Numb to violence

NOT only has the spectre of violence across Pakistan terrorised the population, it has, conversely, also brutalised it. Far from taking steps to ward off its pernicious effects on mind and body, we have come to accept blood and gore as part of our daily life. Routine crime, armed guards, suicide bombings and the presence of millions of illegal weapons in the country are the most obvious manifestations of the culture of violence that now defines our society. But it is the sight of a growing number of children flaunting toy weapons, especially on holidays and festive occasions like Eid, that points to the shape of things to come. Children, taking their cue from computer games, TV programmes and indeed the general aggression around them, are growing up to be more numb to the effects of violence than adults who have known some peaceful times. Their pliable minds soak up more than just the blood that is being shed; they also imbibe the sense of drama and excitement that many TV programmes, including cartoons, impart in their depiction of violence. Equating fantasy with reality is the next step, and given that there is no getting away from the images telecast by local news channels showing the turmoil caused by militancy, the process has been a natural one.

Unfortunately, instead of attempting to mitigate its effects, the state has had a hand in actually eulogising the gun culture, thus contributing to distorted perceptions of violence. Patriotic songs of militaristic bent, the glorification of war heroes in our textbooks and frequent references to Pakistan as the only Islamic nuclear power have become part of the national mindset. Moreover, awareness and debate have made an appearance only now, thanks to the communications explosion in Pakistan. So far education for the lucky few has never been of the kind where children are taught to think for themselves, to analyse and to question what they see around them. In the context of violence and its different aspects, this has led them to accept aggression at all levels as part of their existence. Because of the virtual absence of child protection laws, many children are victims of physical and mental abuse themselves. This too has contributed to the process of desensitisation.

Merely paying lip service to the idea of peace will not do; the government has to be seen to be actively working towards it. At the school level this would mean drastically revising textbooks so that violent events stand out as a sober fact rather than a rallying cry for justice. At a more general level, this would require strong legislation to prevent violence at home, in school and at the workplace. Such steps would be a starting point in the exercise to make young minds shun violence and to realise that the world would be a better place without it.

Cheap roti, anyone?

BETWEEN supply and demand lies the government. This is how the market for wheat and wheat flour has been operating in Punjab for decades. But this equation is increasingly becoming unsustainable, if not redundant. The reason is simple: spending money raised through taxes to keep the prices of commodities under control is a flawed mechanism that seldom benefits the consumers. Two latest initiatives by the Punjab government explain why. Under the first initiative, the government subsidised every bag of flour produced and sold in the province to keep its retail price at Rs300 per 20 kilos. Meant only for the month of Ramazan, the scheme could not be sustained beyond a fortnight due to its enormous cost. The second one aimed at providing roti at Rs2 per piece. Set to continue throughout the year if official proclamations are anything to go by, this initiative is at best working only half as effectively as it should. Finding subsidised rotis in Lahore on Eid was as difficult as setting a consensus date for the festival itself. Even on ordinary days, tandoor owners use ingenious tricks to bypass official restrictions on the price of roti. One of their favourite is to bake more naans than rotis and the other is to complain that the official supply of subsidised flour is always much shorter than their actual requirement. Enforcement of the restricted price also remains uneven. While a few ‘sensitive’ areas in big cities like Lahore see regular inspections and police raids on those overcharging, the rest of the province remains a fiefdom of the profiteers.

No matter how significant these enforcement blues are, they are not the fundamental reason for the official inability to keep wheat and flour prices in check. It is the warped and convoluted system of providing subsidies that lies at the heart of the problem. With subsidies paid directly to millers and traders, and now to bakers, the government can only hope that some of them will eventually pass on the savings to consumers — something that seldom happens, if at all.

The net result is that tax-payers’ money used for subsidies ends up messing up market forces and creating artificial shortages even when there is plenty of wheat and flour to go around. The Punjab government will do well to find a newer, more direct and more effective way to reach out to those who cannot afford to buy their roti and flour at market rates. Old and flawed mechanisms will never achieve that.

Scourge of child marriage

IT is a fact that child marriage, far from being an anomaly, is the norm in many parts of Pakistan. Worse yet, a child bride’s life is further marred by violence at the hands of her new family. This was the unfortunate fate of Shahnaz, a 12-year-old girl recently rescued by police in Larkana from her ‘husband’, an alleged drug addict who tortured his ‘wife’. There are many variants of child marriage: some girls are sold into marriage just for the money, others are bartered to settle blood feuds or to compensate for crimes, while many fall victim to a medieval mindset that sees nothing wrong with underage marriage. The reasons why girls suffer disproportionately are all too familiar: negative social perceptions of the girl child; a patriarchal society afflicted by economic hardship and disparities; and resilient tribal traditions that have shunned modernity.

While certain segments of society may condone the shameful treatment of young girls, the law does not. In 1990, Pakistan ratified the UN Convention on the Rights of the Child, which prohibits child marriage. Also, under the Muslim Family Law Ordinance, a girl must be at least 16 years old and a boy at least 18 to marry and they both must give their consent free from any coercion. With depressing familiarity, however, the law has been largely overridden by custom. While lax enforcement by the police and weak oversight by the judicial system definitely shoulder a major portion of the blame, there is an additional problem: the difficulty in detecting child marriages. Unaware of their rights or cowed into submission, child brides often suffer in silence. Many, as in the case of Shahnaz, are sold or bartered by members of their immediate family. A well thought out awareness campaign in primary schools and at the grassroots level would help eradicate this scourge. Rescue centres and responsive helplines set up jointly by the government and NGOs familiar with local conditions are also needed. The time to act is now.

OTHER VOICES - North American Press

The vice-presidential debate

The New York Times

WE cannot recall when there were lower expectations for a candidate than the ones that preceded Sarah Palin’s appearance in Thursday night’s vice-presidential debate with Joseph Biden. After a series of stumbling interviews that raised serious doubts even among conservatives about her fitness to serve as vice-president, Ms Palin had to do little more than say one or two sensible things and avoid an election-defining gaffe.

By that standard, but only by that standard, the governor of Alaska did well. But Ms Palin never really got beyond her talking points in 90 minutes, mostly repeating clichés and tired attack lines and energetically refusing to answer far too many questions.

Sen Biden did well, avoiding one of his own infamous gaffes, while showing a clear grasp of the big picture and the details. He left Ms Palin way behind on most issues, especially foreign policy and national security, where she just seemed lost. It was in those moments that her lack of experience … was most painfully evident.

Asked about Israel, Ms Palin reeled off her support for “a two-state solution, building our embassy also in Jerusalem, those things that we look forward to being able to accomplish with this peace-seeking nation.” Asked about the possible use of nuclear weapons, she declared “nuclear weaponry, of course, would be the be-all, end-all of just too many people and too many parts of our planet.” On Iraq, all she had to offer was the false accusation that Barack Obama wants to surrender.

Mr Biden directly challenged Ms Palin’s debate prep on Afghanistan — pointing out that the commander there had disagreed with Mr McCain’s call for an Iraq-style ‘surge’ in Afghanistan. Ms Palin tried to contradict him, but the most memorable part of her answer was that she got the general’s name wrong….

Ms Palin’s primary tactic was simply to repeat the same thing over and over: John McCain is a maverick. So is she. To stay on that course, she had to indulge in some wildly circular logic: America does not want another Washington insider. They want Mr McCain (who has been in Congress for nearly 26 years). Ms Palin condemned Wall Street greed and said she and Mr McCain would “demand” strict oversight.

There were occasional, disturbing flashes of the old, pre-campaign Sarah Palin. Asked about the causes of global warming, Ms Palin suggested that man had some role — but she wasn’t saying how much. In the end, the debate did not change the essential truth of Ms Palin’s candidacy: Mr McCain made a wildly irresponsible choice that shattered the image he created for himself as the honest, seasoned, experienced man of principle and judgment. It was either an act of incredible cynicism or appallingly bad judgment. — (Oct 3)

Big pharma and physicians

Medicine is, at its centre, a moral enterprise grounded in a covenant of trust. — Crawshaw et al, 1995

GLOBALLY, concern is growing over the influence of the pharmaceutical industry on the prescribing habits of physicians.

Pharmaceutical companies are under intense pressure to garner and retain market share, leading the World Health Organisation (WHO) to refer to “an inherent conflict of interest between the legitimate business goals of manufacturers and the social, medical and economic needs of providers and the public to select and use drugs in the most rational way”. In the United States the pharmaceutical industry spends an estimated $25bn to $30bn every year peddling prescription drugs, and much of that money goes to physicians in the form of free samples, meals, conference fees, air fares and continuing medical education activities.

The pharmaceutical industry is adamant that these gifts have no influence on which drugs physicians prescribe to their patients. But a growing body of evidence shows that the drug companies’ generosity may in fact be guiding the pen across the prescription pad.

According to Dr Sidney Wolfe, director of the Public Citizen’s Health Research Group, USA, “The drug industry doesn’t spend $20 or $30bn a year on advertising prescription drugs unless they believe it has an impact on doctors prescribing”.

Alarmed by the influence of ‘big pharma’ on physicians, many US states have instituted laws requiring pharmaceutical companies to disclose all gifts to physicians in excess of $50. Many top US academic medical centres have placed various restrictions on their faculty vis-à-vis interaction with the pharmaceutical industry. Now a bill, the Physician Payment Sunshine Act, has been introduced in the US Senate that requires disclosure of all financial ties between physicians and pharmaceutical/medical device companies. This is to ensure greater transparency in an area that has become increasingly murky.

These steps have become necessary because of the inherent conflict of interest issues involved when physicians interact with the pharmaceutical industry. Pharmaceutical companies operate in a world of high stakes with potentially high returns on their investments. Recouping the money they have invested in drug research and development means using marketing techniques that will ensure increased sales. With billions of dollars at stake, companies do everything to get as big a share of the market as possible. The physician therefore becomes a crucial player in the process.

Unlike consumer products where the customer makes an independent, informed decision about a certain product, in the case of medicines the physician is the decision-maker for the patient. What influences a physician to prescribe a certain brand of drug depends on a number of factors, the critical one being his or her interaction with drug companies.

Numerous studies have shown that the more contact physicians have with drug companies the more likely they are to prescribe medicines produced by those firms as well as prescribe them inappropriately. Pharmaceutical companies know this and exploit it to the fullest. Today drug company representatives are highly skilled sales professionals whose training is generally company-specific and more oriented to the art of selling than to therapeutics.

In Pakistan, inducements range from items like diaries, calendars and ballpoint pens to more expensive gifts like briefcases, laptops, air conditioners and even cars. In addition there are drug launches in foreign countries, conference sponsorships and funding of private functions like weddings, etc. Many companies do this under the guise of ‘academic’ activities. Every interaction between physicians and pharmas is to one and one end only: to establish a relationship with physicians and use it to manipulate them to prescribe more of their drugs. There is no other motive.

On the other hand, a physician’s primary responsibility is to the patient. The doctor-patient relationship is a unique but unequal one. The former possesses the power, control and knowledge while the latter is in a vulnerable state due to his or her compromised health. This relationship is based on core features like trust, objectivity, impartiality and keeping the patient’s interest paramount at all times. The relationship must be free from all external influences.

When a physician prescribes a certain brand of drug to a patient, the patient believes the physician has done so keeping his or her best interests in mind. What patients do not know (and have no way of knowing) is what inducements a physician may have received from companies that may be influencing his prescribing habits.

All inducements from pharmaceutical companies to physicians are legalised bribery. Physicians must be aware of this and not fool themselves into believing they are not influenced by gifts or company-sponsored trips. Even small gifts like coffee mugs, diaries and ballpoint pens have a cumulative effect over time and influence prescribing habits.

Today, the profession of medicine in Pakistan is suffering from a serious crisis of integrity. The health system of the country is in shambles. Millions of Pakistanis continue to be devoid of healthcare and countless others suffer the indignity of being treated in poorly resourced public hospitals and subjected to unregulated medical practice, without any recourse to complaint. There is no authority where patients can take their complaints. Against this background the onus on physicians to conduct themselves ethically becomes paramount.

Physicians must stop taking the easy option of approaching pharmaceuticals for funding their activities, be it attending or arranging conferences or getting something for their units like a water cooler. For many companies Corporate Social Responsibility (CSR) has become a euphemism for this kind of bribery. They promote CSR because of the huge profits they make by bribing doctors to prescribe their medicines.

In Pakistan, patients pay out of their own pocket for drugs. So every time a physician is sent on a foreign trip or a foreign speaker is brought to Pakistan by a pharmaceutical company, patients are funding these activities.

Physicians must remember that interacting with pharmaceutical companies causes serious conflict of interest and has the potential to compromise patient care. Hence they should think carefully about seeing medical reps, accepting gifts, going to conferences or organising seminars with pharma money. Unless physicians take this ethical stance, the exploitation of one by the other will continue. And patients will ultimately pay the price.

Above all, there is a need to get away from the culture of greed and profit that has pervaded the medical profession, particularly in Pakistan. Physicians need to take a deep, hard look at themselves and ask why they have been so willing to bargain their integrity for a few thousand rupees. While most things in life are relative, some are absolute. The physician-patient relationship is an example of the absolute variety.

Its sanctity must be maintained at all costs.

The writer is a consultant psychiatrist.

muradmk@gmail.com

Giving up children

AUTHORITIES in the United States are reeling from a sudden spate of children being abandoned by their parents and guardians under a new law that allows caregivers to leave any child up to the age of 19 at hospitals without fear of prosecution.

In Nebraska in September alone, 14 children were abandoned in hospitals and another was mistakenly taken to a police station, which is not covered under the law. In a further case, an 18-year-old presented himself for safe keeping, but was not placed in foster care because he was too old.

The case that has caused most attention has been that of a father who handed over nine of his 10 children aged 20 months to 17 years to hospital carers. They have been placed with two sets of relatives before their fate is decided.

In July Nebraska became the last of the 50 states to pass legislation designed to take criminality out of the abandonment of babies and infants, following a reported rise in such incidents. The process began with Texas, which enacted the law in 1999, and since then about 2,000 babies are thought to have been handed over nationwide.

The Nebraska law, however, went further than that of any other state in keeping loose the definition of those who could be relinquished by their carers. In most states, it was restricted to the early months of life, but in Nebraska it has been left open as any age up to 19.

The first to make use of the law was a woman in Omaha who tried on September 1 to part company with her 14-year-old son, saying she did not want to care for him any more. She made the mistake, under the terms of the legislation, of presenting him at Omaha police department.

— The Guardian, London