By Dr. Anwar Merchant
Anwar Merchant (ISP 88-89, 98-00) is a PhD candidate at the School of Public Health, Harvard University, on leave from the Aga Khan University's Department of Community Health Sciences. He gave this talk at the ISP alumni/student dinner in Boston in November 1999.
I completed a Master's degree in Public Health from Harvard in 1989, returned to Pakistan that year, and took up a job with Aga Khan Health Service Pakistan. The Aga Khan Health Service had just started to get international funding to develop primary health care programs that would eventually serve 500,000 people, mainly in the rural north of Pakistan. There was a lot of rhetoric about Primary Health Care, or PHC for short. But what was PHC? Nobody quite knew, I suspected. When the Chairman of the Aga Khan Health Service introduced me to the Board, and said that I had studied all about PHC at Harvard, I swallowed hard. The courses I took were a medley of technical tools - like epidemiology, biostatistics, and cost-effectiveness analysis - and those that focused on issues in international health. But I had not done a single course even remotely entitled, "PHC made easy".
So, I got down to reading about PHC, starting with the Alma Ata Declaration, WHO publications, UNICEF's role, and the debates of selective vs. comprehensive PHC. In doing so I was pleasantly surprised to discover a well-preserved secret: that UNICEF existed today largely because of a Pakistani. Ahmad Shah Bukhari, better known as Patras Bukhari, the author of humorous short stories in Urdu, was the Pakistani representative to the UN when a motion was brought to shut down UNICEF. UNICEF had been established to supplement the Marshall Plan, which helped to rebuild Europe after the Second World War, and it was felt that the institution had met its objectives. Bukhari made an impassioned plea to keep it going, stating words to the effect that "..while the temporary emergency of the children of war was over, the permanent emergency of the children of poverty was not." And the world, which had more or less decided to shut UNICEF down, voted to keep it going. Some say that it was one of the very rare times when a speech changed the mindset of those voting at the UN.
Next I met with people who had worked in the field. Ms. Shakar Nota was a stern woman who sat across the hall from me. Over 60 years old, she cut an imposing figure in her sari. From the time she came into the office, she was busy with files, meeting people and talking on the telephone. She was a midwife and a nurse who had trained in Bombay and England in the 1950s. Ever since then she had worked with the Aga Khan Health Service in various parts of the country. Now she oversaw the training of midwives. She never compromised on standards, as many nurses and doctors remembered from their experience when she was a matron. But she was very gentle with a poor woman who had just had a baby, or a nervous young girl who wanted to become a midwife. Never having married and raised a family, she was generous in taking those in her charge as her own.
I walked over to her with some trepidation and said I wanted to talk about her experience of working in the field. We set up a time, and before I left she gave me a report she wrote in the 70s with her "humble" recommendations to the then Chair of the Aga Khan Health Service. The report, which consisted of four single-spaced typewritten pages, yellowed and crumpled with time, was based on her experience of working in Gilgit and Skardu. These are valleys that lie between mountains over 20,000 feet. At the time there were no flights and the only way to get there was through a pass that was 11,000 feet high. There was no electricity, no paved roads. People traveled on foot or ponies. They worked hard in the summer, growing and harvesting crops, picking fruit, nuts and berries, storing them away for their families and animals, for the winter. In the winter they just waited for the snow to melt. Between November and March, snow cut the valleys off from the rest of the world. If a woman was having a baby, an old experienced woman in the village (called a dai) would come over to help. Most of the time everything went well, and the mother and baby were fine. But sometimes there was an obstruction, or the mother started to bleed either before or after delivery. There was no time then to get the woman to safety. The mother and child would die.
Ms. Nota, having lived most of her life on the hot and dusty plains in Karachi, in relative comfort and affluence, went to work there. She would train the dais to recognize early signs of problems, and send expecting mothers with complications to the nearest town which had a hospital and a doctor. She taught mothers to cook and eat the right foods to ensure that they gained weight during pregnancy, and received balanced nutrition, thus reducing their chances of getting complications in the first place. She started vaccination and nutrition clinics for mothers and children. She said in her report that the local communities had to be strengthened; that all women should be able to access maternal and child health services; vaccination was a priority; training of midwives was necessary; and there needed to be a place to quickly refer obstetric emergencies. She said all this before the Alma-Ata declaration was conceived. I felt very humble indeed. Here was a woman who knew all the answers, and I knew almost nothing. I developed deep admiration and respect for her, and she tolerated me, perhaps just because I was willing to listen.
My next stop was Vur, a collection of villages two hours from Karachi on a dirt road. This was the site where the Aga Khan Health Service had set up pilot a PHC program. The lessons learned here would help implement the big PHC program in the north. There I met Dr. Qurban Khwaja, an ex-Captain from the army, who was in charge at Vur. He was handsome, moustached, well dressed and courteous, just like a good officer should be. His office was clean and spartan, with a map of Vur behind his desk. He briefed me, over tea and biscuits, on the program using the map and flipcharts. He had divided the PHC area into 22 clusters and identified local leadership, including women, in each of the clusters. He was now trying to form one committee - one in which all groups, including women - would be represented to work for health. This was very impressive, and I was quick to acknowledge it. Then we went and met local community leaders. Dr. Qurban was in complete control. On the way back to Karachi I was trying to absorb the tremendous work done in Vur, and wondering how I could contribute.
Sixteen young women from the north, just out of school, came to Karachi to train as midwives. Upon graduation they would return to work in the big PHC program. I was part of the team to conduct orientation training for them before they started formal midwifery training. Their eyes were glued to the floor, heads were covered with scarves, and when I walked into the classroom, some even covered their faces. They giggled a lot when I asked them questions, and spoke among themselves. Finally, one of them who was bolder than the others would answer my question. Conducting a class was a challenge. I was teaching them medical terminology in English, and this first session raised grave doubts in my mind about my ability to get beyond the cardiovascular system. But, much to my surprise and delight, I was able to go through the course, and even get them to speak up.
Finally, I went to the arena of the big PHC program in the north. It was a 20 hour journey from Islamabad to Gilgit. For the most part there was mountain on one side of the road, and a sheer drop of 2-3,000 feet on the other. The road was winding all the way, and it made me carsick. I subsequently went north many times, and was sick on each occasion. I earned the reputation of being a "softie" - but one that was later qualified as a "persistent softie".
There was a very optimistic and happy atmosphere in the north. Perhaps it was due in part to the area's sheer natural beauty. The sky was the bluest blue, that sharply contrasted with brown mountains, white snow-capped peaks, and the dark green of the pine forests. New England has beautiful foliage, but the rust and gold on the steppes of the mountains by the Hunza river is indelibly imprinted in my mind as the very best.
Each PHC team in the north consists of young doctors and the midwives (who trained in Karachi and returned to the north). At the end of a day's work they would sit together, talk and laugh about what happened during the day. For me some of the proudest moments over the years were when I would see the young girls who came with eyes cast on the ground to become midwives, now hold their heads high, and answer difficult questions. They looked the men, including the doctors, straight in the eye and spoke their minds. They were confident, competent and respected professionals. The result of the program was spectacular. In 1985, 150 babies out of every 1000 born did not live to see their first birthday. In 1998 this statistic was down to less than 30 per 1000. It reminds me of the verse in Urdu, "Zara nam ho to ye mitti bari zarkhez hai saqi", which translated means, " if there is a little bit of water, this land is very fertile".
This was a team effort, but out there on the front lines were the young girls and it was clear to all that without them this would never have happened.
At the Aga Khan Health Service we implemented PHC programs. The Aga Khan University, a sister organization, also worked in PHC, but with a slightly different focus. One of its aims was to train excellent physicians, competent at treating the sick on a one-to-one and community level. Community Health Sciences, or CHS as it is known, made up approximately 20% of the undergraduate medical curriculum, and was the largest department. The Community Health faculty spent its time teaching, conducting research and working with health systems. I used to encounter them at professional meetings and was impressed by their slick presentations, and excellent grasp of theoretical issues. And they always seemed to be having a good time. Many of them became good friends. I had worked with PHC and health systems for four years, and now felt the urge to do something slightly different. And I enjoyed teaching, and working with data. My move to the Aga Khan University became almost inevitable.
The World Bank had recently funded a program to improve the health system of the government of Sindh, and Aga Khan University was asked to provide consultants. This was my first job at the university. Dr. Ali Mohamad Ansari was my boss. He was a distinguished professor of orthopedics, ex-principal of Dow Medical College, Karachi, and Ex-Director General Health of Pakistan. I expected the worst, but Dr. Ansari was gentle, humble, honest, yet very sharp, with a quick sense of humor. Every year he would lecture the first-year medical students about the health system of Pakistan. He would give a historical perspective. All the issues and potential solutions were identified well before Alma-Ata. At the end of the talk, every year, one hesitant hand would rise. The student would ask, "Sir, were you able to change things when you were Director General?"
And every year Dr. Ansari would reply, "I could not make a substantial difference. You know, it is very difficult to make changes in the government." But he continued to try, and urged us on. He traveled with us to remote villages, and stood by our side when we had to meet with senior government and World Bank people. He was always there to cheer us up when we'd despair. I could not hope for a better mentor.
But this was one of the things I had to do. As faculty were also expected to teach and conduct research and excel at it all. Often on my way back from meetings with government officials or a visit to the field, in the Karachi traffic and heat, I would review for my afternoon class, not because I had not read the papers, but to get into the teaching mode. There would be about 15 medical students waiting for me, and we would discuss the epidemiologic aspects of a research study appearing in the New England Journal of Medicine, comparing mortality in relation to beta blockers and calcium channel blockers to treat hypertension.
Haji Sultan, with a white beard and bright eyes, sold fruit in shantytown (or katchi abaadi as we call it in Urdu) in Karachi. He went there as a young man to seek his fortune. Over the years he prospered, built a house, raised a family and established a business. He never left the katchi abaadi, and because he was honest and generous, his neighbors held him in high esteem. The Aga Khan University was testing the effect of community development as a strategy to improve health status in his katchi abaadi. We met Haji Sultan and some other community leaders. They agreed to work with us on condition that there would be no talk of family planning. But when we surveyed the area we found that mothers and young children were in poor health. This was because mothers were under-nourished, and had too many babies one after the other. Their bodies did not have time to recuperate. The result was that the children were also undernourished. The women did use family planning, and the most common method was tubal ligation - an irreversible method, which they submitted to in desperation after they had had five or six babies. When we presented this to Haji Sultan and his colleagues, they listened in stony silence. We continued, and said that it was essential for the sake of the mother and child to increase the gap between pregnancies. Even the Koran recommended breast-feeding for two years, and breast-feeding reduced the likelihood of getting pregnant. There were a few murmurs followed by a heated discussion. At the end, Haji Sultan said, that they would support a program of birth spacing, but one that did more for the health of the mothers and children, than just birth spacing. I could hardly believe what I was hearing. There was more pragmatism and common sense in what he said than I had heard at many meetings of experts.
At the Aga Khan University, there was absolutely no time from 8 in the morning to 5 at night to do research. I wrote my manuscripts or analyzed data at night, as did so many of my colleagues. I would come in after 9 o'clock at night and go home after midnight. My younger colleagues, who were not spouses or parents, routinely spent their nights there. It was intense, but a lot of fun.
When the department was looking for a faculty member to manage a large international grant it had received to test the efficacy of combining injectable and oral polio vaccines in newborn children in Karachi, I volunteered. This was the first clinical trial we were doing, so there was no prior local experience. Four months into the project, I was convinced that I had made a big mistake. Everything that could possibly go wrong had. We were targeting about 1,200 children from two hospitals, but recruitment was lower than expected, and we needed to get a third hospital. That was hard. There was infighting in the team, and there were frequent changes in staff before the team seemed to settle.
All my life I have been a mild person, but the demands of this polio study forced me to become hard-nosed, make tough decisions that would increase the likelihood of success of the study, but that could hurt others. I earned the reputation of a tyrant, was verbally abused and even threatened with my life. But I had taken on the challenge, and there was no way to back off now. I just had to get on with it.
The third doctor on the team was a young pediatrician, Dr. Maqsood Yousofzai. It was his first week, when he came up to me and asked, "Do we give the children who receive the injectable polio vaccine DPT separately?"
"No," I said, "didn't you read the protocol? The polio vaccine has DPT in it."
"Yes," he replied, "I did read the protocol, but the actual vaccine says just injectable polio vaccine. There is no mention of DPT, either on the package or on the insert."
I went with him to the refrigerator where the vaccines were stored, and behold he was right. If the vaccines were only injectable polio vaccines, we had about 600 children out there who had not been not vaccinated against diphteria, tetanus, and whooping cough. My legs turned to rubber, and I had a sinking feeling in my stomach. I felt I could not sustain this blow. If it were true, it would surely be the end of the study, or at least the end of it for me. Feeling sick and worried, I went straight to Dr. McCormick, who was the principal investigator and the chair of our department. I asked him why, if the vial contained polio vaccine and DPT, it said only polio vaccine on the label. He said he would have to talk to the suppliers in France, and picked up the phone. It was July, and almost everybody in France was on vacation, so we could not get an answer. Dr. McCormick promised to continue to try to call from his home. There was nothing else we could do, so I went home. That night I could not sleep. The next morning I got to work early, and as I was getting a cup of coffee I saw Dr. McCormick at the end of the corridor. He had a huge grin on his face. He did not have to say anything, but it was music to my ears when he said, "It's OK. The vaccine has DPT in it. They did not bother about the labeling because it was not for commercial use."
We never looked back after that. The remainder of the project was a smooth ride. Dr. Maqsood's easy style slowly but surely filtered down to the rest of the team. There were fewer crises, less blaming each other, more discussions in the meetings about "What is the problem, and how do we fix it?"
When I came to Harvard to do my MPH, I promised myself that I would return and work in Pakistan. I selected courses that way, did not participate in job fairs or apply for doctoral studies. One year went by too fast, and if I had a slight regret it was not going on to do a doctoral degree. But my mind was made up, and as soon as I graduated I returned to Pakistan and started looking for a job.
It was not at all easy to find a job. There were few openings and, though there were not many qualified candidates in the field, the old guard was reluctant to let a new person enter. It was extremely frustrating, and I had to struggle all the time. But when I think about my experience in retrospect, I remember Ms. Nota sharing her wisdom with me. I remember helping Dr. Qurban and his team from Vur, form and register the Vur committee as a non-governmental organization, and help them get funding. I remember the girls from the north, who had come to train as midwives and would not lift their eyes from the ground, hold their heads high and become confident health professionals. And I was part of the process. I remember the Secretary of Health holding up the report of a survey at a high level meeting and saying, "The Aga Khan team has put together these data, and I believe in them." And I was part of the Aga Khan team. I remember with affection Dr. Ansari's support and belief in me, his optimism, and continued struggle even when things seemed hopeless. I remember Haji Sultan allowing me to step into his world, letting me share his aspirations and fears, his vision for his people, and helping me expand my view of the world. I remember the satisfaction of enrolling the last subject in the polio study and completing the study on time and on budget. Any one of these memories would have made it worthwhile, and I was fortunate enough to have them all and many, many, others. I became a stronger, more humble, and I hope a better person because of them.
I am grateful to Allah that I was able to keep the promise I made to myself in 1988, and return to Harvard 10 years later to attend to my unfinished agenda: getting a doctoral degree. A poet of New England, indeed, one who walked these very hallowed walls, Robert Frost, captured best my feelings when he said, "..two paths lay open in a wood, and I - I took the one less traveled by and that has made all the difference."
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