Shank’s mare

Missing a bus could be a wonderful experience, provided you utilize this time to ponder over your life’s curve. These small pockets of time could come handy if one is given to introspection. Other day, I missed a bus and I decided to tred back home by shank’s mare.

On the way back, I saw a swan sitting in the middle of the road, by the lake side, calm and cozy with her beak buried deep in her feathers. Instantly my mind went to the good Lord in the blue canopy above and around us, to whom we all belong, who is watching over us all the time. One’s heart and soul find peace and comfort in His reassuring presence. There are the situations when you could feel that God is around, in cool breeze ruffling the feathers of the swan, moments like these bring you closer to Him. We have to believe in His presence, only then we can actualize such moments. In the words of Lawrence, ‘if in this life we would know the serene peace of Paradise, we must school ourselves in familiar, humble, and loving converse with God”.

Some would argue that belongingness is a basic need for all human beings. It is a basic need like eating and sleeping, which we all need to have before we can move on to higher order needs on Maslow’s hierarchy. Fulfillment of this would encourage the search for higher order attainments – self actualization can only come once this is formidably consolidated.

One way to find real peace of mind is to follow one’s dreams and work towards actualizing the cherished goals in life. Any time management technique which doesn’t put a person in touch with his inner self is a marketing gimmick. Question to ask is why have we cramped our lives and time with clutter of activities – from absolute nonsense to things that we actually don’t enjoy doing? Happiness, we are told lies in pursuing worthy goals and actualizing our true potential. However before we can have it, we have to confront our fears of saying ‘no’. Only then we can redirect the course of our lives- individually and collectively. It takes courage to say no to an old routine, which has become a familiar way of life. The hound of disapproval might come back to haunt us. However saying yes to our dreams brings a new stride in our feet, an attitude with which we can actualize every possibility. With such small decisions we could redirect the course of our lives.

So on next working day, miss a bus or take a walk back home. Think about the course of your life. What needs to be shed – like an old cloth? This will make room for more challenges and happiness. You might also see a spectacle of joy and presence, telling you that you were created to be happy, to enjoy the serenity of days in your life. An everlasting presence might dawn upon you, fulfilling you days with peace and joy.

Suicide Prevention day!

It is estimated that one million people commit suicide every year; one death after every two minutes. Rates of suicide vary over the course of life span. Among all the suicide related death 60% are happen in Asia. Concerning fact is that it is the highest cause of mortality in the age group of less than 30 years. Another grave statistics is the high estimates in married females. Suicide leaves a grave scar on the psyche of the family, which struggle with the remorse of this tragic event for all the days to come. While the relative may be alive physically, they lose the will to live. Most of them end up with depression. All efforts should be made in order to prevent this dreaded cause of death. Looking at its consequences, one death is too many, in case of suicide.
Suicide is on the rise in Pakistan, so informs research carried out over the course of decade at Aga Khan University. The various social and religious factors which use to protect people from the suicide are changing. The fine balance between the will to live and impulse to harm oneself is being disturbed. What are the factors which cause this: literature informs us that there are some immediate factors while other are long term contextual difficulties which makes people vulnerable to deliberate self harm. Social and economic deprivation makes people vulnerable to self harming behavior. World Health Organization (WHO) estimates that for every suicide there are at least 10 to 20 cases of deliberate self harm. Delayed dispensation of justice, social inequity, economic deprivation and sustained stress push people towards hopelessness. In desperation individuals resort to self harm. Once they cross this threshold than it becomes difficult to get back to the baseline mental health.
It is encouraging that there is an international recognition on the burden of this issue. A concerted effort on parts of International Association of Suicide Prevention (IASP) and WHO has made it possible to organize a World Suicide Prevention day on September 10th , 2009. This was organized initially in 2003, catching momentum in subsequent years. This year a conference is being organized at Aga Khan University on September 30th, 2009, with a theme ‘Suicide – Hidden realities in Pakistan.
This task is too important to be dealt by mental health care professionals, alone. Media along with the civil society has to play its role in propagating the message that suicide is preventable. This needs to be done in cultural context. One of the biggest impediments in reducing the stigma attached with this mental health problem is its legal status in the context of Pakistan. According to Pakistani law, suicide is a crime, punishable by jail term and financial penalty. Though conviction rates are low, it impairs help-seeking, limiting it to handful of centers with medico-legal cell. Most victims seek care in the emergency care departments of general hospitals, which are ill equipped, in terms of training and expertise related to psychological management of such cases. This slipshod approach leaves many hanging. Easy, over the counter accessibility of drugs is another menace which feeds this problem. Perhaps the most troublesome predicament is the availability of Organophosphates in the rural and semi-urban settings. It is not surprising that these factors contribute to the rising suicide rates.
Relatives and family members have to deal with the issues of Suicide. It is ironic when they get blamed for the death of the relative. However burden of this grief can be heavy; mind goes back to things which could have been done differently, the micro-expression of relief which, in hindsight, are dreaded way of saying a farewell to long period of misery. Therefore it is equally important to address the grief and guilt inculcated in the relatives of the deceased. Media when employed constructively can reduce the burden of this mental, social and public health problem.

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.