Of medical costs and cadaver law

THIS articulate colleague of mine was very bitter, last evening, over the rising costs of healthcare and medical facilities over the years, and in particular he mentioned that not many doctors and specialists in the “business” were found talking about this disturbing angle publicly. In fact, he observed that while newspapers kept focusing on the prices of petrol, atta, tomatoes and even on that of ready-made garments, with such regularity, why there was such scanty and inconsistent coverage of what was happening on this front?

He took me by complete surprise, as he began one of his angry monologues on how people were finding it frustrating and humiliating to cope with the costs of medical care in the private sector, and with the poor quality of most public sector hospitals. There was nothing new in what he was saying, except that his views needed to be considered seriously and consistently.

For a city with a steadily rising population, and in a society where the population growth rate remains on the higher side, the state of healthcare affairs needs urgent attention.

The citizens of Karachi have become conscious, with the passage of time, and are demanding better standards of healthcare, which sadly are denied to most of the public, even by some of the reputed hospitals here.

It is not surprising to find educated Karachiites hurling worst kind of criticism, laced with despair and cynicism, on some of the best hospitals in the city, which they allege have appalling degrees of mismanagement and heartlessness, even though these facilities charge exorbitant costs.

Of course, there is much to say on this theme, but let me tell you what this colleague of mine emphasised. He perceives a certain heartlessness and callousness, characterising the way in which our hospitals and clinics work, and how the men and women who manage them, at all tiers, go about their jobs in most cases. I suggested to him that a reason why he was so concerned about this aspect of the society, was because he was growing old and had been visiting hospitals and doctors quite frequently, for one reason or the other. He did not agree and smiled, and we spent the rest of the evening sharing notes and perceptions on how an average citizen met his medical needs, both, where some organization (even if it is government) paid for it, and in other instances where the person had to pay for it himself.

One cannot resist referring to what a medical representative of a foreign pharmaceutical company remarked recently, when I asked what a poor man would do for his failing eye-sight except going to one of the leading eye hospitals for relief. He said “there is no scope for the poor man in this society,” looking at me without any feeling. I wasn’t expecting that kind of a brutally realistic comment from him. But that is perhaps the kind of truth that stares at us in the face. Poor man, no scope?

See what a well-known professor, Adibul Hasan Rizvi, said during the week, when he spoke on the sad point that 25,000 lives were lost every year for want of legislation on cadaver transplants. He also spoke of the draft legislation that was lying pending in the senate, gathering dust. A Dawn report discloses that “the doctors who took part in their formulations are at a loss what to do next,” which seemed strange.

One senses a certain symbolism in this. It reflects the nonchalant attitude of the power lobbies in the land, the decision makers, and the weary way in which the process of making decisions and of their implementation is carried out. Prof Rizvi pointed out that cadaver donation has been legalised by several Muslim countries, including Saudi Arabia, Egypt, Malaysia and Bangladesh, adding that one cadaver (dead body) could produce up to 17 organs, to be utilized to save up to 17 lives.”

Now coming straight to the point: What stops such a law, when reportedly, even the legislators are with the idea, and believe in its good to the society. The professor said: “the religious leaders we have talked to have always supported us. It is time for the clergy, journalists, and doctors to join the efforts to convince the legislators for passing a law on the cadaver donation of organs.”

But for all the passion, optimism and justification that he appeared to represent in his point of view, he was also quoted as saying that “you know better than me what motivates our legislators. I don’t have to dwell too much on the subject.”

There is indeed much to contemplate about in this between-the-lines comment that the seasoned doctor made. There is perhaps also a bitterness in his perception that he has tamed with his grace, and tempered it with his mildness of manners.

It is said that in the late 80s and early 90s, some doctors involved in the transplantation of kidneys, feeling the need for laws on cadaver donation of organs, formulated a law, which was submitted to the legislators of the country for approval. Prof Rizvi said at his mid-week press conference “Shame, Shame, shame, this law has been sitting in the Senate since 1992, despite repeated reminders.”

In passing, one may recall that the occasion for that press conference was a success story (yet another one) of the Sindh Institute of Urology and Transplantation (SIUT).

Of course, there are public sector hospitals, which, at least in theory, are expected to provide medical facilities at affordable prices, if not free. But these state-owned hospitals have recurring resource constraints, as does the State itself.

As my colleague and I conversed on this disturbing theme, the point that emerged as a challenge of the future was how would the health sector meet the rising expectations of the people.

The rural population moves from undeveloped areas to the urban “dream” in the hope that here they will get what they need. Sometimes they take their leaders promises seriously, even though the common man is fairly unsure and cynical of all the utopia he is promised. Politics, or its absence, have both taken their toll.

In revisiting this forever relevant theme, one is conscious of a troubled section of Pakistan’s population that has to borrow heavily from friends and extended families to pay their medical bills, especially, of those hard-hit families, where the falling rate of savings has multiplied the number of question marks in their lives.

Remembering the paper makers

THERE is no doubt that Gengis Khan wreaked havoc on Lahore, pillaging it, raping the women who did not manage to flee the walled city and butchered all able-bodied men who remained. But then if he can be said to have made one positive contribution that lasted, it certainly must be the introduction of paper to Lahore.

The Chinese were the first to use paper, an invention that goes back almost 2,000 years. In those days a thin strong fabric was used in the Punjab, as paper did not exist here. If you have ever seen the ‘farmans’ of old in the Lahore Museum, you will notice that the older ones are all on fabric. When Sher Shah Suri revolutionized the land record system, he made it compulsory for each ‘patwarkhana’ to have two fabric copies of the entire record of the relevant area. The tehsildar certified the copy with his seal and signature and kept the original. But then came paper, and paper came to Lahore from two routes: from Samarkand via Kashmir, and from the south, thanks to Arab traders who initially came to Multan. In both cases, the initial route was via Samarkand.

We have to thank the Mongols for forcing paper to come to Samarkand. The Chinese prisoners of war, brought to Samarkand after the battle of Atlakh near Talas, first introduced (AD 751) the technique of paper-making from linen, flax or hemp rags based on methods used in China. Ibn Nadim observed in Al-Fihriste: “The Chinese write on paper made from a sort of herbage. The Arabs learnt the technique of paper-making from the Chinese captives at Samarkand and diffused it westward”.

After the paper technology reached the Arabs, the latter improved the technique and supplemented linen with flax and other vegetable fibres. This was the beginning of the modern paper industry. With the conquest of Sindh by the Arabs, Khurasani paper was first introduced in the eighth century AD, and it continued to be imported for several centuries.

The paper-making industry in the sub-continent was established in Delhi and Lahore, the two chief political and cultural seats of the Sultanate period. Generally, Indian paper-making centre produced the glazed variety. One research categorises ancient paper into seven types — Kashmiri, Ahmedabadi, Hederabadi, Faizabadi, Khasah-i-Jahangiri or Lahori, Kanpuri and Aurangabadi.

While Kashmiri paper was stout and glazed, some Kashmiri centres produced superfine paper called silken. Khasah-i-Jahangiri, or Lahori paper, was made here though later on Sialkot also acquired a reputation for quality paper. The paper was glossy, thin, polished and bluish white. The Lahori variety was a class product in that it was the most flexible of all papers produced in the sub-continent. However, one researcher thinks paper came to Sialkot from Kashmir and from there to Lahore, which also makes sense.

The oldest recipe for making Lahori paper has been described as follows: “To make the pulp, use old clothes, old tents, the bark of certain shrubs and trees. Wash well and soak in water for a few days. Beat these materials with wooden hammer. Mix the pulp with a little limewater. The mixture, when lifted out, would become paper”.

The description further states: “Once removed, each sheet is drawn through a second reservoir of water and then hung up to dry in the sun. A quantity of gum Arabic was dissolved in water and then the beaten pulp was placed. The water in the second reservoir, through which the sheets were drawn, also contained gum in the form of mucilage, as well as some alum dissolved in it. The moulds or forms used by the workmen were generally made of bamboo. The gum Arabic was obtained as an exudation from the babool tree”.

In the old Indian technique of paper-making, the main tools used were: dhegi (hammer), chhapri (screen), and sacha (teakwood frame), kunchawas (soft date-palm brush), and polishing stone. One expert describes the process: “The process of making paper from such pulp was not very difficult. The pulp was moistened with water, taken to the river Ravi and pounded with stones, and washed for three days. It was then taken to a cistern about 7ft x 4ft x 4ft deep, half - filled with water. The pulp was thrown into this cistern.

“When it was thoroughly dissolved, the workman sitting on the edge of the pit, bending over the water, took in both hands the square frame which held the screen serving as a sieve, passed it underwater and drew it slowly and evenly to the surface; such that as the water passed through, a uniform film of pulp was left on the screen. The screen was then lifted up and turned over, and the film of paper was spread on a rag cushion. When sufficient layers had been heaped on this cushion, about 9-14 inches high, a rag was spread over them and a plank weighted with heavy stones was laid over it.

“When this pressure had drained the water and some of the moisture out of the stock of paper, the stones were taken away and two men, one standing at each end of the plank, see-sawed over the bundle of paper by hand. When it was well pressed, the paper was peeled off, layer after layer, and spread to dry either on the walls of the building or on rags laid in the sun. When dried, each sheet was laid on the polished wooden board and rubbed with a shell till it shone”.

In this way, paper was made on the banks of the River Ravi, as it was on the Indus near Multan. In the Punjab, very fine quality paper began to evolve, thanks to the use of cotton, though normally the last pick, slightly rusty in colour, was used.

One researcher claims that paper came to Lahore before it had reached the Arabs. But no matter how it came, there is no disputing that this is the one contribution to learning that Gengis Khan unwittingly made. It would take another 600 years before printing on paper started in the sub-continent, with the 16 pages of Doctrina Christina in Tamil by Fr Henriques and Fr Manoel de Sao Pedro. This was printed in the Malabar coast in 1578. This little work, known only from one copy in existence, is the earliest example of printing in the characters of one of the languages of India.

The 16 pages of Doctrina Christina are printed on a single sheet, in conventional octavo format, the pages measuring approximately 14x10 cm. It is the famous Khasah-i-Jahangiri, or Lahori paper, which goes to show the immense contribution to the fast evolving industrial world that the sub-continent was becoming before it was colonized and thrown into mass poverty. Because of the alum used, it is still intact, a remarkable contribution of the local genius of Lahore. There is need to recognize the early paper-makers of Lahore and Sialkot, for they in no small measure contributed to the spread of knowledge. — Majid Sheikh

Wedding woes and wisdom

MOST of the invitations one is receiving these days are for weddings rather than art exhibitions, and for coping with these ‘exhibitions’ one is in a bit of a fix trying to balance the logistics of limited time, money energy and enthusiasm, and eventually wondering how much of all this is really worth it.

One had imagined that the ‘new generation’ would be more practical and opt for simpler weddings, but in most cases, it appears that the need for extravaganza is gaining momentum by the day. While the level of aesthetic sophistication that one now witnesses on such occasions, courtesy the professional designers, ‘event managers’, etc., is admirable, I am filled with this longing to witness a wedding that is inspiring because of its simplicity rather than its grandeur.

In any case, marriage is a very personal affair (which is why one wonders why it has to be such a public event), so perhaps people should do whatever makes them happy on that special day and hopefully in the days that follow.

It is this latter part of the marriage that is actually more important but often the least planned or anticipated. Somehow, it is the unrealistic expectations we nurse that lead to failed relationships and many a ‘fairy tale’ marriage has ended on a tragic note. Perhaps there is no magic formula to ensure a happy marriage, but there is greater hope for happiness for those who believe in an unpretentious lifestyle and whose relationships are built on genuine affection rather than on a forced sense of social obligation or ulterior motives. Unconditional love is, no doubt, the most essential ingredient not only for those ‘tying the knot’, but also for the other family members who interact with the couple and vice-versa. With love comes forgiveness, and this is indeed important, considering that relationships and circumstances can never be perfect or as smooth as we would like them to be. In fact, keeping expectations at a minimum level is a pretty wise thing to do.

The essence of happiness and inner peace lies deep within our own selves and unless we cleanse and beautify what lies inside our souls, no amount of outer beautification, be it in our attire or our physical surroundings can help us. May God grant us the wisdom to bring out the best within ourselves and of those with whom we love. — SAIRA DAR