Talking doctors
Doctors appearing on TV shows need a code of ethic
By Adnan Adil and Zafar Omer
The advent of electronic media has brought to people wider access to information. But in the process it has also caused some problems: Take medical advice given to television viewers sitting at homes.

RIPPLE EFFECT
Thought control
By Omar R Quraishi
In Pakistan, the minute you start writing objectively and/or critically of the state and specifically the military establishment's policies, you are branded as a traitor -- as someone who is playing with the country's integrity and giving the country a bad name. A good example of this is what happened to journalist Hamid Mir when he wrote an article for this newspaper in which he made the rather shocking revelation that one top jihadi killed in a recent drone attack in Waziristan, Ilyas Kashmiri, was a former SSG commando.

As the Parliament debates the Kerry Lugar Bill and, in a unique development, the army high command expresses its "serious concerns" after a corps commanders meeting, The News on Sunday tries to bring out the political economy side of the argument. This is not a set of for and against interviews as it may appear. Broadly speaking Kaiser Bengali supports the bill while Sartaj Aziz does not outrightly oppose it. Both interviews explain the bill and its context in simple words

"I am okay with the conditionalities"

-- Member National Finance Commission Kaiser Bengali

The News on Sunday: What does Kerry Lugar bill do for Pakistan in economic terms?

Kaiser Bengali: It's very simple; it gives us foreign exchange. There is a need for support because of Pakistan's own fiscal situation.

I fully support the bill as well as the conditions. I don't know about the 1960 and 1970s but 1980s onwards, the interests of the United States and the people of Pakistan were completely divergent. Today they converge. The US wants to end terrorism and so do our people. So any condition that the United States puts on the Pakistani state to effectively counter terrorism is very welcome.

TNS: But there is huge opposition to the bill from political parties and the media.

KB: I think this opposition is misplaced. We have to realise the pitiable state Pakistan has been brought down to by successive governments, particularly the military regimes. When individuals who were actually part of the Musharraf regime say that US will come to us begging on its knees, it is absolutely laughable.

Of course, no one gives money without conditions; some of these we may not like. As for sovereignty, Pakistan effectively lost it in the 1980s. And when our political leaders including Nawaz Sharif and Shahbaz Sharif went to the United States and Saudi Arabia asking them to bail us out, they had already bartered our sovereignty.

TNS: Having lost the sovereignty does not mean we have no chance to regain it?

KB: You don't regain your sovereignty when you are on your knees which we are right now. I certainly would like us to be a respectable nation and I have always been a vocal opponent of the role of US in Pakistan over the last twenty years. The US secretary of state has actually acknowledged the US responsibility. I feel there is a genuine change within the power structure of the US.

The important thing is there are elements within the Pakistani state that support terrorists and the political government cannot fight these elements without external support. I acknowledge that these external elements helped create these bastions of terrorism. But now that they are extending their help to dismantle it, we should not turn it away.

TNS: In effect you are saying that these conditionalities are good for democracy in the country?

KB: They certainly are. They have clearly said that military intervention will not be accepted. They have put certain conditions about non-proliferation. The democratic forces in Pakistan have always supported non-proliferation. We are opposed to the nuclear programme; although on practical grounds, India forced us into a corner. India is responsible for nuclearisation of South Asia.

I would strongly oppose some of the conditions under normal circumstances but these are not normal times. We are at war; there is fifth column inside the state and we do need external support.

TNS: People are comparing this aid package with other such legislations like the Pressler Amendment after which the US turned its back on Pakistan?

KB: That is always possible. The US is doing it for its own interests, not for our interest. No country does it for the other country. But I don't see American interests changing in the short or medium term. We should use this opportunity -- these five to seven years of funding -- to rebuild our economy, to build up our economic assets. My disagreement is with the manner in which these funds will be used. A lot of money is coming for social projects. That is a mistake. Health and education are rupee expenditures; we should finance them out of our own resources by cutting on other expenditures.

Over the last ten to fifteen years, a lot of foreign assistance, primarily from the World Bank, has come in the form of budgetary support. If the government has a budget deficit, that assistance covers it. This way a major part of our domestic debt has become external debt.

The correct principle is that you take foreign exchange loans for financing foreign exchange needs. If you take foreign exchange loans to finance rupee expenditures, then the pressure on the government to economise on wasteful expenditure is no longer there. This is a big problem in Pakistan's economy. When you take loans that you are not using to create economic assets, you are not creating a new flow of income and your ability to repay the loan is not there.

In the 1950s and 1960s, we used loans to create infrastructure like Mangla Dam, Tarbela Dam, Steel Mill, highways, Heavy Mechanical Complex. If you look at the data, there were quantum jumps in output. We should use this money from Kerry Lugar and FoDP to build economic infrastructure. For rupee expenditure, we should cut the size of government and the unnecessary defense expenditure.

TNS: What is the actual flow of aid? It is being said that the amount that eventually reaches Pakistan will be very little?

KB: I have not seen the figures or how this aid is structured. But generally all aid is structured in a way that a major part of it goes back to the donor country. The Japanese aid is the strictest in this regard. But the point I am trying to make is that if you want the money, you will have to accept the conditions.

We have to build the economy to a stage where we are not dependent on foreign aid. Our economy cannot survive without foreign exchange inflows.

TNS: There are varied reports as to whether this aid will be spent through the non-governmental sector or the government sector?

KB: I don't know the factual situation but I would strongly recommend that the money should be channeled through the government of Pakistan.

The problem that the government today faces is that its writ is weakened by the creation of a large number of non-state actors. Taliban and al-Qaeda and Lashkar-e-Jhangvi are not the only non-state actors. There are organisations like Poverty Alleviation Fund and NRSP and NGOs who have become like powerful states with budgets that are larger than ten ministries put together. We have created non-state actors that have weakened the writ of the state. More competent civil servants take leave and join these projects, and then they interact with their own ministries on behalf of these projects. This is actually undermining the state.

What the US must realise now is that by going around the government, they are weakening the core state. And then they expect the state to tackle the Taliban!

TNS: Then there will be the issue of credibility of the government which is stated to be corrupt?

KB: There is a bunch of people in this country who have made a career out of corruption-bashing. A lot of people have made money out of the corrupt system introduced in this country since the 1980s. The consultants get the 600-800 dollar per day consultancies out of the foreign money that has come, these are the consultants who have made money by doing studies on poverty. Consequently, their bank balances have improved but the poor have remained where they are. And they are the ones who then scream about corruption. We have made laws where large sums of money go into the pocket of rich. But that is not defined as corruption. This corruption mania is the fetish of the coffee-pary elite, who will not do anything themselves to give away a part of their privileges to the people.

TNS: This aid is supposedly about social development. Do you think we have a social development policy plan in this country?

KB: No we don't. There is no policy. Since the 1980s the governments in Pakistan stopped making policies. I say this from experience. Whenever we talk about policies, policy is laid down by the donor along with the loan.

TNS: You claim to support the bill. If the government does not have a plan, how is the money going to be spent?

KB: That's where I have my reservations. The government does not seem to have a plan and the donors -- whether it's the World Bank or the USAID -- are taking us on a path which is not going to help us. It is going to be a lot of money floating around in the next five years but ten years down the road we'll again be going before the world with a begging bowl, expecting it to bail us out. We should use this money to create economic assets so that there is a large flow of income, manufacturing sector takes a boost and our exports increase. That has to be the basic principle of policy.

TNS: What is the alternative to Kerry Lugar Bill?

KB: In the short term there is no alternative. I had said in 2006 that Pakistan will have to go back to IMF. The way our import and export bill and capital flows were going, it was easy to see this would happen. But no one believed me. Dr. Ishrat Hussain, then Governor State Bank, said I had forgotten my economics. I didn't like going to IMF but there was no choice. Whatever conditions IMF had put, we had to accept.

Similarly now we have no choice. For every dollar worth of goods that we export we import two dollars worth of goods and this is apart from the debt repayments. The economy cannot survive in this way. We need serious economic restructuring. We should use this money as bridge financing. Once the economic base is strengthened and our economic survival is not dependent on aid, then we will have the luxury of accepting or rejecting conditions.

The News on Sunday: Kerry-Lugar Bill is widely criticized in Pakistan. Do you think the criticism is justified?

Sartaj Aziz: The underlying objective or purpose of the Kerry-Lugar Bill is to develop the Pakistan-US relations on more stable and sustainable lines. Interestingly, through the Bill, the US gives an indication that it is pursuing a long term, not year-to-year, relationship with Pakistan. This is probably to dismiss the apprehension of the 1990s when the US deserted Pakistan after the Russians left the scene. The other objectives outlined in the Bill -- such as combating terrorist groups, dismantling nuclear supply networks, ensuring democracy, continues are Pakistan's objectives too.

So, basically the Bill is desirable -- because the two countries are pursuing more or less common objectives. But the nature of conditionalities and the manner in which the US secretary of state is supposed to report on the implementation of the Bill is in line with Pakistan's national interest. Therefore, if the civil society and the political circles are criticizing the Bill based on the prescribed conditionalities then they are quite justified.

Also the decision to take the bill to parliament is the right one. In fact this bill has been on the books since May-June, 2009. It is not something that has come out of the box suddenly. The government should have realised the sensitivity of the issue and presented it to the parliament earlier this year. It could have then negotiated with the Americans in the light of the parliamentary guidelines.

TNS: Which conditionalities outlined in the Kerry-Lugar Bill worry you most?

SA: There is a formidable list of requirements on which the US wants monitoring. Take Section 302 on Monitoring Reports, which requires the secretary of state, in consultation with the secretary of defense, to submit to the "appropriate congressional committee a report that describes the assistance provided under this Act during the preceding 180-day period". The Section contains further details that are alarming: A total of 15 points iterate the method of monitoring, which includes surveillance of "incidence or reports of waste, fraud and abuse of expenditure", "an evaluation of efforts undertaken by the Government of Pakistan to disrupt, dismantle, and defeat al Qaeda, the Taliban, and other extremist and terrorist groups in the FATA and settled areas", "eliminate the safe havens of such forces in Pakistan", "prevent attacks on neighbouring countries", "increase oversight over curriculum in Madrassas", "a detailed description of Pakistan's effort to prevent proliferation of nuclear-related material and expertise", "the process of promotion of senior military leaders"...

The monitoring requirements apply to all assistance including security, economic and social. The question is: How can a foreign government monitor all these activities for 1 to 1.5 billion dollars a year? And I have yet to see an administration in Pakistan fulfill these reporting requirements. It's impossible. Undoubtedly, the reporting requirements are excessive and oppressive.

TNS: Do you think Pakistan will compromise its sovereignty/ national interest by accepting the Bill?

SA: It appears that the civil assistance strategy will be dictated by the US and Pakistan's national strategy will become irrelevant. For instance in Title III on Strategy, Accountability, Monitoring, and Other Provisions, the Bill states a complicated set of planning, reporting, auditing and accounting. Documents are included to ensure that Pakistan utilises the aid as per the desires of the US. It lists civil liberties, rule of law, control corruption, immunisation rates, public expenditure on health, girls' primary education completion rates, expenditure on primary education, trade policy, inflation control, etc.

Again while iterating the Comprehensive Regional Strategy Report, the Bill says the "President shall develop a comprehensive interagency regional security strategy to eliminate terrorist threats and close havens in Pakistan…" It basically transfers the responsibility of dealing with the objectives to the US.

To my knowledge, and in Pakistan's 40-year history of receiving aid, the normal practice was to present Pakistan's plans, programmes and projects to donors and based on that an aid agreement was drafted. Effectually it is always the country's prerogative to ascertain the requirements and needs. Donors cannot prepare a plan or a strategy. However, in case of the Kerry-Lugar Bill seemingly US will be outlining our priorities and strategies. This I find very troublesome.

TNS: Is it likely that the Pakistan government uses the aid to overcome the budgetary deficit?

SA: Presently, Pakistan's total expenditure is 25 billion dollars. If Pakistan is lucky to get 1 billion of the 1.5 billion dollars pledged by the US through the Kerry-Lugar Bill, it will constitute only 4 percent of the total expenditure -- which can easily be covered by increased remittance (already expected to be $2 billion higher this year), and the rest can be covered by cutting the non-development expenditures. If the spirit of self reliance prevails we can very easily do without the Kerry-Lugar Bill.

Yet, the truth remains that the government is desperate for budgetary and balance of payment support. I do not foresee Pakistan to meet its tax targets either. Our exports are low. But in the longer run budgetary support can go into the development budget; for instance in education and health, in income support programmes. Budgetary support does not mean that it should all go in the non-development budget.

TNS: What would be the best possible mechanism for the disbursement of aid?

SA: My priority for social sector would be that more than half of the aid allocation should be transferred to the provinces, so they can prioritise their needs and spend accordingly. The federal government can prescribe how much of the allocated funds be spent on private and public sector. It'll be a mess if foreign contractors and consultants are brought in to do the job. Organisations such as USAID can be involved in the monitoring and evaluation within the framework provided by the government.

But in the process we must not spoil our relations with the US. Hopefully after an intensive parliamentary debate Pakistan will be able to convey to the US that while we share the objectives, we do not need such a comprehensive framework as one outlined in the Kerry-Lugar Bill.

The true irony lies not in the fact how trade deficit, economically challenged or politically unstable our country is. It lies in how vitamin D is not penetrating down into the bones of the individual Pakistani. Vitamin D deficiency has taken its toll and is rising in Pakistan.

Vitamin D comes from two sources: endogenous, which is produced in the skin on exposure to sunlight, and exogenous, which is ingested in foods and supplements. Unfortunately the dietary source of vitamin D is negligible. The only foods rich in vitamin D are fish, egg yolk and cod liver.

This vitamin is biologically inert and must undergo two hydroxylation reactions in order to be activated in the body. Calcitriol (1.25 Dihydroxycholecalciferol) is the active form of vitamin D found in the body. Its deficiency is caused by the lack of achieving it through dietary sources, poor sunshine exposure and also because of skin pigmentation. The darker your skin, the harder it is for UV-B rays to penetrate through it and produce vitamin D -- thus increasing your need for sunlight exposure.

It indeed is humiliating for the inhabitants of a country that enjoys four seasons, receives ample sunlight to suffer the deficiency of vitamin D. When TNS surveyed a few laboratories in Lahore, it found that number of people coming in for 25-hyroxy Vitamin D test has increased drastically over a period of past six months. Labs which ran this test on a routine basis are now using batches. Looking at the spreadsheet data of the number of 25-hyroxy Vitamin D tests that had been conduced in the past one month, Chughtai's Lahore Lab manager said that there is an overall increase of 20 percent each month. A test which costs between Rs.1800 to Rs.2000 is suddenly becoming an essential for those who have been hit by the awareness tide.

Mehrunnissa* was diagnosed as a vitamin D deficient patient after going through a long period of discomfort -- visiting doctors as her "achy feeling" seemed to have no cure. Later she found out that all she required was a dose of vitamin D. "After the dose I was up and on her feet," she recalls.

Mehrunnisa's children complained of the same "achy feeling". She took them in for the same test, and lab results disclosed that they were also vitamin D deficient. Now they are all taking supplements and bridging the gap to the healthy life. "I suggest everyone should get the vitamin D test done if they have any pain in their bones because there is nothing more important than living a quality life," she says.

TNS visited GNC, an international chain that specialises in vitamin supplements, to inquire about the sales of vitamin D supplements. It found out that its sale has significantly gone up. "We used to have one or two customers who would come up and buy vitamin D supplements in three or four months but now we have more then ten people buying these supplements every month," says the salesman.

Dr. Farah Shafi, associate professor at Services Hospital Lahore, says that the main reason of this deficiency is lack of its intake through dietary sources. "As there is limited variety of food from where we can choose to get vitamin D; patients either ignore it or cannot afford it," she informs. She also adds that patients living in crowded streets of Bhati gate and Lohari gate don't receive ample sunlight as the streets are incredibly narrow and there are too many shades. Women living in rural areas have restrictions on leaving their houses and are strictly asked to stay in pardah are also prone to be deficient in vitamin D.

Diseases caused by vitamin D deficiency are Osteomalacia, a bone-thinning disorder, Osteoporosis, a condition characterised by reduced bone mineral density and increased bone fragility Rickets, a childhood disease characterised by impeded growth, and deformity, of the bones. Research shows that even weak sunscreens (8 SPF) block your body's ability to generate vitamin D by 95 percent. This is how sunscreen products actually cause disease; by creating a critical vitamin deficiency in the body while we are too busy preventing our complexion from darkening.

The recommended daily intake of vitamin D is 200 international units (IU) for people up to 50 years old. The recommended daily intake of vitamin D is 400 IU for people 51 to 70 years old and 600 IU for people over 70 years old. The nutritional guidelines for vitamin D intake must be carefully re-evaluated to determine the adequate intake, balancing sunlight exposure with dietary intake, to achieve good health.

The increase in the patients suffering from vitamin D deficiency in Pakistan where the sun never forgets to shine is troubling. The reason is that even if you get enough sunlight and your body is malnourished there is no use as vitamin D has to undergo two hydroxylation reactions in order to be activated in the body. This cannot be achieved without proper nourishment. It is about time that an average Pakistani knows the importance of vitamin D and the havoc its deficiency can play. Vitamin D is one of the most powerful healing chemicals in our body. If you are experiencing pain in your bones, go to a nutritionist, start eating healthy and if recommended get yourself tested. Quality of life is essential. Roger that!

*Name has been changed to protect privacy.

The advent of electronic media has brought to people wider access to information. But in the process it has also caused some problems: Take medical advice given to television viewers sitting at homes.

Some people turn to medical websites through the internet to obtain medical information. The recourse to the medical websites is actually resulting from a lack of required communication between patients and doctors. A doctor's failure to communicate well with patients about his or her ailment leads many people to turn to websites designed to provide medical information. This, in fact, has become a major problem.

Taking cue, the electronic media has started airing talk shows that invite doctors to give general medical information on common ailments and their treatment. This if anything gives publicity to doctors.

A doctor's word is considered near-gospel truth; he is an institution, standing between the ill person and the Almighty. This places additional responsibility on his shoulders while appearing on the television screen. The viewers on the other hand must keep in mind that doctors writing in the daily press or expressing their opinions in public through television channels have always been small in number. It is generally believed that a doctor with a flourishing practice will have no time to appear on TV. So, are the ones appearing in talk shows mediocre?

Sometimes the doctor's incompetence becomes obvious when asked a question on a slightly complicated disease or health problem. This is when the anchor person comes to his rescue with his half-baked information.

But this phenomenon is not specific to Pakistan. Media the world over finds it difficult to invite competent and authentic doctors on screen.

There is a way to get out of this situation: One solution is establishing a proper training institute for television and radio comperes, where they can be trained in ethics of conducting medical programmes. These doctors must be instructed not to give clinical advice or suggest preventive methods to a questioner. Also, before suggesting a treatment and diet they must first conduct a detailed interview of the patient.

We must bear in mind that doctor's each word matters. He must refrain from passing dogmatic judgments. The motto must be: caring with curing. The uncalled for and irresponsible remarks of doctors can make viewers apprehensive and hypochondriac which could have far-reaching impact on the public health.

It goes without saying that doctors have every right to present their point of view on TV but would be an unethical practise on the doctor's part to invite viewers for private consultation at their private clinics -- they cannot use media to advertise and market themselves.

It is unfortunate that this unethical practice is in vogue even in the so-called developed countries of the West, and is being emulated in countries like Pakistan. Basically, Pakistani media needs to formulate a code of ethics for programmes on health so that they can be useful for public by imparting them basic information on the topic and should not create panic or uncalled for worries among viewers.

In Pakistan, the minute you start writing objectively and/or critically of the state and specifically the military establishment's policies, you are branded as a traitor -- as someone who is playing with the country's integrity and giving the country a bad name. A good example of this is what happened to journalist Hamid Mir when he wrote an article for this newspaper in which he made the rather shocking revelation that one top jihadi killed in a recent drone attack in Waziristan, Ilyas Kashmiri, was a former SSG commando.

This got a response from a man by the name of Adnan Jehanzeb who basically tried to call Hamid Mir unpatriotic and alleged that he was motivated by considerations that seemingly were more sympathetic to Pakistan's enemies rather than Pakistan itself. In other words, the journalist was being called a traitor – because he had, in his (Hamid Mir's) estimation – exposed the fact that several of today's jihadis have had very close ties in the past with the state and the military establishment. Now, this is not exactly a revelation and if correct – since there should be little reason to doubt what Hamid Mir wrote – such reporting of events and things only makes things more transparent in the country.

Many readers may not be aware of the links that have existed between the state and various non-state actors in the past (some people say that these links continue to exist, albeit in a more tenuous state now perhaps) and such reporting makes them clear to the general public. Also, publication of the said report at a time when the country is battling extremists and militants in much of the northwest is crucial towards making the general public aware of the dangers of having a state policy that mollycoddles or appeases any section of the extremists for perceived gain against countries deemed to be our enemies. Hamid Mir's reply was quite to the point and contained two important rebuttals. One was that he was asking the man who had written the letter that on what authority was he denying that Ilyas Kashmiri had never served in the army. The second point was that he had advised the man to write under his real name next time, indicating his view that the man had written under an assumed name.

And now coming to another case of thought control -- and this comes from far away Norway. It involves a female scholar and researcher from Pakistan at the University of Oslo. She has managed to make quite a name for herself while writing on terrorism, security and NWFP/FATA-related matters in this newspaper. After her last article, in which she alleged that the military establishment was looking the other way as the Taliban targeted an anti-Taliban lashkar in the Salarzai area of Bajaur Agency, her supervisor and director of a research centre at her university in Norway, quite shockingly, received an email from four students who said they were Pakistani researchers at the University of Essex. The woman (the one who occasionally writes for this newspaper's editorial pages) was kind enough to send me a copy of the email that her academic supervisor had received from the Pakistan 'PhD' scholar.

Sent on Sept 29, the four "scholars" (surely a true scholar would never indulge in this kind of nonsense) wrote that their intention was to bring to the department's (at the University of Oslo) notice a research fellow (the very one who forwarded me the whole exchange). As if to justify their sneakiness, the four also mentioned in passing that they had written to the said research fellow but had failed to elicit a response from her.

They wrote that the female researcher was "simultaneously [sic] bringing very bad name to your institution and the Pashtun community (which she claims to be belonging to)". They said that her research work was "loaded with bias [soc] and thus totally flawed". The interference was such that they suggested to the supervisor that the woman's thesis and research be vetted by someone who was an expert at the cultures that the woman was researching and writing on. They mentioned the woman's M.Phil thesis -- which they said was on women police stations in NWFP and which they than straightaway accused of being not a "piece [sic!] of research" but "propaganda literature". They also mentioned a recent article of hers, in which the researcher had made some factual error -- which when pointed out she had immediately apologized for -- and even went to the trouble of sending the Norwegian supervisor links of a rebuttal (also published in this newspaper -- in the letters' section). Suffice it to say that the original article was questioning the role of the security forces in fighting the Taliban in Bajaur Agency and that the rebuttal was sort of sympathetic to the point of view of the security forces.

The 'scholars' from Essex then went on to say that their endeavours were "purely academic" (yeah right!) and that they had nothing against the researcher. However, they said, they were "really hurt" (why do so many Pakistanis not know how to use this word?!) that she was unable to "project the real picture of her research area" and that she was becoming "a propaganda tool". They also went on to say that research was "never about your feelings only [sic]" and I can only wonder what in god's name that means. The four 'scholars' concluded by asking the supervisor to stop this research so that the dissemination of the "biased views" of the woman scholar at Oslo could be stopped and the name of the Norwegian institution where she was a researcher could be salvaged. They also claimed that by doing so the supervisor would prevent Pashtun society from being sullied!

Of course, a couple of things are clear. These four 'scholars' thought that the west works like in Pakistan where a motivated email or two, no matter how false or misleading, about a writer and calling his or her work against the national interest, or unpatriotic or biased, will prevent the publication and dissemination of such work. Surely, when they were going to the University of Essex to do 'scholarly' work they would, or should, have known that this isn't how things work in western academia.

Also, these 'scholars' did not know that by sending such emails they would be exposing only their own ignorance and idiocy. As one would expect, the University of Oslo centre's director wrote back -- the next day -- to them, saying that she had read the said article and that since she had "very limited" knowledge of Pakistan's domestic situation she could judge neither the article nor the comments sent by the four 'scholars'. She said that the article by the Pakistani researcher at the (Oslo) university had nothing to do with her topic of research. She also said that the researcher's work was being carried out under the guidance of experienced supervisors and that "it was assessed regularly on a scholarly basis. She concluded by saying: "What our researchers and PhD students write on other matters in the media are at their own responsibility and is not in our country seen as an issue for the university to which they are affiliated."