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.

As I was walking from Aga Khan University Campus to Noorabad colony for a volunteer duty, the strap on my sandals broke. I could have walked back to my residence but that would mean that I would be late for my duty. And so I made it to the colony by dragging my feet as I was not about to walk barefoot! On my way to the colony, a bird decided to go to the toilet on my head! It wasn't enough that I could barely walk but now I have bird doodoo on my head.

Now this situation made me laugh. I could not stop laughing! And then I realized something about myself. I realized that before coming to Pakistan this situation would have made me irritated and frustrated. I may have said, "It's just one thing after the other! Why does it have to happen to me!" But after living in Karachi for approximately 3 months now, I have seen death, poverty, and destitution but I have also seen hope and happiness amongst all this. And so I have seen a change in myself. By crying over petty problems, not only have I realized that I become ungrateful for the blessings showered upon me but it shows complete disregards towards others and their situations. One tends to become unsympathetic and fails to realize that we do not live in isolation.

I am finally beginning to understand Pakistan's deep roots and history and why there is so much controversy in Pakistan. Understanding the situation in Pakistan is very complicated as it involves multiple factors.

It is only through understanding the past can we truly appreciate the present and prepare for the future. Hence, I wish to share some interesting historical facts. However, I will not dwell into too many details.

Pakistan gained independence from British India on 14 August 1947 in order to establish an independent Muslim state. Pakistan's Independence was possible through the works of the All India Muslim League, which was found in 1906 to protect Muslim interests. The League became popular in the late 1930s amidst fears of neglect and under-representation of Muslims in politics.
Many Muslims feared that an independent united India would subsequently be "ruled by Hindus." There would then be a need to address the issue of Muslim identity within India. Some important individuals that spear-headed the Muslim league were: the poet Muhammad Iqbal, Muhammad Ali Jinnah (founder), and Sir Sultan Mohammad Shah Aga Khan III.

Pakistan means "the Land of the pure or clean." It is composed of letters taken from the names of Pakistan's provinces: Punjab, Afghania (North West Frontier Province), Kashmir, Sindh, and Balochistan. You are probably wondering where the ' i ' came from. Actually, Pak Stan wasn't flowing and that is why ' i ' was added. Pakistan is a federation of four provinces (Sindh, Punjab, Balochistan, and NWFP), a capital territory (Islamabad), and federally administered tribal areas (Northern areas). However, tribal areas exist in NWFP as well as in Baluchistan.

The National language of Pakistan is Urdu and the official language is English. However, during independence Aga Khan III had suggested Arabic as the national language for Pakistan. This suggestion was not taken to heart, obviously. If Arabic was adopted as the national language then Pakistan would not only be united as a country but also with other Islamic countries such as Saudi Arabia and Egypt. Conflicts that are now occurring in Pakistan are mainly due to issues over language and the presence of multiple sectoral and tribal divisions. Keep in mind that the provinces have been divided based on language: Sindhi is spoken in Sindh, Punjabi in Punjab, Balochi in Baluchistan and Pastun in NWFP. Within these provinces, there are various linguistic dialects of a particular language. For example, Sindhi consists of multiple dialects, including Katchi. Recently, Balochistan is protesting to be an independent state, separate from Pakistan. You may remember what happened with Bangladesh.....


More lessons on Pakistan's history to come.....

When we were in the Northern areas, we got to witness how people lived in the most remotest areas.

For those living high in the mountains, they have to face extreme cold temperatures. To make matters worse they do not have heating or electricity, something we in the developed world take for granted. Many a times I witnessed an entire family huddled around a stove in the center of the room. Young kids would gather wood and twigs in order to keep the fire going.

For those living in isolated villages, it takes at least two hours to get to the nearest health center. Imagine if there is a medical emergency (ex. heart attack) and the individual needs to be taken to a hospital right away. As a cardiac nurse working in a hospital, I have everything at my disposal in case of medical emergencies like this. As you can tell working in conditions like these is no easy task. Thankfully, Aga Khan Health Services, Pakistan in collaboration with the government has and is continuing to train community birth attendants, health workers and lady health workers. Therefore, a pregnant mother does not need to deliver at a health center if a trained birth attendant is present and residing within that community.

Living close to the mountains come with multiple risk factors. For example, as the glaciers melt the road conditions become treacherous. Landslides and mudslides make it difficult to access the only road leading to the city center, where one can find health centers, stores, etc...
If these roads are accessible, they are extremely narrow and dangerous with sharp curves. Night driving is next to impossible.

Even in Karachi, where living conditions are not always "first world standards," I am extremely thankful for all of life's little and big pleasures.