Posts Tagged ‘Health’

Healthcare: Dubious Distinctions

March 20, 2018

By Samia Altaf

Two recent reports about Pakistan’s health system tell of deficiencies of far reaching significance.

The first, from UNICEF, confers on Pakistan the dubious distinction of registering the highest number of deaths in newborns (neonatal mortality) in the past decade. It is now number one in the world, climbing from number three, and ahead of Afghanistan and the Central African Republic. The second, a National Nutrition Survey, informs that 45% of Pakistan’s children are stunted, suffering from chronic, extreme, and irreversible malnourishment that causes permanent physical and cognitive deficiencies. What would this half of future generations be capable of with its severely limited capacity to learn even if the opportunity for education is available? It would fall sick much quicker and get better a lot slower creating a permanent burden on the already constrained health service delivery system.

The situation in other areas of healthcare, though not part of these reports, is equally grim. Measles continues to be endemic with 6,494 cases last year in Pakistan compared to 1,511 in poor Afghanistan and 513 in war-torn Syria. This is a stinging indictment of the national Expanded Program on Immunization, underway since 1988, which provides 50% coverage when 90% is minimum needed for herd immunity. Maternal mortality, deaths in women due to pregnancy related events, continues to be unacceptably high — 286 per 100,000 nationally and 786 in Balochistan. Deficiencies in large city hospitals with patients dying in hospital corridors or refused treatment have forced the CJP to step in the mess that should be cleaned by the Ministry of Health. The story of spurious drugs and the problems of DRAP are too familiar to need recounting.

Isn’t it remarkable that the marked decline in health outcomes has been accompanied by a sharp increase in the number of medical colleges and universities, hospitals, doctors, nurses, and midwives. Advances in technology and fancy apps have facilitated diagnosis and treatment. Donors continue their generous funding — Punjab has received a $65 million grant from DFID and the loan of an equal amount from the World Bank. This has  led to the current reform of the ministry of health — two ministers instead of one and two secretaries instead of one.

What is going on? Is it that we still don’t have enough doctors for our population? It is true that the doctor to patient ratio is half that recommended by the WHO. But then, why are so many young doctors unemployed? Why are so many people going to non-doctors? China’s population is five times that of Pakistan. Its Infant Mortality Rate (deaths in children under one year) is 12, seven times less than Pakistan’s and its Maternal Mortality Rate is 27, ten times lower. Yet, China has never tried to get its doctor to patient ratio up to the number recommended by the WHO.  

“The state needs to take charge,” exhorts an editorial in this newspaper (28.2.2018). But the state is firmly in charge. New programs are launched every few months and plans to control communicable diseases in children and provide services to women are articulated in documents PC-1s. Frenzied activity is manifested in fancy new programs such as the health card scheme, the formation of public companies to manage hospital waste, the engagement of expensive foreign consultants, all amidst regular pronouncements from government officials. The state has a panel of technical experts — eminent doctors working in its system — that has been advising governments for the past many decades and continues to do so now. The results speak for themselves. Why would future results be any different if the same experts continue as advisors?  

There are two sets of problems. First, there is no mechanism to critically evaluate the  recommendations of the experts to determine if they are in the interest of citizens or in the self interests of the experts. No oversight is provided either by citizens or by their representatives who either do not know how to monitor or don’t sufficiently care about the situation. Ironically, suo moto notices by the Court call on the same set of experts to provide answers to the problems they should be held accountable for.

Second, the Ministry of Health lurches from one leaking hole-in-the-dyke to another driven by donor is offering funding, bright ideas of dignitaries, or explanations called forth by the judiciary. There is no overarching systemic vision compatible with the country’s constraints and challenges, none that has stood the test of time, regime-change, or public scrutiny. The mindset that survives is that more is better – more consultants, more doctors, more beds, more ministries. The results are staring us in the face as documented in the reports mentioned above.  

Solutions at the margins in the absence of a robust public health system will not resolve the healthcare crisis. Just as more flyovers and underpasses cannot stay ahead of traffic congestion if the city continues to sprawl, increasing the number of doctors or hospitals cannot make up for the growing burden of disease in an unhealthy environment. Take air pollution as an example, where, on average, the exposure of Pakistanis to critical particulates is 6.5 times the safe level recommended by WHO. Asides from adding to morbidity, air pollution killed about 60,000 Pakistanis in 2012 making the country the fifth-deadliest in that category. Here too, we could be vying for first place with the commissioning of numerous coal-based power plants across the country.

The task is by no means impossible and much can be achieved with a simple focus on the provision of clean air, clean drinking water, safe sanitation, a critical education, and gender equality. In 2012, the Infant Mortality Rate in Bangladesh was less than half that of Pakistan’s although the rates were comparable in 1990. This remarkable progress in Bangladesh has occurred despite the fact that it is only two-thirds as affluent as Pakistan in terms of per capita income.    

The Pakistani story has been one of neglecting the basics and channeling funds to intermediaries on half-baked schemes that yield no benefit to citizens. The global rankings provide evidence that is impossible to refute.

The writer is a public health physician and author of So Much Aid, So Little Development: Stories from Pakistan. This opinion appeared in Dawn on March 19, 2018 and is reproduced here with permission of the author.

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Healthcare Needs a Warning Label

March 22, 2017

By Anjum Altaf

Healthcare is dangerous to your health. Ask your neighbor for verification. You will likely hear more than one first-hand experience of someone dead who should be very much alive.

This outcome is unsurprising for three principal reasons related to peculiarities of the industry, social attitudes of the population, and  commercialization of the economy.

First, the industry. Healthcare is a field exhibiting the starkest asymmetry of information between providers and consumers. Every incidence of illness is in some way new and patients have insufficient knowledge to question diagnoses or prescriptions without second opinions and retesting for which there is often no time. In healthcare lives are literally at stake unlike, say, in education, where, if dissatisfied, one can change a child’s school and start again.

Second, social attitudes. People, by and large, still attribute unfavourable outcomes to divine will. Even when convinced of poor service, they rationalize that intentions of providers must have been good but that the patient’s time to die, one way or another, had arrived. This no doubt provides solace to the bereaved but does nothing to hold poor service accountable or provide countervailing pressure for improvement.

Third, commercialization. The logic of the market has now fully permeated the provision of healthcare earlier regarded as a social service yielding providers a respected status in society. Income maximization is now a much more salient motivation. In private conversations, medical professionals even point to the emergence of collusive networks among physicians, laboratory owners, pharmacists, and equipment and medicine suppliers aimed solely at fleecing patients without even the pretence of providing care.

As a result standard norms of economic theory are upended – the free market in healthcare does not minimize cost of service, competition does not drive out bad providers, and it is not only the fittest that survive. Because patients do not have the luxury of withdrawing from the market, poor performance actually increases the revenue transferred to providers as patients shuttle helplessly from one facility to another.

Given these factors, the only way to protect patients is very tight regulation in which the state, the traditional regulator, despite continuing attempts, has failed to measure up to needs. In fact, standards of service and accountability have continued to slip simply because growth in the number of providers and facilities has outstripped regulatory capacity.

While there is no alternative to regulation, it is generally accepted that expecting the state to discharge that function in Pakistan is unrealistic. The record shows that the state politicizes the operations of the regulatory body and compromises its independence. It uses its powers for patronage and does not appoint competent professionals to positions of leadership. Many of the officials it does appoint use the opportunity for rent seeking. There is no other explanation for the number of private medical colleges licensed without adequate faculty and the number of facilities advertising themselves as hospitals without fulfilling basic requirements.

Given that lives are at stake, citizens cannot afford to wait indefinitely for a caring state to emerge. A second-best solution is urgently called for. One alternative is to push to privatize the regulatory function while being cognizant of the private sector’s weaknesses and hedging appropriately in the interest of the citizens.

The only function remaining with the state regulator would be to bid out the regulatory contracts for predefined terms to established private audit firms with reputations to defend. Since this is a major departure, the experiment can be piloted in one sub-district or small city. The private regulator would categorize and register all facilities, ensure compliance with minimum requirements, introduce standard record-keeping protocols, and initiate a regime of random inspections. Based on cumulative review of records, facilities would be assigned quality rankings to be disclosed to citizens. Facilities falling below acceptable standards would be given a limited time to improve to avoid losing their operating license. Registration fees could partly finance the experiment.

In parallel with this privatization, a board of credible individuals would serve as an independent watchdog on behalf of the local population. In addition, the federation of newspapers could nominate a set of journalists to report regularly on the experiment. Thus circumscribed, the second-best alternative could be expected to prove more effective than the state regulator. Based on the results of the pilot, the arrangement could be fine-tuned before expanding its coverage.

For the longer run, however, the existing model of curative care is unsuitable in a country where incomes are low, the incidence of ill-health is high, and basic public health infrastructure – safe water and sanitation, clean air, pest control, etc. – is missing. Populist attempts to make curative care affordable will prove to be unsustainable. We need to transition to a wellness model based on preventive care in which households are visited, monitored, and guided at regular intervals independent of episodes of sickness.

Such a model could also be tried on a pilot basis in one jurisdiction. There are a number of very successful examples to learn from. In 2014, the Director-General of the World Health Organization recommended Cuba’s preventive healthcare model to the entire developing world even though it is not considered politically correct to applaud anything happening in that country. In Cuba, family physicians supported by para-medical staff deliver primary care and preventive services at the local level to panels of patients, about 1,000 patients per physician, with patients and caregivers generally living in the same community.

Even an affluent country like England subscribes to a similar model in which family practitioners and ancillary staff responsible for registered populations of patients act as gatekeepers to specialist care.

Healthcare in Pakistan is out of control and in bad shape and it is up to citizens to articulate alternatives to avoid more tragic losses. This can be a common cause for the rich and poor because not even all the well-off can travel abroad for their check-ups and medical needs.

This opinion appeared in Dawn on March 21, 2017 and is reproduced here with permission of the author.

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Still learning as we go along … are we?

July 23, 2016

By Jacob Steiner

A review of So Much Aid, So Little Development: Stories from Pakistan published by the Johns Hopkins University Press in 2011. The book was republished in 2015 by Ilqa Books in Pakistan and is available there in book stores and online.

Some months back I visited a rural support program in a Central Asian country, executed by one of the world’s biggest development organizations with an excellent repute here and in similar areas in Pakistan. A European consultant, with ample experience in the area and his field – sustainable construction solutions – had recently visited the project. The outcome of this visit, a number of manuals as guidelines for the local execution, had just been printed and handed over to the local engineers. Among them seismic proof housing, and split latrines. These toilets are currently a very fancy topic in sanitary engineering for developing countries when discussed among experts in the West. They are very easy to construct, turn human excrements safely and without special treatment into fertilizer and are hence theoretically a sustainable and environmentally friendly solution. But the link between smart and fancy ideas in the donors’ offices in Europe and sustainable solutions on the ground seem to be a hindrance that few want to deal with.

In default of pre-constructed toilet seats for this system in the respective country, the technical expert thought of a solution. Food bowls in two different sizes were acquired at cheap prices in the local market and assembled to a locally made split toilet. That sounds awfully convincing in a report, “using locally acquired material”, “supporting local merchants”, “easy to assemble”. The local program manager and a village engineer have already assembled the first sample. Sure, a smart idea from their friend the expert. They acknowledge his input and technical expertise, and are convinced that his intentions are the best. “But what will the people say when we propose to them to use food bowls to shit in?” They both laugh heartily. No, that won’t work, but they’ll do it anyway. Results need to be shown, reports are due and they are already behind schedule. It’s a comical situation, if it wouldn’t be frustrating to see so much effort, and money, brought to waste. A new book on similar encounters in Pakistan shows how this phenomenon may be an essential part of failures in international development initiatives.

Samia Waheed Altaf, former senior advisor of the Office of Health in the USAID Mission in Islamabad, has collected such comically frustrating episodes from her participation in the Social Action Plan (SAP) in the 90s in her So Much Aid, So Little Development – Stories from Pakistan (Wilson Woodrow Center Press, May 2011). The SAP was developed by the Pakistani Government and funded by the World Bank from 1993 to 2003 and targeted health supply services amongst others in Pakistan with a multi billion $ budget. It’s probably the most famous failure of aid and development in Pakistan. A number of papers have already been published on this issue, most notably from the CGDEV, which also Altaf refers to time and again. These papers are looking at why that could happen and how it could be avoided in future, providing mainly the dry figures of wasted inputs and unintended outcomes. They are essential reading to grasp how so much money could be invested in the country in recent decades with so little progress and conclude with definite policy recommendations. But they seldom go beyond the gross calculations of a development economist. Altaf portrays how these figures of failure are produced by the “human factor”…

Read the full review here.

Jacob Steiner’s addendum to the review:

There are other reviews out on the book.

In Dawn, by Sakuntala Narasimhan (you may go to the SouthAsianIdea to comment and discuss it with other critical minds) and in Regional Studies, Volume 45 by Claudia R. Williamson.

They are interesting to read together, since they are written from the two perspectives, the Western ‘Expert’ (in this case a researcher) and the Eastern Intellectual (in this case a journalist). Those two which Altaf manages to include in a single narrative. And they are more or less stuck in precast conceptions of the problem. Williamson wants to read more on where failure is to locate in the local institutions, Narasimhan criticises the Western Experts decadence and ignorance. They are both not wrong in their criticisms, their understanding of where failures may be located. But they are both looking for where they are convinced failure emanates from and seem not to be too receptive to an alternative explanation – a change in mindset and acknowledging responsibility. This is which I think both parties – the International (Western) Expert and the Local Expert – should take from the book. If everyone just understands it as a confirmation of ones own best intentions, brought to no avail because of the failure of the Other, we stay stuck in the dilemma. Question expertise – of others and your own – and be prepared to reassess opinions.

Manan Ahmed has been writing on the ‘Expert’ problem on a wider and more political/historical scale. I think his thesis in this aid example so well documented by Altaf is backed up on the local scale and just confirms how this is an issue that should be studied with more depth in future.

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“Helping the Poor”: The Idea, the Reality and the Shadow

February 22, 2011

By Anjum Altaf

Between the idea and the reality, Eliot wrote, falls the shadow. The phrase is so well known as to be almost cliché, but as with many clichés, there is truth to it. There is universality, too – the metaphor could extend to many areas; there are shadows everywhere. Foreign aid, for example: there is the idea and the reality, the theory and the practice, the intent and the execution.

The theory of foreign aid is simple enough: If those lacking capital and technology and ideas were provided with such, they could be launched on the path of progress. In practice it has rarely ever worked like that – there is more to the equation than capital and technology and ideas.

There is the shadow that falls between the theory and the results, a shadow full of objectives stated and unstated, incentives of this party and that (and, of course, their representatives, who develop in the end their own interests, their own goals, their own shadows) – all this, more often than not, causing enough distortions for the reality to mock the idea.

This happens not only in foreign aid, but in any transaction where one party has advice or help or assistance that the other desperately needs, when negotiations are not equal, when representatives of each come with their own axes to grind. Consider the shadow now visible between the idea and the reality of sub-prime mortgage lending: the unstated objectives, the incentive distortions, the regulatory winks and nods, the quick fix to keep the game going for at least one more round. In 1961, Jane Jacobs, who had little to do with foreign aid, was astute enough to realize the pitfalls. Based solely on her observations of how federal assistance was implemented in low-income areas of American cities, she remarked in her seminal book, The Death and Life of Great American Cities: “I hope we disburse foreign aid abroad more intelligently than we disburse it at home.”

Much of this has been obvious for years to those in the aid and lending communities who have kept their eyes and ears open; what has eluded us is that blinding insight that lays it all bare, the kind of insight that comes most often from literature. As literature identified the existence of the shadow, it was literature again that unraveled its nature. Theodore Dalrymple has written an account of the writer Rhys Davies (1901-1978) whom he has called the Welsh Chekhov. I can’t vouch for that since I haven’t yet read Davies but I intend to, especially the story that illuminated for me the shadow of foreign aid – “I Will Keep Her Company,” published in The New Yorker in January 1964.

The story, in Dalrymple’s words, concerns a couple in their eighties, living in an isolated farmhouse in the Welsh hills and snowed in. The old woman has died and the husband, refusing to acknowledge her death, is staying by her bedside. There is in the story a district nurse assigned to the care of the couple:

Meanwhile, Nurse Baldock has geared up a rescue operation involving a snowplow, a van, and a helicopter. She is, as her name seems to suggest, conscientious and bossy and, having completed a diploma in social studies in her spare time, believes herself entitled to a promotion. She had visited Evans a few days previously, when his wife had just died, and was prevented from removing the body by the snow. Now she is returning, determined to get his agreement to leave for the old-age home. When she finds him dead, she utters a bitter yet self-satisfied recrimination:

“This needn’t have happened if he had come with me, as I wanted six days ago! Did he sit there all night deliberately? . . . Old people won’t listen. When I said to him, “Come with me, there’s nothing you can do for her now,” he answered, “Not yet. I will keep her company.” I could have taken him at once to Pistyll Manor Home. It was plain he couldn’t look after himself. One of those unwise men who let themselves be spoilt by their wives.”

In a few pages, with a highly sophisticated simplicity, Davies arouses emotions and thoughts as impossible to resolve into full coherence as life itself. John Evans’s death is both tragic and a triumphant final expression of the love that gave his life meaning; we oscillate between sorrow and joy, between discomfiture and reassurance, as we read. As for Nurse Baldock, she encapsulates the mixture of good intentions, condescension, and careerism that is the modern welfare state. Rationally, we cannot refuse to endorse the efforts to rescue Evans; it would be a terrible world in which his predicament evoked no response. At the same time, we know that these efforts are not only beside the point but, at the deepest level, incapable of being other than beside the point.

There it is: The Evanses are the recipients, Nurse Baldock the donor, “encapsulat[ing] the mixture of good intentions, condescension, and careerism” that is the modern aid enterprise. Her judgments of John Evans echo the familiar comments of the aid executive – poor people “won’t listen,” “men [have] let themselves be spoilt” by their unwise ways. If only he had heeded her advice; if only poor countries would follow the instructions given to them by the well-intentioned donors.

The notion of “helping the poor” is a noble one, but it comes with this shadow that falls between people, states and their citizens, donors and recipients, between individuals and representatives, and this shadow grows darker and deeper as we try to pretend that it is not there, that it can be fixed with one quick step (always one quick step, just to keep us going for the next round).

Perhaps the story offers another insight as well. Nurse Baldock, with her plow and her van and her helicopter, her diploma in social studies, the full weight of the state behind her, is immeasurably more powerful than a weak, devastated, poor old man. Of course to her it is simple; she knows what is right, she knows what he needs far better than he himself could. But what if Nurse Baldock could meet John Evans as her equal?  What if she could try, instead of helping him by force, to engage with him? In this light, might the shadow finally begin to fade?

Theodore Dalrymple’s article (The Welsh Chekhov) can be accessed here.
Nurse Baldock is reincarnated as Lucymemsahib in our fellow panelist, Samia Altaf’s book (So Much Aid, So Little Development: Stories from Pakistan) forthcoming from the Johns Hopkins University Press in May 2011.
For more on foreign aid on this blog, see:
Should Pakistan Receive More Foreign Aid?

How to Aid the Health Sector in Pakistan
Remaking Public School Education in Pakistan

 

 

How to Aid the Health Sector in Pakistan

August 1, 2010

By Samia Altaf and Anjum Altaf

This op-ed appeared in Dawn, Karachi, on July 30, 2010. It was intended to initiate a discussion on the possible approaches to sector reform and is being reproduced here with permission of the authors to provide a forum for discussion and feedback.

We must state at the outset that we have been wary of, if not actually opposed to, the prospect of further economic assistance to Pakistan because of the callous misuse and abuse of aid that has marked the past across all elected and non-elected regimes. We are convinced that such aid, driven by political imperatives and deliberately blind to the well recognized holes in the system, has been a disservice to the Pakistani people by destroying all incentives for self-reliance, good governance, and accountability to either the ultimate donors or recipients. (more…)

Why Indians are Stressed and Unhealthy

January 27, 2009

By Aakar Patel

Manmohan Singh had his arteries bypassed on Saturday, a procedure that increasing numbers of Indians are having. Last year, medical journal Lancet reported a study of 20,000 Indian patients and found that 60 per cent of the world’s heart disease patients are in India, which has 15 per cent of the world’s population.

This number is surprising because reports of obesity and heart disease focus on fat Americans and their food. What could account for Indians being so susceptible — more even than burger-and-fries-eating Americans?

Four things: diet, culture, stress and lack of fitness.

There is no doctrinal prescription for vegetarianism in Hindu diet, and some texts explicitly sanction the eating of meat. But vegetarianism has become dogma.

Indian food is assumed to be strongly vegetarian, but it is actually lacking in vegetables. Our diet is centered round wheat, in the north, and rice, in the south. The second most important element is daal in its various forms. By weight, vegetables are not consumed much. You could have an entire South Indian vegetarian meal without encountering a vegetable. The most important vegetable is the starchy aloo. Greens are not cooked flash-fried in the healthy manner of the Chinese, but boiled or fried till much of the nutrient value is killed.

Gujaratis and Punjabis are the two Indian communities most susceptible to heart disease. Their vulnerability is recent. Both have a large peasant population — Patels and Jats — who in the last few decades have moved from an agrarian life to an urban one. They have retained their diet and if anything made it richer, but their bodies do not work as much. This transition from a physical life to a sedentary one has made them vulnerable.

Gujaratis lead the toll for diabetes as well, and the dietary aspect of this is really the fallout of the state’s economic success. Unlike most Indian states, Gujarat has a rich and developed urban culture because of the mercantile nature of its society. Gujaratis have been living in cities for centuries.

His prosperity has given the Gujarati surplus money and, importantly, surplus time. These in turn have led to snacky foods, some deep-fried, some steamed and some, uniquely in India, baked with yeast. Most Indians are familiar with the Gujarati family on holiday, pulling out vast quantities of snacks the moment the train pushes off.

Gujarati peasant food — bajra (millet) roti, a lightly cooked green, garlic and red chilli chutney, and buttermilk — is actually supremely healthy. But the peasant Patel has succumbed to the food of the ‘higher’ trader and now prefers the oily and the sweet.

Marathi peasant food is similar, but not as wholesome with a thick and pasty porridge called zunka replacing the green.

Bombay’s junk food was invented in the 19th century to service Gujarati traders leaving Fort’s business district late in the evening after a long day. Pao bhaji, mashed leftover vegetables in a tomato gravy, served with shallow-fried buns of bread, was one such invention.

The most popular snack in Bombay is vada pao, which has a batter-fried potato ball stuck in a bun. The bun — yeast bread — is not native to India and gets its name pao from the Portuguese who brought it in the 16th century. Bal Thackeray encouraged Bombay’s unemployed Marathi boys to set up vada pao stalls in the 60s, which they did and still do.

The traveling chef and TV star Anthony Bourdain called vada pao the best Indian thing he had ever eaten, but it is heart attack food.

Though Jains are a very small part (one per cent or thereabouts) of the Gujarati population, such is their cultural dominance through trade that many South Bombay restaurants have a ‘Jain’ option on the menu. This is food without garlic and ginger. Since they are both tubers (as also are potatoes), Jains do not eat them, because in uprooting them from the soil, living organisms may be killed (no religious restriction on butter and cheese, however!). The vast majority of Ahmedabad’s restaurants are vegetarian. Gujaratis have no tolerance for meat-eaters and one way of keeping Muslims out of their neighborhoods is to do it through banning ‘non-vegetarians’ from purchasing property in apartment buildings.

Even in Bombay, this intolerance prevails. Domino’s, the famous pizza chain, has a vegetarian-only pizza outlet on Malabar Hill (Jinnah’s neighborhood). Foreigners like Indian food, and it is very popular in England, but they find our sweets too sweet. This taste for excess sugar extends also to beverage: Maulana Azad called Indian tea ‘liquid halwa’. Only in the last decade have cafes begun offering sugar on the side, as diabetes has spread.

India’s culture encourages swift consumption. There is no conversation at mealtime, as there is in Europe. Because there are no courses, the eating is relentless. You can be seated, served and be finished eating at a Gujarati or Marathi or South Indian thali restaurant in 15 minutes. It is eating in the manner of animals: for pure nourishment.

We eat with fingers, as opposed to knives and forks, or chopsticks, resulting in the scooping up of bigger mouthfuls. Because the nature of the food does not allow for leisurely eating, Indians do not have a drink with their meals. We drink before and then stagger to the table.

As is the case in societies of scarcity, rich food is considered good — and ghee is a sacred word in all Indian languages. There is no escape from fat. In India, advertising for healthy eating also shows food deep-fried, but in lower-cholesterol oil.

The insistence by family – ‘thoda aur le lo’ — at the table is part of our culture of hospitality, as is the offering of tea and perhaps also a snack to visiting guests and strangers. Middle class Indians, even families that earn Rs10,000 a month, will have servants. Work that the European and American does, the Indian does not want to do: cooking, cleaning, washing up.

Painting the house, changing tyres, tinkering in the garage, moving things around, getting a cup of tea at the office, these are things the Indian gets someone else to do for him. There is no sense of private space and the constant presence of the servant is accepted.

Gandhi’s value to India was not on his political side, but through his religious and cultural reforms. What Gandhi attempted to drill into Indians through living a life of action was a change in our culture of lethargy and dependence. Gandhi stressed physical self-sufficiency, and even cleaned his toilet out himself.

But he wasn’t successful in making us change, and most Indians will not associate Gandhi with physical self-sufficiency though that was his principal message. Indian men do no work around the house. Middle class women do little, especially after childbirth. Many cook, but the cutting and cleaning is done by the servant. Slim in their teens, they turn thick-waisted in their 20s, within a few years of marriage.

Since we are dependent on other people, we have less control over events. The Indian is under stress and is anxious. This is bad for his health. He must be on constant guard against the world, which takes advantage of him: the servant’s perfidy, encroachment by his neighbors, cars cutting in front of him in traffic, the vendor’s rate that must be haggled down. Almost nothing is orderly and everything must be worried about.

In the Indian office, the payroll is a secret, and nobody is told what the other makes. Knowledge causes great stress, though the lack of information is also stressful, leading to spy games and office gossip.

Because there is no individualism in India, merit comes from seniority and the talented but young executive is stressed by the knowledge that he’s not holding the position he deserves. Indians are peerless detectors of social standing and the vertical hierarchy of the Indian office is sacrosanct.

Dennis Kux pointed out that Indian diplomats do not engage officially with an American of lower rank, even if the American was authorized to decide the matter. In the last decade, when Indians began owning companies abroad, the Wall Street Journal reported on cultural problems that arose. Their foreign employees learnt quickly that saying ‘no’ would cause their Indian bosses great offence, so they learnt to communicate with them as with children.

Indians shine in the west where their culture doesn’t hold them back. In India honor is high and the individual is alert to slights from those below him, which discomfort him greatly.

There is no culture of physical fitness, and because of this Indians don’t have an active old age. Past 60, they crumble. Within society they must step back and play their scripted role. Widows at that age, even younger, have no hope of remarriage because sacrifice is expected of them. Widowers at 60 must also reconcile to singlehood, and the family would be aghast if they showed interest in the opposite sex at that age, even though this would be normal in another culture.

Elders are cared for within the family, but are defanged when they pass on their wealth to their son in the joint family. They lose their self-esteem as they understand their irrelevance, and wither.

This article is reproduced from The News (January 25, 2009) with permission of the author. Read the article in French here.

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Pakistan Picaresque

January 9, 2008

A chat over tea at a government office in Islamabad reveals why billions in aid have done so little for Pakistan’s poor… 

By Samia Altaf

Not enough nurses. Not enough jobs. Nurses working as “doctors.” Trained nurses being encouraged to leave the country. Untrained and uncertified “nurses” being recruited in sheer desperation by private hospitals. What a strange and paradoxical situation! Yet there is no discussion of these crucial issues. And new training programs are being developed, because there is pressure from international organizations to include more women, supposedly to meet the human resource ­shortage.

My companion sat shaking her head. Mrs. S. was starting to look restless. She signaled to the attendant for tea. In a government office, a tea break can become a project unto ­itself.

“The problem with women,” Mrs. S. volunteered conversationally, again adjusting the dupatta delicately on her hair as the tea service was laid out, “is that they all want to get married.” Quite a problem, and one the world over. “So eventually they must leave the profession to take care of their husbands and children.”

We let this pass, and raised another possible solution to the “problem” with women: training more male nurses. As the primary wage earners, they would not be compelled to leave once they married, and they could tend to the male patients, making it easier to attract women to the ­profession.

“Not a good idea,” according to Mrs. S. And why ­not?

“Because men are very unreliable. As students, they will agitate the girls,” she continued in the same conversational mode, oblivious to the effect of her remark on her audience. “If they are in classes together, they will induce them to strike on petty matters.”

“But the girls are under no obligation to do their bidding,” Lucymemsahib ­said.

“Yes, but the poor girls have no choice but to follow the boys. It is natural for them to do so. By themselves, girls never cause any problems. They quietly do what they are told or get married and go away.” Mrs. S. warmed to her subject. “Look what is happening in Liaquat National Hospital, Karachi.” Liaquat hospital is a major training institution for nurses, one of the few in the country that prepare male nurses. About a third of each entering class was male (as is still the case today). During the weeks before our visit to Mrs. S., the nursing students at Liaquat had gone on strike, demanding better living conditions, apparently at the instigation of male ­students.

“All because of these boys!” Mrs. S. continued. “So many headaches these boys are causing us.” She struck her forehead with the palm of her right hand in the traditional gesture of frustration, causing the dupatta to flop off her hair. She hastily retrieved it. “And the girls are not listening to us either. They are naturally listening to the boys. Stupid things!” She shook her head in ­indignation.

Lucymemsahib looked at Mrs. S. as if she had come from another planet. Thankfully, the tea arrived at this point, and we fell to it with gusto, under Mr. Jinnah’s enigmatic smile from his perch on the wall. Mrs. S. very generously ordered her attendant to run out for some mint chutney to go with the samosas, which were really out of this ­world.

[The complete article can be accessed at the Wilson Quarterly (Winter 2008) here.] 

Samia Altaf was the 2007-2008 Pakistan Scholar at the Woodrow Wilson International Center for Scholars in Washington, DC. Her book (So Much Aid, So Little Development: Stories from Pakistan) was published by the Johns Hopkins University Press in 2011).

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