Dawn Editorials (with Summary and Vocabulary)

 

DAWN EDITORIALS

January 26, 2024 (Friday)

Day’s Vocabulary

• Smithereens.        small pieces
• Egress.         the action of going out of or leaving a place
• Colliers.      a coal miner
• Downtrodden.     oppressed or treated badly by people in power
• Dubious.     hesitating or doubting
• Dearth.        a scarcity or lack of something
• Bereft.          deprived of or lacking (something)
• Pedagogy.  the method and practice of teaching, especially as an academic subject or theoretical concept
• Exasperation.      a feeling of intense irritation or annoyance

Graveyards of coal

Summary

• Coal mines in Pakistan are extremely dangerous and lack basic safety measures.
• Over 300 coal miners die in Pakistan every year.
• Many mines are unregistered and unregulated.
• Miners often work without safety equipment like masks, shoes, and gas detectors.
• The government has failed to enforce safety regulations.
• The government is partly to blame for the dangerous conditions in coal mines.
• Government mine departments are corrupt and inept.
• The government has not updated mine safety laws since 1923.
• The government does not collect or publish data on coal mine accidents.
• Coal miners in Pakistan are exploited and abused.
• They are often paid less than the minimum wage.
• They do not have access to social security benefits.
• They are forced to work in dangerous conditions.
• They often suffer from health problems due to their work.
• The new government in Pakistan must take action to improve the safety of coal mines.
• This should include enforcing safety regulations, updating mine safety laws, and collecting data on coal mine accidents.
• The government should also work to dismantle the "deathly Bermuda triangle" of greedy mine owners, corrupt mine departments, and dysfunctional EOBI.

Article

Other than the oft-quoted figure of over 300 coal miners dying in Pakistan’s coal mines every year, the exact number of mines, their workforce, lives, deaths, injuries and EOBI registration is a wild guess. Anyone who smells coal in his backyard can hire a contractor equipped with a pickaxe, spade and two labourers to dig a cave that will sooner or later collapse and consume the finest but neediest children of Pakistan.

After years of futile attempts to obtain data on coal mines and linked tragedies, I began to create a database of mines and daily accidents from Jan 1, 2024. By Jan 10, at least eight deaths of miners had been recorded — this was just the data of some prominent mines. Newspapers reported less than half of these deaths. The government and mine departments remain silent. After all, these calamities are of their own making.

Pakistan is home to 186 registered and over 1,500 unregistered, unregulated, unsafe and contractor-operated coal mines. The mines offer less than the minimum legal wage, no EOBI benefits and no social security. What they do offer is the bright possibility of being blown to smithereens in methane explosions, or being killed by crumbling roofs and uncontrollable fires. Survivors find themselves loaded with carbon dust and affected by asthma, tuberculosis and blindness. Thanks to complicity among influential mine owners, greedy contractors and corrupt inspectors, the coal mines largely operate without gas detectors, wireless communication, ventilation systems, smart helmets, air blowers, oxygen supplies, alternative egress routes, rescue services, and personal protective equipment (PPE). The equipment used in mines such as motors, fans, plugs, sockets, lights, junction boxes and cables are mostly inflammable and often a source of ignition/explosion.

Over half the miners perform the hazardous task of digging without masks and shoes. The four provincial mine departments were recently asked under the Right to Information Act, to provide basic health and safety SOPS in coal mines such as checks, tests, responsibilities before entry and during mine operations, emergency procedures and egress, equipment specifications, training, gas testing procedures, communication protocols, rescue and medical facilities, mandatory PPEs, structural testing procedures, etc. Sadly, not a single department could provide this information or appeared to have any clue of this subject.

The tragedies are of the government’s own making.

While we whitewashed the old mine laws by changing their cover pages, Pakistan’s coal mines are essentially regulated by the Mines Act, 1923. If there had been even an iota of interest or professionalism, our archaic mines departments could have simply adopted (with only minor changes) and implemented the 187-page ILO code for safety and health in coal mines, which provides for a complete safety management system. This would, however, call for either the replacement or massive training of existing mine officials and inspectors.

The other essential task for mine departments ought to be to conduct physical surveys and place updated data of the GPS location, output, workers, EOBI registration, accidents, injuries, and deaths of all coal miners on their respective websites. This is also a requirement under Pakistan’s right to information laws.

Sadly, over 90 per cent of coal miners are not registered with the EOBI. This is an unforgiveable failure of the institution. Describing the miners’ exploited lives, the secretary general of the Pakistan Central Mines Labour Federation said, “They usually start working at the age of 13 and by the time they reach 30, they are forced into unemployment due to chronic respiratory illnesses, tuberculosis, loss of eyesight, and injuries.” Also deprived of EOBI benefits, the pension-less coal mine retirees are driven into a life of misery, poverty, and dependence.

The government’s tolerance of the almost total absence of health, safety, labour and EOBI regulations is inexplicable. It amounts to deliberately pushing Pakistan’s children into hazardous death traps without the provision of masks, goggles, gloves, shoes, gas detection, communication, or recovery systems. Just one village of Pakistan, Shangla, receives over 50 dead and over 200 crippled bodies of coal miners every year. Why has our collective conscience not rebelled against this exploitation, cruelty and neglect that leads to about 300 innocent colliers dying every year. The first task for the new government in Pakistan ought to be to dismantle this deathly Bermuda triangle of greedy mine owners, corrupt and inept mine departments, and dysfunctional EOBI. Caring for the well-being of downtrodden citizens is the key to a progressive and prosperous Pakistan.

Intersectoral health

Summary

• Healthcare systems can act through three approaches:
• Preventing diseases and promoting health at population and individual levels.
• Providing curative health services at an individual level.
• Intersectoral action addressing the determinants of health.
• Distal determinants of health include:
• Peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity.
• Proximal risk factors for health are grouped into two categories:
• Environmental risks: lead and other chemical contamination, climate change, occupational hazards, unsafe roads and vehicles, outdoor air pollution, indoor air pollution, unsafe water, and poor sanitation.
• Behavioural risks: inadequate nutrient intake, excessive nutrient intake, suboptimal breastfeeding, risky sexual behavior, physical inactivity, tobacco use, harmful alcohol use, harmful use of injectable drugs, and other addictive substances.
• DCP-3 has proposed a package of 71 essential intersectoral interventions to meaningfully advance universal health coverage.
• Over half of Pakistan’s total burden of disease is attributed to behavioural and environmental risks.
• The major behavioural risk factors are child and maternal malnutrition, dietary risks, and tobacco use.
• The major environmental risk factors are air pollution, unsafe water and sanitation, and occupational risks.
• Pakistan has developed a draft ‘Health Related Intersectoral Interventions Action Plan 2022-30’ consisting of 30 high-priority interventions recommended by DCP-3.
• The Action Plan will be implemented in a phased manner and will involve seven ministries.

Article

In my last column, I discussed the Essential Health Services Package (EHSP). I mentioned that healthcare systems act through three approaches: by preventing diseases and promoting health at population and individual levels; by providing curative health services at an individual level; and through intersectoral action addressing the determinants of health. All three are interconnected.

This is what we know about the third aspect — intersectoral health interventions.

The WHO Constitution (1948) and Ottawa Charter for Health Promotion (1986) have mentioned peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity as fundamental prerequisites. These are considered the distal determinants of health.

According to the DCP-3 (Disease Control Priorities), the more proximal risk factors are grouped into two categories: environmental and behavioural. Environmental risks include lead and other chemical contamination, climate change, occupational hazards, unsafe roads and vehicles, outdoor air pollution, indoor air pollution, unsafe water, and poor sanitation. Behavioural risks to health include inadequate nutrient intake, excessive nutrient intake, suboptimal breastfeeding, risky sexual behavior, physical inactivity, tobacco use, harmful alcohol use, harmful use of injectable drugs, and other addictive substances.

There are 30 high-priority intersectoral health interventions for Pakistan.

If not controlled, these risk factors result in a plethora of infections, injuries, cancers, cardiovascular, respiratory and other non-communicable diseases, and mental, neurological and substance use disorders.

Assessing the magnitude of health loss due to specific health risk factors is a complicated process. However, in 2015, it was estimated that one-fourth or more of the 57 million deaths globally could be attributed to one or more behavioural or environmental risk factors.

As specific evidence-based examples, air pollution studies have estimated life expectancy losses of 3.3 years in India in 2015 and 5.5 years in northern China. Losses from unsafe water and sanitation in Mexico were estimated to be one year. Tobacco studies have estimated that smokers in India, Japan, the UK and US have their life expectancy lowered by about 10 years in comparison to their non-smoking peers. Likewise, a US study estimated that physical inactivity, defined as sitting for more than three hours a day, decreases life expectancy by three years.

Among the distal determinants of health, interestingly, education level has a much higher impact on health than income level. In 2017, a study concluded that about 14 per cent of the decline in under-five mortality between 1970 and 2010 resulted from improvements in education levels. Likewise, about 30pc of the decline in adult mortality resulted from improvement in education. Female education was found to be much more important than male education in reducing child and adult mortality.

In order to meaningfully advance universal health coverage, DCP-3 has also proposed a package of intersectoral interventions along with 218 essential health services.

The DCP-3 intersectoral package consists of 71 essential policy/ fiscal interventions. These interventions are health taxes and subsidies, regulations, built environment (roads, parks, buildings, etc) and information provision. These four kinds of interventions are made in five risk domains: addictive substance use, diet, environment, injuries, and others. Out of these 71 essential interventions, 29 are shortlisted as the highest priority.

The analysis of health risks in Pakistan, conducted by the Global Burden of Disease Study (1990-2019) by the Seattle-based Institute of Health Metrics and Evaluation, informs us that over half of Pakistan’s total burden of disease (53.5pc of total DALYs) is attributed to these risks. DALY is a metric that stands for Disability Adjusted Life Years, which presents years of life lost due to premature death plus years lived with disability.

Among the behavioural risk factors, child and maternal malnutrition is at the top (68.4pc), followed by dietary risks (13.2pc), and tobacco use (12.6pc). Forty per cent of stunted children under five reflect this particular behavioural risk. For the environmental/ occupational risk group, the major contribution to DALYs result from air pollution (64pc), followed by unsafe water, sanitation, handwashing (28pc), and occupational risks (8pc). The 2020 World Air Quality Report ranks Pakistan as the second-most polluted country in the world; Lahore has the dubious distinction of the top polluted city in the world. Air pollution exposure is responsible for 15.7pc of the total deaths in Pakistan each year.

Risks related to unsafe water, and sanitation (including handwashing), are the third highest contributors of BoD (burden of disease) in Pakistan responsible for 79,813 deaths annually.

Occupational risks in Pakistan contribute to 22,690 deaths annually, out of which around 44pc are due to injuries at the workplace, 37pc due to occupational particulate matter, gases, and fumes, 12pc due to occupational carcinogens and 6pc due to occupational asthmagens. Lead exposure contributes to around 21,167 deaths annually in Pakistan.

The burden of injuries in Pakistan has increased from 10,641 per 100,000 in the year 2000 to 13,885 per 100,000 in 2019. Of these, more than one-fourth (27pc) are transport-related injuries; 31m injuries during 2019 resulted in 85,346 deaths, out of which 20,747 deaths were related to road accidents.

In Pakistan, the development of a package of intersectoral health interventions was part of our vision. After completing the development of EHSPs at the federal and provincial levels, the Health Planning, System Strengthening, and Inf­ormation Analysis Unit at the Ministry of National Health Service, Regulation and Coordination continued the work on the intersectoral package.

A draft ‘Health Related Intersectoral Interventions Action Plan 2022-30’ consisting of 30 high-priority interventions recommended by DCP-3 has been developed. Considering COP26 commitments, the intervention of the Climate Resilient Health System has been added. The package is to be implemented in a phased manner and will involve seven ministries including Nat­ional Health Service, Regulation and Coordi­nation (10 interventions), Climate Change (10), Planning, Development and Special Initiatives (4), Education (2), Communications (1), National Food Security and Research (1), and the National Disaster Management Authority (1).

MHPSS roadmap to KP

Summary

• The Ministry of Planning, Development and Special Initiatives (MoPD&SI) is piloting a project to integrate mental health services into primary care in Khyber Pakhtunkhwa (KP).
• The project involves training primary care physicians to manage common mental disorders and providing them with online supervision and support.
• Over 400 cases have been reported on the project's web portal so far, with the majority of patients being under the age of 40 and female.
• The most common diagnoses are depression, stress, and grief.
• There is a severe shortage of mental health specialists in KP, with only nine districts having any psychiatric services.
• **The MoPD&SI is working to develop a system for scaling up mental health services in primary care, including:
• Registering doctors
• Providing standardized training tools
• Providing supervision
• Evaluating and monitoring performance
• Developing a referral mechanism
• Collecting vital data**
• At the provincial level, mental health needs to be identified as a priority public health issue.
• A coordinating mechanism is needed between the health department, humanitarian agencies, and development partners.
• At the tertiary care level, a team of trainers needs to be selected and trained to build the capacity of doctors in primary care.
• At the district level, it is important to:
• Carefully recruit doctors for training
• Include common mental disorders in the information management system
• Make basic psychiatric medication available at primary healthcare facilities

Article

In early November last year, a primary care physician from Chitral reported a case on the Mental Health and Psychosocial Support (MHPSS) web portal of the Ministry of Planning, Development and Special Initiatives (MoPD&SI). The case pertained to a 30-year-old married woman who had been unwell for 16 months. The patient’s family had sought advice from a few aalims and pirs, spending Rs50,000 without any relief. The patient had also made seven trips to Peshawar to consult a handful of psychiatrists and a neurologist, and even travelled to a major hospital in Karachi to seek help, incurring a total cost of Rs400,000, multiple psychiatric medications with associated side effects and a couple of mis-diagnosed labels.

Three days after the case was reported, the lady was assessed (online) by a psychiatrist from the MoPD&SI team in Islamabad and a diagnosis of a dissociative disorder was confirmed. Following this, the reporting doctor from Chitral was supervised to manage the case to rationalise the patient’s medication, and to support her and counsel the family. This supervision continued over the next three months. Today, the patient is symptom free — for the past seven weeks — and has resumed all domestic responsibilities. The reporting doctor feels confident about his skills to identify and manage such cases.

In 2023, approximately 100 doctors from Chitral, Haripur, Kohat, Lower Dir, Mansehra, Mardan, Nowshera, Peshawar and Swabi were trained under this project. The doctors received a five-day training in mhGAP-HIG guidelines (recommended by the WHO and UNHCR) to help non-specialists manage common mental conditions. These guidelines had been adapted for Pakistan’s cultural and healthcare context and published by the MoPD&SI. The trained doctors are now registered and thus connected to the web portal through a mobile application which systematically takes them through the assessment and management protocols described in the guide. Here, the doctors can share clinical information of the patients they manage and can also seek supervision when needed. So far, 400 cases have been reported on the portal, including vital demographic and clinical information. Over 70 per cent of people presenting with mental health conditions were under the age of 40; two-thirds of the total cases were women. Over half of all cases were diagnosed to be suffering from depression, with another 30pc suffering from conditions related to stress and grief.

This pilot project in KP is a part of the MHPSS work initiated by the MoPD&SI after mental health was identified as a critical but neglected aspect of healthcare in the country in 2021. Noting a huge mental health burden and severe dearth of specialist services, the ministry developed a model for delivering evidence-driven, rights-based and scalable MHPSS services across the country. This is a comprehensive multilayered model which aims to provide care in the community and at primary, secondary tertiary healthcare levels. The pilot was undertaken during the second half of 2023, in collaboration with the Directorate of Public Health in KP and supported by the International Medical Corps to build the capacity of primary care physicians in the selected districts.

At the provincial level, mental health has to be identified as a priority public health issue.

A situation analysis shows that KP has 37 districts with a population of over 40 million with at least 80pc living in rural areas. Only nine districts have psychiatric services, and some of these are limited to just one or two psychiatrists per district. There are no psychiatric services at the primary level. In addition to the expected prevalence of mental disorders, the province has borne the brunt of conflict and terrorism, natural disasters, internal displacements and a huge refugee population. It is estimated that at least 20pc of those living in KP need MHPSS services. In addition, worrying suicide rates have been reported in some districts such as Chitral and Parachinar neither of which have any psychiatric services.

At the same time, consider that the average district has at least 100 doctors working at the primary care level who are potentially a huge resource for providing MHPSS services. This is because, according to the WHO, 70pc of common mental disorders can be effectively managed in the primary care. This is where the MoPD&SI comes in. It has the technical expertise to develop, lead and scale up a system for integrating mental health into primary care services. This includes instituting a mechanism to register doctors, provide standardised training tools for training, provide supervision, evaluate and monitor the performance of trained doctors, develop a referral mechanism and collect vital data.

This is just the first step. At the provincial level, mental health has to be identified as a priority public health issue. A coordinating mechanism is needed between the health department, humanitarian agencies and development partners. At the moment, many projects are undertaken in silos with blurred and short-term outcomes. A clear direction needs to be set with focused objectives so that all resources can be pooled.

At the tertiary care level, a team of trainers need to be selected and trained for building the capacity of doctors in primary care. This is challenging because, one, specialists are already overwhelmed with teaching, clinical and administrative responsibilities; two, they are heavily invested in private work after official working hours; and three, there is no incentive for them to integrate mental health services into primary healthcare. Ideally, mid-career specialists who are motivated and interested should be incentivised into a specifically designed career path.

At the district level, finally, three aspects will be vital. Firstly, doctors need to be carefully recruited for training. Unfortunately, not all doctors may be interested in continuing professional education, or in providing mental healthcare. Younger, tech-savvy doctors interested in expanding their skills and likelier to have overcome stigmas associated with mental disorders will be suitable. It is crucial that women doctors too be targeted. Secondly, common mental disorders — particularly depression — must be included in the information management system. Thirdly, basic psychiatric medication especially anti-depressants must be made available at primary healthcare facilities, if this plan is to work.

She knew best

Summary

• Farida Akbar, a leading expert on Montessori education in Pakistan, has died.
• She was a strong advocate for giving children freedom of choice within a safe environment to help them discover their own potential.
• She believed that critical thinking cannot be taught but instead comes naturally to children if they are allowed to express themselves in their own language.
• She was a key figure in sustaining the Montessori pedagogy in Pakistan and served as a trainer of trainers and director of the Montessori Teachers’ Training Centre.
• She was deeply committed to education and generously shared her expertise with others.
• She was a versatile personality with a love of Urdu literature and intellectual activities.

Article

Why the hurry to leave? Why no farewells? Regrettably, we will never know. Farida Akbar, the best exponent of Dr Maria Montessori’s philosophy in Pakistan, is no more. She passed away on Jan 10, leaving her loving family, friends, Montessori fraternity and admiring students bereft.

Mrs Akbar’s unassuming and quiet personality concealed a beautiful mind that revealed itself when she spoke. Her knowledge of various social philosophers, the education systems in vogue and child psychology was phenomenal. Given her love of books and huge capacity to listen patiently to others made her what she was: an excellent and reassuring counsellor to parents and students alike.

Gool Minwalla, who studied the Montessori system from Dr Maria Montessori herself, founded the Pakistan Montessori Association in 1949. Mrs Akbar never tired of reminding us of the greatness of her mentor who had helped her discover the miraculous world of the child. Mrs Akbar already had two Master’s degrees — in psychology and education — when she obtained her Montessori diploma in 1975. There was no looking back thereafter. Having joined the PMA and emerged as Mrs Minwalla’s ‘right-hand woman’, she became the key figure in sustaining the Montessori pedagogy in Pakistan. She went on to become the ‘trainer of trainers’ and was appointed chief executive and di­­r­ector of training of the Montessori Teach­ers’ Training Centre in 1999, retiring in 2020.

Having a deep knowledge of the Montessori philosophy and an understanding of its application, she became the best friend a child studying in Pakistan could have. Only if the government had sought her advice! She believed in giving a child freedom of choice within the bounds of a safe environment to help the child discover her own potential, while allowing her sensory, motor, emotional and cognitive development to advance at its own pace. “Why do teachers try to control a child to discipline it?” she would often say, with exasperation in her voice. “You cannot teach critical thinking to a child. It comes naturally to it if you allow it to express itself in the language it has been learning since birth. It explores by asking questions in its own language and you must provide it answers. Teaching it in a language that it doesn’t know at this stage will dumb the child.” There was much wisdom in what she had to say and I could go on quoting her on a child’s needs and how the child must be handled.

Farida Akbar believed in giving a child freedom of choice.

It was the best learning experience for me when she agreed to guide me in an experiment: I launched a play centre called the ‘Aao Khailein Markaz’ to see how young children learn in a relaxed environment where they could communicate in their own language (in this case Urdu) and play with the learning material of their choice. Although the Markaz could not survive for long (the parents failed to understand our aims), I learnt a lot myself by tracking the progress of the child, especially in articulating its thoughts. Mrs Akbar was deeply interested in the Markaz and would visit frequently to demonstrate her pedagogy to Hawwa, my friend who had volunteered to teach the students. Mrs Akbar would graciously invite Hawwa for lunch to explain the principles underlying the practice. She would also make flash cards herself, pushing aside my protests, saying she enjoyed doing it.

I think it was the teacher in her that drove her. Her commitment to education was unmatched. I often invited her to accompany me on school visits. I was amazed by her meticulous observation and analysis that turned out to be spot on when I probed further. She never said no when her advice was needed in any matter pertaining to education. Once she spent the entire day with two teachers from the community school in Kheiro Dero, teaching them how they could make the Montessori material themselves and use them in their classrooms. As a member of the PMA, she helped establish schools in the northern areas, attended numerous Montessori conferences and was appointed external examiner for Montessori institutions in many countries. She was an asset and her contributions will be remembered. The Association Montessori Internationale in Amsterdam appointed her twice to the Scientific Pedagogical Committee.

Hers was a versatile personality. Her love of Urdu literature, and her interest in intellectual activities, such as panel discussions, lectures, festivals and book club sessions, made her a willing and enjoyable companion. Rest in peace dear friend. It seems Allama Iqbal wrote this verse just for you:

(There is no limit to your knowledge and love/ In the orchestra of nature there is no song sweeter than you.)