I am becoming more and more frustrated with the Government of Pakistan. These feelings have been there since the day I got here but it has now been intensified as I am taking classes in PHC and HSM.

I have already mentioned the inadequate provision of health care services for the people of Pakistan as well as decreased health expenditure based on GDP in my earlier blog. Second, is the issue of a decreased will to act and implement on behalf of the government and its ministries. Pakistan has beautiful health policies, probably the best in the developing world. However, these policies are only beautiful on paper. Pakistan lacks the will to properly implement these policies so as to achieve maximum health outcomes. I am having a hard time understanding whether this is about lack of will or lack of human and material resources. Let me give you an example. Pakistan's Polio Policy is top notch but there is an absence of proper monitoring and evaluation surveillance systems. Each year polio vaccinations, polio drops and Vitamin A capsules are dispersed to health care clinics based on rough estimates. Numbers from the previous year are simply rolled over to the next year. There is no up-to-date data available in order to analyze trends or patterns. There is a system in place, but it is not followed due to reasons X, Y, and Z. How is a program that is needed in a country with the highest polio prevalence rate supposed to survive and sustain when there is mismanagement and lack of accountability?

Second example, a country wide food program was implemented in Pakistan by AKU and other NGOs a few years back for primary and secondary school-aged girls. Based on the squatter settlements randomized, close to 4,000 schools were identified by the government. Upon initial assessment and field visits, some schools were only written on paper but did not actually exist. The government had claimed such schools when funds were being allocated to each school. If these schools did not exist, where were the funds going? I am sure you can figure this one out.

There is no sense of ownership and accountability. Money is pocketed by the elite and the powerful at the expense of citizens. These citizens are well aware of the corruption but their words are, "We have been dealing with this for as long as we can remember." When questioned as to why nothing is being done about it, they reply, "What can we do. This is how it is." This reminds me of a statement made by His Highness the Aga Khan at the Seerat Conference in Pakistan, " The anchors of moral behaviour appear to have dragged to such depths that they no longer hold firm the ship of life. What was once wrong is now simply unconventional, and for the sake of individual freedom must be tolerated. What is tolerated soon becomes accepted. Contrarily, what was once right is now viewed as outdated, old-fashioned and is often the target of ridicule." (1976) I fear that we have reached this state. Many Pakistanis have lost faith in their countrymen and their government, yet they chose to do nothing about it.
As for me, I will try to remain hopeful....

What is the purpose of education?

Is it to memorize? Is it to regurgitate what you have memorized? Is it used for the purpose of application so we can continue with our existence? Sadly, this is exactly the case in most institutions of learning. Some would call this 'intellectual ignorance.'

According to Paolo Freire, education serves two purposes. It either domesticates or liberates.

Domestication simply means to take something away from its natural environment and place it in a controlling environment. Another word to use for domestication is 'taming.' Through this, there is a degree of control. Conversely, liberty is a condition which allows individuals to act according to their own will.

Therefore, the purpose of education is not to domesticate but to liberate. Domestication of education confines an individual to one realm of thinking. There is no room for creativity, neither is there encouragement for critical thinking. Through coercion we learn to accept someone else's point of view, instead of exploring our own. We become engrossed with memorization and regurgitation.

So if the purpose of education is to liberate, then liberate from what and from whom?
In ancient Greece, Socrates argued that education was about drawing out what was already within the student. Education comes from the Latin meaning "to lead out." Hence, education plays a key role in self-awareness and self-reflection. It allows one to become aware of one's own abilities, goals, aspirations, and even gaps. In a way, one becomes aware of his/her own oppression and seeks out avenues to eradicate this oppression. We liberate ourselves.

I can go on and on with this topic but I will stop here, for now. I am writing about this because I was recently inspired by a wonderful professor at the Aga Khan University, Karachi. Her style of teaching was similar to how I was taught at my University, which was quite liberating. During my university years we were given the freedom to explore various domains of learning whilst covering the major aspects of nursing. I never really appreciated this style of learning until I started to apply these principles regularly after graduation, both professionally and personally. It brings me great pleasure and pride to see AKU implementing the principles of 'popular education.' The educators at AKU are interested primarily in each student's intellectual journey by supporting their growth. Grades are not seen as ends. I am honored to be a recipient of this form of liberation, once again.

A couple nights ago, I woke up from my sleep in distress because of a dream. I was distraught and overcome with immense sadness and feelings of hopelessness. I think I must have cried for almost half an hour. I know dreams are just that, dreams, and usually they are meaningless. However, I would say this was an exception. Let me share with you what this dream was about.

We were driving around Karachi when I noticed a dead body lying on the road. Worse, the head was cut off and lying next to the body. Next to this dead body was a man asking for help from everyone and anyone. He needed help to find a proper burial spot for the man. Unfortunately, this man had no legs (common across Pakistan either due to polio or other circumstances) and hence was not able to seek further assistance. What got me was the fact that people were walking and driving by but no one was willing to provide any help. They were too engrossed in their own worlds to care. The dead man had no family or friends around him. The other man was begging for help but no one could hear his voice.

That night I was too sad to reflect on the dream, and so I cried myself to sleep. The next morning I tried to gain some insight, especially because I could not erase the picture out of my mind. The picture is till clear in my mind. Through the help of friends and soul-searching, the following are a few of my reflections. There are just too many to include here.

1) I took this dream to be a message, a sign to act. I feel that too often we are concerned with treating the symptom of poverty but hardly do we try to understand the root problem. By no means am I saying that we should not help those who need our help because a little bit definitely goes a long way. If we want to eradicate poverty, then we must explore issues perpetuating this. This is not simple, in fact, it is quite complicated. After this dream, I am feeling that I have to, no, I need to do something. I have always felt this way (hence the reason for going into nursing and coming to karachi) but these feelings have now intensified. Rest assured that these feelings are not based on pity, but rather on feelings of responsibility and simply because...I want to....

2) I know I need to re-channel my energy from feelings of hopelessness to that of hopefulness. It is our responsibility to re-kindle the spark of hope for those who need it and who have lost all hope. I say re-kindle because we are all born with this spark but sometimes we need support and encouragement from others. I too need to be hopeful because this will guide my attitude towards others and what actions I will need to take to help others.

Thanks to my cardiac perfusionalist friend, A.J, and Dr. M, I had the wonderful opportunity to observe an open heart surgery at the Aga Khan University Hospital a few days ago. I have observed two open heart surgeries back in Canada but the one I observed here was for an 8 month old baby, who was diagnosed with a congenital defect termed, Tetraology of Fallots (TOF). Most of my nursing practice has been centered on adults as I had always believed that I was not emotionally ready for pediatric nursing. This, therefore, was my first pediatric exposure. TOF is a collection of four (tetra) defects of the heart. Without going into too much detail, all this basically means is that the baby is not receiving oxygenated blood to nourish her vital organs. When any cell of your body does not receive oxygen or nutrients for a long period of time it dies, obviously.

I am amazed by the facilities at AKU, especially in the operating room. There are 10 operating rooms and two are reserved for cardiac surgeries. The equipments being used during the surgery were state of the art and within best practice. The surgeon and his fellow were knowledgeable and up to date about recent guidelines and practices. I know this because I had the chance to talk to them after the surgery about the surgery. Also, during the surgery they were explaining to me what they were doing. The cardiac perfusion team was highly capable! Maintaining a child's perfusion is not easy but they were able to wean the baby off of the bypass machine with ease. All in all, I was impressed!

The female doctor arrived in the operative room holding the baby. I would rather have had the mother come in holding the baby but this was not feasible or advisable due to infection control practices. The operative room had already been prepped and sterile field set up. However, the mother was present with the child up to the time the child was taken into the operative room for psycho-social support. When the child entered the operative room, I become emotional. The baby appeared to be so small and helpless. I completely understand that this surgery needs to take place in order to save the baby’s life but I could not help but feel that we were torturing this child. My mind was then overcome with questions about life and the purpose of it. This happens to most, if not all of us, when we witness someone suffering or if we ourselves are overcome with adversities. It is too bad that some of us, including me, do not reflect on life on a regular basis but instead wait for moments like these. However, I am a firm believer in the fact that one does not know ‘good’ if he/she does not experience the ‘bad.’ Ask me later what I mean by this.

As the surgery commenced, a drape was set up over the child’s head so as to separate it from the rest of the body. It resembled more like a curtain. Therefore, the surgeons only had the surgical field to work with. When we prepare the individual for surgeries while they are unconscious and even during the actual surgical procedure, we often forget that there lies a human being just like us. We are more prone to this during the surgical procedure when there is a drape over the head. Even though the individual has no understanding or memory of what took place, respect and dignity for human life should be maintained at all times. Sadly, I had observed total lack of respect for the human body during a surgery some time back. The body part that was not being operated on was not covered. Whether the body part is a leg or an arm makes no difference. If the individual was conscious and lying on the surgical table, would they not want themselves to be covered? Should you then not treat the body with the same kind of respect when the individual is unconscious? I would certainly hope so!

Some people call me ‘weird’ because of my interest for watching surgeries. They even call me a vampire because I love blood. Everyone has the right to voice their own opinions, but allow me to voice mine. Watching surgeries and nursing is one of my many ways to get closer to the Creator. It is through learning about the human body that I appreciate the magnitude of the Creation. I know that my simple mind will never understand nor comprehend the Creator as He is higher and greater than all that exists but at least I am provided with a glimpse and for that, I am always grateful. How the human body functions with all of its intricate details just blows my mind because, in my opinion, that is a manifestation of the Creator. That is the Artist’s masterpiece. Such magnificence! Such excellence!

As part of my internship experience, I had the chance to visit both a private and a public hospital. I do not lie nor do I exaggerate when I say that there is a world of difference between these two health sectors. I was in a state of shock as I received a tour of one of Karachi’s most populated public hospitals. There were stains from beetle leafs (paan) and tobacco in every corner of the hospital. Fresh blood on the ground as people stepped over it with their sandals without a second thought. There was only one garbage bin for miles around, which too was overfilled. It was difficult to find at least one wash basin, even around the nursing wards. Patients received health care out in the open without any curtains to protect their privacy and dignity. The hospital was undergoing construction while patients were receiving care, thus being exposed to harmful chemicals and dust. What shocked me the most was the hygiene, or lack thereof, practiced by one of the critical care doctors. I observed him as he obtained an alcohol swab to perform phlebotomy on a child. He then started to talk to a fellow colleague all the while rolling that alcohol swab in his hand. They talked for a bit, after which he used that same swab to perform the procedure. We do not know if he had already washed his hands or not. Regardless, the alcohol swab must have become dry in his hands and its effective agents lost. To make it worse, he was not wearing gloves.

Upon leaving that hospital, I concluded that I would rather die then be admitted to this hospital. The sad part is that MANY individuals living in Pakistan and other developing countries do not have the option of choosing which health care facility they would like to receive care in. They have only two options: 1) receive health care in an institution where you may come out sicker than when you came in or 2) become sicker and not seek health care of any sort. These individuals do not have the money or the resources to seek care at well-recognized institutions that provide quality care. However, some health care is better than no health care, right? Private hospitals in Karachi charge an arm and a leg, literally, before providing acceptable health care. If health care is a universal right, then why is there not equal access for such? So the rich not only get richer but they also get healthier while the poor become poorer and sicker. Why such disparity? One of the major causes of this disparity, in my opinion, is governance. Good governance dictates that the people elected to run parliament (ethically or not) of a specific country are directly responsible for the health status of its people. It is a known fact that changes in health spending of a country, significantly affects the health status of its people. Developing countries, where 78 % of the world population lives, spend only 10% of the total world health expenditure. In 1991, developing countries spent only 4.7% of their GNP on health, whereas the ratio was 9.2% for established market economies (EME). In 2006, Pakistan’s total health expenditure was 2.1% of GDP, of which 80% was private expenditure and 20% public. Out-of-pocket expenditure accounts for 98% of private health expenditure. About 2.3% of households are estimated to experience financial catastrophe due to health care costs. Pakistan spends more money on its defense system than health care or education. Military spending in Pakistan accounts for 3.5% of GDP. In 2005, it was close to 4.90%! Additionally, of the 11 billion dollars given to Pakistan as aid money from America in 2008, 8 billion dollars was spent in strengthening the military. However, America’s involvement with Pakistan and its army is a whole different issue that one can write a book about it! Regardless, changes in health expenditure eventually affects the people who rely on government services for their well-being. When government services are not up to par or lacking, then the people left to seek the services of private enterprise whose quality of services may be excellent but nothing comes without a price. In this case, the price can be quite hefty and can even claim a life.

I would like you to reflect on these two stories which were in a local Pakistani newspaper:
1) “My wife suffers diabetes. Her feet are now swollen and she often feels tired. Apart from medicines, the doctors have suggested a special diet - but how can we afford to give her fruit and meat when I earn only Rs 8,000 [about $106] a month and must educate my children as well,” said ______, 35, a father of two. ______ suffers from a shortage of breath, but says: “If I go to a doctor they will prescribe expensive tests and medicines and I cannot afford them. Therefore I simply do not go”.

2) “I suffer from hepatitis C. Please help me live by giving your charity to help me buy medicine. I have five children who depend on me.” Thus reads a placard next to ________, who has taken to begging on the streets of Lahore in her spare time in a bid to afford the medicines, which could save her life. As a cleaner she earns about US$40 a month. On this income and about $53 handed over each year by her brother, she must support her children - the eldest of whom is 15. Her husband, a drug addict, abandoned the family two years ago. “I don’t know how I contracted hepatitis C. It could have been when my youngest daughter was born about 18 months ago. A dai [traditional, untrained midwife] delivered her. But now doctors say I need injections that cost at least Rs 50,000 [$666] for a six-month treatment plan if I am to live,” she said. “I beg, even though I hate doing it, because somehow, for my children, I must live,” she said.

As part of the special lecture series, AKU invited Nazir Sabir last week to share his experiences with AKU staff and students. Just a quick overview, AKU lecture series has invited such guests as Abeeda Parveen and Karen Armstrong.

Nazir is a mountaineer, an environmentalist and a humanitarian. Born in the lap of the Korakorakum in the Northern areas of Pakistan, Nazir has developed a keen love for mountains at a very young age. With mountains at every corner, Nazir believed that he would be able to see all of Pakistan and her cities from the mountain top. Nazir has climbed almost all the mountains in the Northern areas, including the Rakaposhi , and is the first Pakistani to climb Mount Everest. His inspiration and motivation stems from sheer fascination and love for the Divine creation. His talk was truly inspiring and thought-provoking and that is why I am sharing with you his stories and his words of wisdom.

“Mountains always have something to give to all”

“Mountains strengthens belief about eternity”

“One develops an eternal relationship with nature”

“We realize how insignificant we are when we up against a mountain”

“Even though the mountains took my brothers life, I continue because like anything else, you are always living under the shade of death”

“When you are climbing, you are putting your life in the hands of nature-you are at her mercy”

“Mountains allow you to discover your strengths and your weaknesses”

“Climbing is similar to making a pilgrimage”

“As Pakistani, I wonder if we truly deserve such beauty. Have we really been able to take care of this?”

“We Pakistanis travel the world but we have yet to discover our own land”

“It is sad that our youth are losing connection with nature”

“We climb our own mountain everyday. We fall but we get up but we learn from our mistakes”

“One really appreciates the meaning and value of life”

Nazir talked about one of his near death experiences as he was falling off a mountain. He started to have a dialogue with God, fighting with the Great Power that he was not “ready to die.” He tried to negotiate with God in the attempt that God would grant him a second chance. After many negotiations, he felt defeated and started to accept his fate. He proclaimed, “I am ready!” However, soon after his acceptance, Nazir found himself close to the edge of the mountain but safe. He was granted a ‘second chance.’

Nazir attempted to climb the K2 twice. His first attempt claimed the lives of 5 of his closest friends and climbing partners before reaching the summit. However, Nazir made a promise to himself and his friends that he would attempt the k2 again-that he would not give up. After a long and arduous climb during his second attempt, Nazir and new his partners reached the summit of K2 hand in hand. However, this moment was an emotional moment for Nazir as memories of his late friends overpowered him. He shared with us a picture depicting him at the summit of K2, kneeling and prostrating before the Divine. Submission to the Divine will and grace. There he offered prayers for his friends and the rest of their souls. If a picture could say a thousand words, this one was it.

Human beings are complex individuals whose survival depends on the continuous interchange of multiple factors. Similarly, sustainable and equitable community development can only be achieved through an integrated approach. Hence, it is seen as a multi-input strategy, as described by His Highness. It involves collaborating with grass roots levels in order to address their needs. The emphasis is on what they perceive to be important. His Highness states, “The disadvantaged amongst us must be able to build a sound and secure future with dignity and pride - and not merely to survive” (Islamabad-11th-March-2002). It is also imperative to understand that developmental efforts should reach to the masses and not to a selected few. Since majority of the world’s population live in rural areas, efforts should be directed towards them.

Let me bring you back to the Northern areas as in example. The Aga Khan Development Network is involved in various projects that serve to provide rural stabilization to this mountainous region. The Aga Khan Rural Support Program, The First Microfinance Bank, Teacher Training Program, Aga Khan Planning and Building Services, and Aga Khan Trust for Culture are only a few agencies within the AKDN whose aim is to enhance the quality of life and living standard of people living in the Northern Areas. From innovations in water and land management to providing supportive infrastructure such as roads, irrigation channels, and small bridges, AKDN’s presence has proved to be instrumental in re-shaping the community and the lives of its people. Individuals now have access to services and resources, which was once impossible. Cultures are crossing that bridge of understanding and acceptance as they are exposed to each other’s way of life. Historic places and forts (ex Baltit Fort) have been and are in the process of being restored so as to revive the community’s rich history. A lesson that I have learned as a Heritage Discovery Program Delegate is that reviving a country’s history through restoration also provides economic stability and expands the labour market. Local folks become contributing members of society through empowerment and capacity building.