ARE WE MISSING THE BASIC LINK IN BREAST FEEDING INTERVENTIONS?

lactation blues

The great decision

The breast-feeding practices in Pakistan, over the years have either been stagnant or showing a decline. Various, social, cultural, health services and nutritional interventions have been suggested and implemented. However, there seems to be not a significant change; the blame is always put on the media and its abuse by artificial milk producing companies. This in a way may be justified.  But, perhaps we need to step back and reflect on the basic physiology, the ‘lactation reflex’ and factors influencing interruption of this process.  This blog is an attempt to draw some attention, on how the mothers’ mental health problems may be an important factor in decline of breast feeding trends varying from its early initiation, exclusive breast milk and then continuing it for at least 6 months.

The dilemma of breast feeding management commences initially due to the artificial divide between the ‘birth attendants’ (of any level of expertise) and the care-giver of newborn/infant (varying from LHW, doctor) later.  Both disciplines have their varying compartmentalized approaches as well as messages; above all both focus separately & exclusively on mothers and newborn/infant respectively. The dilemma gets further compounded when we tend to underestimate the basic lactation reflex and look for quick fixes based on various pre-determined but mainly medicalized and sometime socio-cultural factors.

Pakistan ranks highest among the prevalence of Post-Partum Depression (PPD); figures vary from 28% to 63% have been quoted among various studies.  Interestingly studies demonstrate that breastfeeding can protect depression, however, this association may be in the other direction, i.e PPD may lead or be associated with poor lactation and breast-feeding decline. The causality in either direction is still not clear but in terms of logical thinking the PPD has pre-disposing factors and keeping in mind the lactation reflex and arc, one can imagine that a mentally disturbed mother would experience interferences in the stimulus for lactation. This get furthers complicated when various ‘advisors’ at home and care providers load her with different messages and remedies. The baby gets more irritated and hungry all leading to the declaration that “mother is just simply not producing milk” and an easier decision by all to move on to bottle feeding and related alternatives.

We always cherish in conducting research and big seminars on breast feeding issues and its remedies, but have we ever thought of addressing the issue of PPD, which I believe is easy to screen and detect, and hopefully mange, also. Unfortunately, in our society, seeking an advice for mental health and its related experts is akin to declaring oneself as “mad” or mentally sick. Alternatively, the elders and husband label this situation (PPD) as being normal.  Its high time that we think out of the box and also look into this important dimension, rather than prescribing and promoting recopies for breast feeding, with apparently no significant changes.

Thinking out of box – Malnutrition fiasco

Malnutrition

Public Health Professionals

“Insanity is doing the same thing, over and over again, but expecting different results.”

We, in Pakistan, are at least doing same things consistently with ‘malnutrition’; we do the survey, cry over the high rates, bully the government and come with same interventions (but with newer names). And then after few years, we repeat the cycle. In my lifetime, I have been quoting the famous 1976-77 survey and then so on; the latest is being undertaken or may be completed. We, all do the academic luxury by presenting it in 4-5 star hotels, presenting and writing the papers and beefing our CV, in addition to monetary benefits.

I don’t have any hesitation to admit that the only exam I failed was for my Diploma in Child Health (DCH) and the examiner was actually the teacher of my teacher (Prof.  Billoo) and just because I could’nt satisfy the examiner about management of malnutrition in a child; her exact words were “you can’t do a Pediatric practice without proper understanding & management of malnutrition”.  This is also true on a larger scale for Public Health practitioners for managing the malnutrition at a community/district/provincial levels.

Perhaps we all need to appreciate many dimensions related to malnutrition and its management.

  1. There can be a whole spectrum or pathway to malnutrition, starting from normal to at risk, getting into developing obvious signs of complications.
  2. There is a biological dimension & illness-malnutrition nexus.
  3. The social norms, taboos, maldistribution within family/society.
  4. A number of influencing &/or contributing factors other than just food insecurity and poverty.
  5. What intervention, how, by whom and how the malnutrition is being managed
  6. What percentage of time is being contributed to managing malnutrition by mothers, workers, doctors, nurse, hospitals?
  7. Are we doing enough with whatever resources we have got? How many success stories do we have on a small scale and how many have many have been scaled up.
  8. Is there a strong political will and commitment or is it just restricted to policies, strategies, big reports and a big push by the bi-laterals or multi-laterals (donors).
  9. Above all what are we focusing; on promoting good nutrition, preventing malnutrition or managing malnutrition.

As a “hopeful-pessimist” (or sarcastic), I don’t expect large and longer-term investment by respective provincial and even federal governments, except for knee-jerk responses or project-oriented (max for 5 years) by donors and lenders. Unfortunately, it appears that we act too late when the malnutrition (wasting or stunting has developed); the worst part is both are difficult to manage and need higher-cost.  Even disturbing ritual related to malnutrition is mis-interpretation & abuse of “growth chart” when it is used to pick up malnutrition and send the data at a higher level to be fed (in computer) and reported; neither instant action is taken by community health worker nor the manager except to put it in the report and present as needed. As big “nutrition advocates” we join the bandwagon of ‘multi-sectoral’ approach without appreciating the fact that at the end the malnutrition has to be managed by a health worker working at some level—from a community to hospital.

So do we keep on doing the same…… Let us think out of the box!!. Let us go back to basic of Public Health.

  • Why can’t we put our efforts on “positive-deviant” approach and understanding why in the same community some children are still healthy.
  • Why not put our efforts on maintaining the good nutrition of a child (and for that matter her mother’s).
  • Why not pick a child when the growth on “growth-chart” starts faltering rather than wait to let him/her slip into malnutrition? It is much easier and less costly to adopt this approach for promoting good nutrition.
  • Why can’t mother herself and mothers in a community be taught to handle nutritional status of their children by using social media and digital technology?
  • Why not address adolescent girls before their marriage rather than giving iron and nutrients at the time of pregnancy.
  • Above all, whatever we keep on doing, if we don’t address rapidly expanding the population, we will just keep on adding more malnourished children in our community.

Well, one can say, these all are being done!  However, I would contest that based on my observations, discussion and some actual work. For those having some academic flavour, please refer to my few papers (through the web) related to risk approach, P in GMP, undernutrition in squatter areas, intermittent growth monitoring, on rickets etc.  Even if all or something has been done, it must be a time-bound, projectized and small-scale approach.  Of course, more inputs are needed for discussions and actions.

 

 

Measles and miseries: A gift or curse

Measles was described by Muhammad ibn Zakariya ar-Razi (860-932) or Rhazes – a Persian philosopher and physician, in the 10th century A.D. as a disease that is “more dreaded than smallpox”. Razes published a book entitled “The Book of Smallpox and Measles” (in Arabic: Kitab fi al-jadari wa-al-hasbah)[1]. Interestingly a lot of myths and misconception had been carried with Measles, especially calling it as “Sheetla Mata” (the gift of Goddess)[2] and/or “ouri Maata”. Interestingly while working in one of the Hindu communities in an urban squatter of Karachi, I had observed that the child who had developed Measles was put in a separate room and it was pretty cleaned with some ‘Naeem’ branches. In fact I had heard from my parents and some elder relatives that it is much better to allow the disease to come out rather than suppress it. I thought that these must be related to a particular ethnic group or religious group, however, while discussing just yesterday with one of the colleagues, I was told that in Sindh in Muslim families, this myth still persists.  However the children are managed differently. They are not give bath, the room is not cleaned, rather closed and to add to miseries, other children are also put in that room, so that they also “benefit” from this gift!!!

Almost 4 decades back, as a student and then as House Officer, I had seen not only the early signs but also all types of complications ranging from, Koplik’s spot, Maggots in mouth (because of unhygienic conditions and Pneumonia and meningitis.  Unfortunately, we are still having Measles complications being manifested as Pneumonia, ultimately leading to death.

The recent WHO estimates about the status of Measles in Pakistan are very disturbing to all of us. We are still grappling with communicable diseases, without realizing that quite a population has now also contracted non-communicable diseases and last but not the least, MNCH/RH issues and rapidly aging population.  Of course not to forget the rapidly increasing population which is adding more and more and children.

The government alognwith bilateral and multilateral partners have been coming up with lot of projects/interventions including the so called “surveillance system, the vaccination campaigns and yearly MNCH days etc etc. I really what had happened to all these efforts and suddenly WHO comes with the news that 65% of Measles cases in South East Asia are from Pakistan. It seems that our vaccination efforts has not made a difference due to ineffective surveillance system which has not been able to pick due to faulty data; ineffective vaccination; lack of awareness and willingness to vaccinate their children and above all no advocacy by our leaders to make a difference.

Considering a health systems approach, availability of vaccines by GAVI may be just one component, converting it into success will require the need to put attention on other components. We have yet to get rid of Polio, but if take that “single-targeted” approach for controlling the immunizable diseases, we may not achieve our targets in the so many future targets.  Let us do something out of box; there are examples of success stories from different parts of the world, it is high time that rather than inventing a new wheel, we try to adapt the wheel already prepared by someone

[1] https://www.news-medical.net/health/Measles-History.aspx

[2] https://www.quora.com/Why-is-there-a-myth-associated-with-chicken-pox-in-India-What-are-those-myths

Political will or ill-will: The case for “Population” in Pakistan

The rapidly growing population in Pakistan, and its horrible consequences have been known & articulated by all the stakeholders including especially the Government and donors, besides the civil society.  A quick look at historical evolution to address this issue reveals that at the end of the day, it’s the political will or otherwise which makes a difference.

Modest but impressive beginning

In ’60s, FP (Family Planning was initiated by an NGO, which made a big difference to capture the attention of Government and later within some decades we had a formal Ministry of Population Welfare and a famous program of Village Based FP Workers along with mobile clinics etc.  Interestingly this was even before the existing Lady Health Worker Program

Good intentions but bad consequences

The Government appeared to have good intentions in having two ministries i.e. The Ministries of Health,  and Population Welfare at Federal level and similarly at the Provincial level.  Perhaps the rationale may be to have focus and desired emphasis on population issues.  However, this artificial divide resulted in compartmentalized approach by putting all the health related issues to Ministry of Health, except for FP; though some lip-service was still maintained.  This issue has further worsened by the devolution in Pakistan and each province is addressing this issue separately; some not paying attention because ‘their’ population is already very low and thus federal distribution of money is also less!!

Playing with Population data

The population have been produced but there had always been issues related to projections and of course fudging of the data at health services delivery levels because of stringent requirements and consequent punitive punishments.  Thus, usually, with few exceptions, the news was that all is well and we are slowly progressing in increasing our contraceptive use rates and the consequent indicators. It was untill when PDHS 2007 and later on 2012 revealed that all is not well.  I remember that the Ministry of Population Welfare held back the results for more than 6 months.  In the meantime several surveys and consultancies (Technical Assistance) work had been conducted to identify the reasons and suggest the solutions. Of course each time we came up with the ‘old wine in a new bottle’.

FP agenda further widened & its consequences

The ICPD agenda and further declarations coined the word for ‘Reproductive Health’ (RH) and then even Sexual and Reproductive Health and we joined the bandwagon as part of political will and international signatory.  I have all the fears that it further diluted the FP focus but opened up the doors for new interventions. This followed the advocacy for Adolescent Health, Abortion Rights, Women sexual and Reproductive Health and lot of talks on population bulge, the demographic dividends etc etc.

Failed efforts for integrating Health & Population

There had always been growing realization that population is part of health and why not the two Ministries be at Federal (before devolution) and Provincial levels be merged. There have been lot of efforts by the UN agencies to make it a reality and I know that even there was all the willingness to do it by the head of state, but just because of one of minister it was postponed and in a way cancelled.  There are some services provided by both the Departments’ outlets and outreach workers but still each one respectively reports to their parent department.  In addition, though some efforts had been made by the other sectors such as education, it has not made a big difference.

Should we keep on using the old wine in a new glass? The way forward

“We cannot solve our problems with the same thinking we used when we created them”, Albert Einstein.

One might be shocked when you start calculating the amount of money put by the Government as well donor agencies and international NGOs to address the issue of FP. Interestingly, most of the NGOs and implementing partners have always showed that they have made a difference in their 1-5 years project. Unfortunately, when money and inputs finishes, all goes to ground zero and no replication, what to talk about scaling up.  Perhaps, all the stakeholders and champions have to make some ‘hard’ and ‘bad’ decisions. It appears the existing government and may be the coming government will not have FP in their political agenda, as they have so many other ‘pressing issues’ to tackle.  But, the question is, has any bilateral, multilateral and Bank has to courage to make these steps; or should we leave it to civil society or at the last to people themselves.  Maybe, let us leave it to Allah, as now we have major populist Islamic dominance who are also not in favour of addressing FP issues.

Educational & Intellectual corruption: The case for Medical & Public Health fields

hqdefault

What is it ? 

Corruption is the abuse of entrusted power for private gain. It can be classified as grand, petty and political, depending on the amounts of  lost and the sector where it occurs. We in Pakistan, have been discussing, especially in cable networks & social media about the “corruption” in context of money, especially after PANAMA leaks and very recently the Paradise leaks. However, another big evil in our society has been the “educational corruption”; it usually follows or sometime exclusively exhibits as “intellectual corruption”. I was surprised to see by searching in Google, About 7,960,000 results (0.51 seconds).  Like other fields, corruptions in medical and Public Health is not an exception.

Story of Medical education & practise

The story begins with admission in a “private” medical college, where special seats, foreigner seats or donation-based admissions are highly promoted. I am witness to a parent (landlord) who wished to get her daughter admitted and I suggested him to actually use the money (quite a lot at that time) to give it to her as a dowry. He in fact said that she is becoming a doctor to get some good name and a proposal matching to their standards.  This follows by the “tuition” system, whereby there is a longer & shorter duration contract along with the guarantee to pass the student; of course all manged by the respective faculty member.  Well, leaking paper is of course no exception and even ignoring cheating being widely practised. More interesting is the fact that when an “honest” teacher (usually a Head of Department) sends the results without maneuvering, the respective University staff sends it back mentioning that there is something wrong as 10-15 students have failed in that subject.  Thus, the Principal calls him and argues by mentioning that since the parents are paying handsome money, they expect their children to pass each year.  The story keeps on for internship whereby cronys are entertained and even the post-graduate exams. in which there are some ‘favourite’ candidates.

The Public Health saga

The Public Health education is even much worse than medical education.  Here there is a bigger motive and incentive for owners/managers of the institution to earn money at any cost.  This would mean admission criteria will be wavered off, entry exam will be easy, and any candidate having completed 14-16 years of education will be legible to admission. Then, there will be half-a-day, evening , weekend and even no classes and of course exams and results may also be manipulated. The external examiners for thesis will be the ones who are ‘well-wishers’ of that institution.  Above all the faculty is told that as long you are able to get the admission of X number of candidates, your job will continue.  So the poor faculty, has to do their best to get enough students and have a “good” reputation, so that the cycle keeps repeating.

All the above results, inevitably, into the products who are out there in various institutions and hospitals and serving people and various other stakeholders. There is another dimension to intellectual corruption which is observed in health related institutions, whereby the employees (of any level tend to keep on neglecting the truth & denying the facts, just because that’s not their organization’s ‘punchline’ or more so because they don’t want to get labelled as ‘bad’ guy at the cost of losing their jobs.

The consultancy gimmick

The other intellectual corruption, is practised in awards of contracts, whereby networking, under-table deals or already decided party is unduly favoured. The reports prepared are ‘modified’ to suit all the audiences and only those points are highlighted in big ‘dissemination’ seminars which suits to bot donors and the ones who gets the money; sometimes even for the government department. Highly talented experts sitting in government institutions either keep quite to promote/advocate what the big ‘bosses’ wish to project; they even don’t argue in those high level meetings.

Is this reflecting our society??

Well, one can say that is an echo of a frustrated person, however I can bet that most of us may have encountered, observed or heard stories shared above.  How long can we keep on acting like a hypocrite in spite of the fact the truth is something else.  We are not only producing but also setting the role models as to who can be successful in the medical and public health career.  Can some of us, stand up and play the role of  “whistle-blower” and point out the evil-doers. Perhaps we, including myself are afraid to do this.  However, I fear that I will, like others may be made accountable for not doing anything against this “zulm”. MY only satisfaction could be that I am trying to show just the tip of iceberg and really fear of the consequences.  May be its the reflection of our society which has deteriorated to that extent.

TAKE OUT “GUNJAISH” گنجائش نکالیں

In Urdu, like for any other language there are so many unique words which may not have the exact translation or meaning as it may have otherwise. In addition, some words (just as Arabic), in Urdu have so many meanings and could be attributed to a particular situation.

So what would be probable meaning of Gunjaish?? Let me try some of them:

  1. If you are shopping and trying to bargain then you can use it for suggesting discount !!
  2. To be considerate or accommodative
  3. To forgo and forget
  4. Let it go

So how all this started; this can be a usual situation; you are supposed to be in a meeting or attending a workshop or attending any party at a described time and place. You out of good etiquette reach on time (may be with many others) and the ‘Facilitator’ of meeting or workshop is also there but there are few (or even half of them) who have not turned up.  Everyone is waiting and/or started looking at their mobile and started surfing around or busy with FB.  Someone like me is anxious to get that meeting done and sort of requests the facilitator to commence it.  And, you get an interesting answer “Dr. Sahib Zara Gunjaish Nikaley”.  And then the debate starts.

We as human beings have not only lost patience but also have forgotten that our behavior are not only reflections of the situation but how we respond, react and attribute to a situation. In that context, we many of the times fall into “stereotyping” and respond, “why should the early birds or those on time suffer for those who are late, may be because they are used to it; or its their habit or do not bother about others. However, there may be some alternate issues which would have delayed the presence in meeting, such as emergency at home; missing the alarm; traffic jams due to VIP moments etc. Thus, then the Gunjaish can have even a wider meaning of “let it go” or be empathic to others. Perhaps, we in this materialistic world have become more of self-centered and wish to see the whole world in our own way.

So giving “gunjaish” is one sided or two-sided.  If the act of delayed reaching at a meeting is deliberate or due to negligence or ill-planning, then why can’t we be more considerate so that others are also do not suffer.  Nevertheless, understanding and practicing of “Gunjaish” has made a big difference to me… so do you?

Higher education programmes: Planning, Challenges and outcome

Pakistan is faced with major task of increasing its basic primary as well higher education; leave alone how and in what fields the products will be utilized.  Today, I will be focusing on higher level education illustrating a comparison between two programmes; one is BSc and other is MSc.

Last days as part of my consultancy work I have been working on evaluating the BSC-Midwifery programme.  This is is one of the pioneer initiative supported by a UN agency and being implemented by School of Nursing and Midwife of a prestigious university. I was surprised and rather embarrassed by the fact that it has been scientifically and strategically designed alongwith international and national consultations and with full support of Pakistan Nursing Council (PNC) and Midwifery Association of Pakistan (MAP). In addition to that there are other groups who are either running the similar programme or in fact have also developed a draft “Midwifery vision 2025”.

so what was embarrassing to me??  Well after spending almost three, decades wherein a bunch of seven “preceptors” working in Community Health Sciences Department ( from 1985) who had then be practicing as well advocating for the role models, and later on joined by so many Public Health experts including the PhDs, we have not been able to achieve the following:

a) A strategic planning for the syllabus and curriculum;

b) no functional and active association (have been having off & on) and

c) no regulatory authority to ensure quality of products (PMDC has its own challenges and rules of business).

I can even add, in this list a dedicated and highly esteemed “Journal focusing on Public Health” issues; we have produced many papers, mainly to beef up our CV.

So where the things have gone wrong.  One can come up with lot of semantics and rhetoric, but as a ‘hopeful pessimist’ I feel that our (Public Health graduates) education/training, job opportunities and the contribution which should have been made to address health challenges –all are showing a downward trend. I am proposing that the academia, teaching institutions as well the young graduates should have to address these issues. My long time observation is that we are not ready and even willing to challenge the status quo, simply because we wish to save our job, consultancy opportunities or just least bothered. We attend big workshops and conferences with luxurious lunches, talk all the good things which everyone wishes to hear, make resolutions and then forget all.  How many of us, including myself is wiling to challenge that building more hospitals are not the solution, that supplying ready to use foods can be replaced by simple home made techniques, and that institutions are not putting lot of efforts to produce high quality graduates.

All is not well !!