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.

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

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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.