CLEANLINESS is next to godliness, they say. Pakistan being a country where there is no shortage of the latter, are we clean as well?

A crucial distinction: cleanliness is not the same as tidiness. One keeps you safe from disease, the other helps you keep up appearances.

Poor sanitation and sanitary practices are most commonly linked with poverty and the lack of education.

This makes obvious sense.

Any understanding of the manner in which diseases are communicated starts with basic concepts such as what germs, bacteria, viruses or transmission are.

Without that, any grasp of the issue can only be superficial. Then, there is the matter of access to sanitation products. It's useless to impress upon a population the importance of washing your hands if it has no running water; which family would buy soap, quite literally money down the drain, when there are greater demands on one's resources such as enough food to stave off starvation? There is no dearth of studies on the lack of basic hygiene and sanitation practices across the country (and a generous number of initiatives taken by local and international organisations to address the situation). But what about the thousands for whom life is not quite so grim, and who potentially have both access to vital information and the ability to make use of it? The concept of bacteria, for example, has been successfully taken up through the numerous animation films and television advertisements created by a leading soapmanufacturer. In areas where television is accessible, the manufacturer should by now be a household name.

Television and radio are full of information on the importance of hygiene, the manner in which diseases are transmitted and how people can keep themselves safe.

The country spends millions of rupees on awareness campaigns about the transmission and control of serious illnesses such as polio and hepatitis. The message that drinking water should be boiled and children vaccinated is repeated often. The indication, then, would logically be that at least in the urban areas, amongst the somewhat educated segments of society, there would be a reasonable amount of health literacy.

At least this is what I had assumed until I started asking.

I was talking to a woman who works as a housemaid in Karachi. She is 39 years old and has six children, at least three of whom went/are going to school and can read and write English with reasonable comprehension. Her household income averages at about Rs25,000 a month, and the flat she lives in is not rented.

The family is under debt to a money-lender (for the purchase of their flat), but they have a television and are thinking of buying a washing machine; the family always looks clean and well-turnedout.

This lady is familiar with hepatitis to the extent that it is a serious illness, but she does not know how it is communicated or can be prevented. She has never heard of typhoid or cholera, and does not know what polio is. She knows that children need tobe given 'certain injections to keep off diseases' but none of her children were ever inoculated against anything.

She has seen advertisements for polio campaigns and her area is visited by the immunisation teams, but none of her children were ever given the drops. She knows it's important to wash your hands after going to the toilet but does not know why precisely. She also knows that it's important to boil drinking water, but does not know why.

And so she does this chore only sporadically, even though she has a stove, a gas connection and a large cauldron.

How does one explain this? This conversation led me to initiate an informal survey amongst friends and colleagues; all the answers were identical. Even in urban Pakistan, amongst people with potential access to the relevant information and resources, there is either very low health literacy or little evidence of acting upon it.

Indeed, one colleague wrote back to say that in his experience, it seemed as though such care was viewed as nakhra a trivial concern of the elites.

And, worryingly, this attitude does not seem to be linked at least in my very small survey with literacy: an actor who didn't know how that tapeworm had entered her system or an 18-year-old who didn't know that under the skin were things called muscles which could be sprained.

Are there gaps, then, in the manner in which the campaigns are run, the information disseminated?1t's a knotty problem, and one that can't immediately be blamed on the fact that Pakistan is anunder-educated or developing country.

Consider, for example, that according to the US Institute of Medicine, an independent organisation established in 1970 that works as the health arm of the National Academy of Sciences, nearly half of all American adults lack health literacy.

Yet the problem must be addressed, for behind the bland terminology are people who continue to fall ill despite having the means to prevent it and further burden an already fragile public healthcare infrastructure. (In this context, a 2009 study published in the Journal of Pakistan Medical Association showed that of 211 respondents, only 4.7 per cent of trainee physicians at a Karachi tertiary-care teaching hospital reported decontaminating their hands before having direct contact with their patients. The majority considered the 'lack of sinks, soap, water and disposable towels' as the major barrier.) Last April, the federal health minister told a conference in Beijing that promoting health literacy is amongst Pakistan's priorities. In January 2010, the National Commission for Human Development and the National Trust for Population Welfare signed a memorandum of understanding on a 'literacy for family health' programme, under which the NCHD planned to introduce health literacy in its adult literacy centres.

Are such and many other initiatives having an effect? Ask the people around you, and let me know.

The writer is a member of staff.

hajrahmumtaz@gmail.com