The woes of the health sector in Pakistan are unending. It is strange that given the large number of people affected by the government's health policy - the people, the medical practitioners, the pharmaceutical manufacturers, the health institutions, the local bodies, the civic agencies responsible for primary and community health - the various issues of concern which crop up from time to time are not taken seriously.
We are constantly being told that a new national health policy will be announced soon. But, (although Sindh has announced a provincial health policy) that beguiling document does not see the light of day. And the masses continue to suffer.
Standard health care is not available to the people at affordable prices. Those who are affluent and can afford it have access to excellent health services in the private sector.
In fact, with increasing privatization people can also exercise their choice in deciding on the treatment they want to take. But those who are of modest means can be doomed.
Not only are they fleeced for whatever treatment they receive. Their condition might actually deteriorate because of the wrong treatment given to them by a careless or an ignorant health professional.
Although from the public's point of view, both access and affordability are as important as the quality of care a patient receives, here we will focus on the quality factor.
This matter has emerged as a subject of debate in public forums for two reasons. First, since November the accrediting body of the medical sector, the Pakistan Medical and Dental Council, has come into the limelight for what is perceived to be the government's interference in the Council's composition and working.
The second event which should have drawn public attention to the standards of health care being provided in the country was the "alternative national health policy" that was unveiled by the Pakistan Medical Association (PMA) in January.
Its emphasis, among others, was on ensuring the quality of medical education and health care provided to the people. It is a telling verdict on our health system that the president of the PMA expressed strong concern about the 600,000 quacks allowed to practise freely in the country but more than that about the "glorified quacks" being produced by many medical colleges.
All this just confirms that the PMDC has fallen short of its responsibilities. At present it is a top heavy body with a governing council of 53 members, most of whom are ex-officio government officials (principals of public sector medical colleges, health secretaries representatives of public sector universities).
All that these worthies have been doing is to issue licences to the doctors who graduate from the recognized medical colleges in the country and to prescribe the requirements of space and staff of a medical college, the curriculum, time of examinations, qualifications of teachers and examiners and so on. It is assumed that if quality medical education is ensured the products of that system - the doctors - will also be competent. But this approach has not safeguarded the interest of the public as the PMA's alternative health policy confirms. Simply licensing a doctor to practise does not ensure that he will continue to upgrade his education and knowledge as the concept of continuing medical education expects him to do.
It also does not ensure that he will be ethical, will follow safe methods and observe the Hippocratic oath he has supposedly taken at the time of graduation. It is said that the primary function of the PMDC is to safeguard public interest. Given the chaotic conditions in the public health sector and the sufferings of the common man, it is plain that the primary interest of the patients is not being protected.
The impression is that the PMDC has emerged as a body to protect the rights of the health professionals, even at the expense of their patients. This is deplorable. Similar regulatory bodies in other countries are assigned a different role altogether.
The General Medical Council of the UK defines its function as maintaining "the standards the public have a right to expect of doctors. We are not here to protect the medical profession - their interests are protected by others. Our job is to protect patients."
The Accreditation Council of Graduate Medical Education of the US states, "Our system of medical education relies heavily on considerable public funding. We, therefore, need to be accountable to the public in terms of both meeting public needs and preparing well qualified new physicians in the most effective way possible".
Isn't it time the PMDC reviewed not just its composition but also its functions? Apart from some entrenched elements in the public health sector, no one disputes the need to include representatives of the private medical colleges on the council.
It is also important that some members of the lay public, the users so to say of the health system, are also taken in the council. The General Medical Council of the UK, the model on which PMDC was set up in 1948, has changed.
Today 14 out of its 35 members are from the lay public and appointed by the Privy Council, 19 doctors are elected by the doctors on the register and only two academics are appointed by medical colleges.
The PMDC should now also be more concerned about the competence and ethical behaviour of the individual health professionals. Prof S. Naeem Jafarey, a senior member of the medical profession in Pakistan and Adviser at the Ziauddin Medical University, proposes, "to ensure a uniform standard among graduates from different universities, the PMDC should hold a national licensing examination.
A licensing examination is not a novel idea. In most countries the right to practise is not automatically granted on acquiring the basic qualification. For the last 15 years PMDC has been holding a licensing examination for foreign graduates. It already has the expertise of holding a licensing examination."
Prof Jafarey - there are many other doctors who share the same view - is also concerned that "at present there is no monitoring of the quality of medical practice and there is no mechanism to redress complaints of 'poor' quality of care".
The fact is that the press reports the malpractices that are rampant in the medical sector only when a major scandal occurs. The day-to-day behaviour of the medical professionals is never reported - though people who have suffered at the hands of their physician/surgeon do grumble about it.
It is not known whether it is the PMDC's responsibility to provide protection and redress to patients from doctors who are "dysfunctional and who, by reason of their misconduct, ill health or poor performance, put patients at risk of harm" - to borrow the terms used by the GMC of the UK in a report.
If the PMDC's ordinance does not empower it to receive complaints from the public, investigate them and cancel a doctor's licence if he is found guilty, it is time this amendment was made. If this provision is there, we do not have much evidence to prove that this responsibility is ever taken up.
Here it would be timely to point out that the health professionals' role vis-a-vis their patients is not to be taken lightly. They should every day before they begin their work recite the Hippocratic oath which they were supposed to have taken when they graduated because many of them have forgotten them.
They should specifically remind themselves of this clause: "I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous."
It is also pertinent to remind them of a new version of the oath which says, "I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability.
My responsibility includes these related problems, if I am to care adequately for the sick." It also reads, "I will prevent disease whenever I can, for prevention is preferable to cure."
Privileged animals
By Hafizur Rahman
From Maharashtra in India came the news some time ago of an apology made by the state education authorities that a cow had chewed up some answer papers of a post-graduate university exam in the house of an examiner. However, I am glad the official spokesman did not suspect foul play by some ISI operative from Pakistan, or even accuse the cow of having Islamic fundamentalist learning's.
In India, all cows and bulls are sacred and imputation of anything immoral to that holy animal would amount to blasphemy and probably spark off a Hindu-Muslim riot. This was quite common when we were young Indians before 1947. The favourite pastime of Muslims was to throw the carcass of a cow into a temple, while that of the Hindus was to dump a dead pig in a mosque. All in a spirit of friendliness, as some people would have us believe today.
The goat is not held sacred in India as the cow is. But ever since Mahatma Gandhi went along with a goat in tow (he drank only goat's milk, and once took his pet goat with him during a visit to Britain) the animal acquired an honorary sort of veneration from Indians.
What a coincidence that the London newspaper which reported the answer-paper munching exploit of the examiner's cow also gave out the story that in Delhi a goat had chewed up the currency notes of its master and caused him considerable loss. Goats have never been accused of corruption, but if this was not corruption what else was it?
Corruption is when you start treating other people's money as your own. Again, no motive has been ascribed to the goat in question though its act fits an Urdu idiom.
In Urdu when we want to describe misappropriation of funds we say "Paisa kha gya," that so-and-so "ate up the money." The goat's action depicts gross indifference to its master's financial interest, if you can't categorise it as downright embezzlement.
The Maharashtra cow's was a one-time act, not inspired by any happening anywhere else, and decidedly not aided and abetted by other cows in the pay of ISI. Former Home Minister Lal Kishan Advani can rest assured that Pakistan was not guilty of cross-border terrorism or interference in the domestic affairs of India on this count.
In our country sacred cows can get away with any amount of munching and chewing of vital national documents. There are no laws that they have not flouted, even though they were themselves instrumental in their legislation. Maybe they felt a proprietor's interest in them and thought that being authors or co-authors they could do with them what they killed.
There are no government rules and regulations which have not been broken by these sacred cows for their own sake or for the sake of their loved ones and their cronies. Bans, prohibitions and embargoes hold no fear for them, for they are the ones for whom the exception clause is always inserted into all acts and rules prescribing legal restrictions for you and me.
Like the cow and the temple bull in India the sacred cows of Pakistan can go wherever they like and graze to their bovine hearts' content anywhere that suits them. They can own any amount of property without paying tax on it.
Allotments and permits are hung around their necks like garlands of marigold. They can ease themselves at will and their dung is cleared away by a battery of flunkeys provided by the state. Or even left to putrefy. They are not bothered.
On their part, the privileged goats of Pakistan too are busy chewing and digesting currency notes, more than they can be printed. As the late Dr Mahbubul Haq was fond of saying even when he was finance minister, these goats "eat away forty billion rupees from state funds every year." He claimed to have a list of the most voracious among them but was somehow reluctant to name any names. Maybe some fo them were friendly goats. Who knows!
Many of you will recall that President Ayub Khan was allergic to goats and promulgated an ordinance to bring about their speedy elimination. I can't remember which goat it was that he disliked more - the one that is the enemy of vegetation and small trees or the fast-breeding one that chews up bank notes with relish. In either case he failed, and so did his successors.
Pakistan has always been an EI Dorado for sacred cows and hungry goats of the breed mentioned by me. Rarely have they come to grief, and if they did it was not for long and the dreaded moments passed soon.
For three years they somehow felt restricted because of the cow-catchers and goat-snatchers going about everywhere in uniform, but you can take it that they must have found out ways (and means) to evade them and protect themselves. Now of course we are back in democracy and there can be a free-for-all for all animals in every respect.
Do you ever feel hopeful that this downward drift, symbolized by the two animals, will be halted, or even slowed down? I don't, for the simple reason that nobody seems to be doing anything towards that end.
It was always thought that democracy was one solution. It may not be ideal and the absolute solution but it helps. I mean the real democracy; not the one we have been seeing during the past decade or so which itself was chewed and munched away by sacred cows and VIP goats.
In democracy there is some sort of accountability of everyone and the people have a voice of some kind in everything. Maybe this serves as a check. But if those who have the authority to hold bad hats accountable and are themselves accountable to no one and run away with the goods (as has been happening since 1988) what then? On the other hand some wise guys in the country believe that democracy is not suited to our psyche.
I wonder what exactly suits our psyche? And what is our psyche by the way? Self-destruction?
Ripples in the Middle East?
By Mahir Ali
It is not hard to discern the equivalent of a spring in the step in the recent output of the commentators and analysts who either supported the American aggression against Iraq, or criticized it desultorily only after they saw it developing into what looked like an unmitigated disaster.
Through the nearly two years of bomb blasts and bloodshed, many of them kept their eyes trained on the unrelieved gloom of the clouds overhead. Their motivated patience has lately been rewarded: they have espied a silver lining.
Many of them were never quite convinced by the argument (even while offering it themselves) that the removal of Saddam Hussein's regime - which was undeniably brutal but possessed no weapons of mass destruction, had no links with Osama bin Laden's outfit, and posed no military threat even to its neighbours let alone to any western power - was sufficient justification for a war that claimed casualties in the hundreds of thousands and destroyed what remained of Iraq's infrastructure. The war of attrition that followed the invasion, the indiscriminate assaults on population centres such as Najaf and Fallujah, the sordid tales of what went on at Abu Ghraib and so many other detention centres, inclined some of them towards questioning their own enthusiasm for the new century's first major conflict.
Lately, however, a seemingly propitious set of circumstances has persuaded them to renew their faith in the foresight of the neo-conservatives who accompanied George W. Bush into power in 2001, and whose influence in Washington has grown with the advent of his second administration.
After all, didn't these neo-cons claim that all they wanted was to spread democracy (never mind the fact that in the documents they produced, they seldom bothered to disguise their hegemonistic intent)? And aren't there signs that a wave of democracy is about to crash through the Middle East, from Saudi Arabia to Egypt and beyond, taking its cue from the elections in Iraq?
So, even if the attack on Iraq violated international law and the elaborate excuses offered for it were largely fictitious, hasn't some good come of it after all?
Well, there can be little question that the Middle East could do with a lot more democracy - provided the dispensation translates into high levels of popular participation and representation, rather than ersatz electoral exercises designed to replace one set of oligarchs with another, chiefly on the basis that the latter are expected to be more sensitive to Washington's whims.
One doesn't have to be embedded in a conservative American think tank to recognize that the region is awash with mediocre despots, and that large numbers of Arabs are hungry for change. Almost none of them, however, would be willing to countenance a fraction of the price paid by Iraqis for the privilege of regime change.
Besides, the fate of Iraq isn't the only reason for being wary of US motives and designs. Even a perfunctory glance at 20th-century Middle Eastern history serves as a reminder that some of the least defensible Arab regimes have owed their longevity, if not their very existence, to crutches made in the US.
Let bygones be bygones, argue some of the apologists; Washington's record in the region is indeed murky, but now behold the new, improved United States, the harbinger of democracy and liberal virtues.
Even if this illusion had some basis in fact, there would be cause to question the American method of exporting these ideals. But the fact is that liberal values are under attack in the US itself - a phenomenon witnessed under every recent Republican administration, although this time around it has adopted a more virulent form than during the Nixon or Reagan years. And democracy has suffered setbacks across many of the nations involved in the assault on Iraq, where governments either symbolically or more substantially contributed to the neo-con project in the face of overwhelming popular disapproval.
What's more, double standards are still rife in the Middle East. There's Israel, of course - a systematic violator of human rights that ignores UN resolutions with impunity, sanctions terrorist attacks on foreign soil and almost certainly harbours arsenals of chemical, biological and nuclear weapons, yet rarely attracts anything other than love letters (and unlimited largesse) from Washington. But even if Israel is left out of the equation, it would be impossible to claim with an iota of credibility that the US is even-handed in its regional approach. To take but one instance, Iran and Syria have been branded outposts of tyranny.
However, even those inclined to accept that description, perhaps with a quibble here and a tiny reservation there, are left wondering why the most politically backward state in the region is conspicuously spared such epithets, while a paltry degree of participation in virtually meaningless Saudi municipal polls is hailed as a symbolically significant concession.
This isn't the only strand of hypocrisy. And there is particular cause for alarm when it finds expression unwittingly. When George W. Bush declared last week, "I don't think you can have fair elections [in Lebanon] with Syrian troops there", what are the chances that he paused even momentarily to wonder why that should be so, given that in his view it's clearly possible to hold fair, free and groundbreaking elections in Iraq amid a vastly larger US military presence? But then, perhaps that's an unfair question. If Bush were capable of sorting such matters out in his head, chances are he wouldn't have revelled in his role as chief recruitment officer for all manner of Islamist terrorists.
It is nonetheless somewhat strange to hear the strongest demands for Syrian withdrawal from Lebanon coming from the only two countries with occupation forces on Arab lands: the US and Israel.
Although Hariri resigned as head of government last October in protest against Syrian interference and may have been instrumental in instigating the much-cited UN Security Council resolution calling for a withdrawal (albeit without naming Syria), he wasn't on exceptionally bad terms with the government of Bashar Al Assad.
At the same time, it is hard to believe anyone in Damascus could have been in any doubt about what such a spectacular "hit" on the streets of Beirut would portend for Syria.
It is not inconceivable, of course, that some wing of Syrian military intelligence hatched the plot without referring it to the government - and, if so, it has done its nation a monumental disservice. But there are other suspects who may have had a clearer motive not so much for targeting Hariri in particular, but for sparking unrest in Lebanon and, perhaps, destabilizing Syria.
It has been suggested that Iraqi insurgents may have hoped to widen the war by embroiling Syria. Again, that's not impossible, but it seems a bit far-fetched; besides, the operation required a sophistication of which such perpetrators are unlikely to be capable.
It is equally unlikely that any US agency would risk direct involvement in such a deed. Israel, on the other hand, had even more to gain than the US from an event that would inexorably increase pressure on its Syrian foe, and in the longer term may even lead to a loss of sponsorship for the Hezbollah militia - the only Arab force to have inflicted defeat on the Israeli army. And Mossad has considerable experience in targeted assassinations. But that doesn't add up to proof of culpability: it's only speculation, and it must be hoped that an independent international investigation will nail the culprits.
Despite having presided over a deeply flawed administration, Hariri is associated in the popular view with Lebanon's reconstruction, however lopsided, following the dastardly 1975-90 civil war. His death, it is said, could lead to a more profound Lebanese rebirth.
Last week, the protests in Beirut forced the resignation of Omar Karami's pro-Syrian government. At the weekend, Assad announced the pullback of Syria's 14,000 troops; although the US state department reacted with characteristic impetuosity, almost everyone else heaved a sigh of relief.
Assad has invariably gone out of his way to placate American concerns, while at the same time trying not to antagonize the so-called hardliners in his government, whose mindset probably harks back to the days of a more radical Syria. Like almost every other Arab state, the country cries out for reform and rejuvenation. But the consequences of external coercion could prove unpalatable for everyone. The impetus for change must come from within, and Syrians alone must decide the shape it takes.
That holds true also for all other countries in the region, from Iran to Sudan. And although it must be hoped that democratization will gather momentum, on present evidence - a passing nod to pluralism from Hosni Mubarak, limited franchise local polls in Saudi Arabia, minor concessions in other Gulf states, the inconclusive "cedar revolution" in Lebanon - the region is experiencing ripples of change rather than a tsunami.
One could argue endlessly over the precise correlation between each ripple and developments in Baghdad, but even the wholesale relegation of despotism within the next few years wouldn't add up to post hoc justification of Iraq's devastation. Nothing can change the fact that the war was a criminal act. And wishful thinking alone cannot transform a silver lining into a rainbow.