motives. Question to ask is: what is your motive in life? 

Just as one shadowy mountain stands beyond another mountain ridge, so does one challenge after another stands in front of human spirit – inciting it towards itself – in order to forge character. The more a person travels towards the mountains, which lie ahead, things seem to go in background. Same is the case with life. As man’s eyes remain ever focused on challenges that lie ahead, he seems to loose sight of old worries and grudges.  

Just as mountains gives way to precious items within itself, so does human mind gives way to wisdom and awareness. One reinvigorates himself, spiritually and physically, by going in mountains like Bhit. All those who suffer from the malaise of meaninglessness of their life, are well advised to seek enlightenment in such places.