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Pushed
hard by scams Talking
to Pakistan |
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Water
woes
Pak off
the hook on Mumbai carnage
A figure
of speech
Besides medical
expertise, a physician has to be equipped with skills to cope with bad
news, treatment failures, patient suffering, medical futility and
death
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Talking to Pakistan
Whether
it is the result of what recently transpired between the Foreign Secretaries of India and Pakistan at Thimphu (Bhutan) or the silent efforts being made for the past few months to get engaged, the easily noticeable change in India’s tone raises certain questions. Why has the posturing by Islamabad on the issue of punishing the guilty of the Mumbai terrorist killings not evoked similar reaction from New Delhi? Earlier it was Pakistan which was trying to persuade India to agree to resume the “composite dialogue process” that got snapped after 26/11. But now it is India which is doing all it can to ensure that the two countries start talking to each other once again. Why? Of course, both have made concessions — India agreeing to start a dialogue on the outstanding issues between the two without calling it the “composite dialogue process” and Pakistan offering to discuss all that was there on the earlier agenda. The unusually conciliatory noises being heard from both sides indicate a welcome change of heart. Perhaps, it is Prime Minister Manmohan Singh’s vision outlined earlier that is the cause for this interesting scenario. Some hidden hand may also be working behind it. There seems to be a realisation that India and Pakistan have a shared destiny and cannot ignore the geographical reality. So, why do they not learn to live as good neighbours? Actually, this question is relevant more in the case of Pakistan because attempts to vitiate the atmosphere have mostly been made from across the border. By adopting an accommodative approach India is, perhaps, telling Pakistan that negative policies like the use of terrorism to achieve geopolitical objectives will take us nowhere. India is patiently waiting for who comes to occupy the Foreign Minister’s position in Islamabad after the exit of Shah Mahmood Qureshi. The two countries are to have Foreign Secretary-level talks before the expected dialogue between their Foreign Ministers in July. It is already there in the air that there will be no difficulty in settling the disputes over Siachen and Sir Creek, as considerable ground had already been covered before the “composite dialogue process” came to an abrupt end. The subcontinent needs an atmosphere of peace and cooperation more than anything else.
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Water woes
Recently, residents of Delhi had to suffer from interrupted water supply not because of shortage of water, but because of the high concentration of ammonia in water flowing down the Yamuna River. The disruption in Delhi drove home the unpleasant truth that most of the rivers in India are being choked by pollutants. The Central Pollution Control Board monitors the water quality of the Yamuna at the upstream of Wazirabad and at Okhla, and its reports are far from encouraging, since they show significant deterioration in water quality. Authorities in Delhi blame the upstream discharge of industrial and municipal effluents, especially in the industrial belt of Panipat, for the pollution in the river. There is no doubt that major industries are always major contaminators. However, with proper treatment plants, the toxicity of the effluents, whether they are industrial or municipal, can be reduced. Those in Delhi who blame Haryana for their woes would do well to remember that according to a study, while Delhi constitutes only 2 per cent of the catchments of the Yamuna basin, it contributes about 80 per cent of the pollution in the river. The river then flows on to Agra, another major polluter. State governments have set up effluent plants, but in the absence of a proper revenue plan, they have remained largely inoperative, since it costs a lot to operate and manage them. The Ministry of Environment and Forests gives technical and financial support for common facilities for the treatment of effluents scheme CETPs and over 80 have been set up throughout India, but their track record leaves much to be desired. Of late, courts have been taking action against erring units, and there has been some activism, but the problem of contamination of drinking water is so serious that it demands that immediate and effective measures be taken to prevent further damage to Indian citizens.
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The best mirror is an old friend. — George Herbert
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Pak off the hook on Mumbai carnage NEW Delhi appears to have lost the sense of direction in dealing with Pakistan. Prime Minister Manmohan Singh came close to fashioning an agreement with President Pervez Musharraf on Jammu and Kashmir, which recognised that “while borders cannot be redrawn, we can work towards making them irrelevant — towards making them just lines on a map.” But his belief that terrorism would not be allowed to undermine the “composite dialogue process” with Pakistan has cost us dearly both before and after the 26/11 attack on Mumbai. A large number of persons, including nationals of the US, the UK, Israel and Singapore, perished in the ruthless terrorist carnage unleashed by the Lashkar-e-Toiba on the people of Mumbai. There is no dearth of evidence about the involvement of the ISI in the Mumbai killings. This was not the first attack unleashed by the ISI. Dawood Ibrahim, the mastermind behind the 1993 carnage, still lives comfortably in Karachi. Mr Atal Bihari Vajpayee as Prime Minister agreed to resume the “composite dialogue process” in January 2004 following an assurance from President Musharraf that “territory under Pakistan’s control would not be used for terrorism against India”. India and Pakistan announced the resumption of what was called the “composite dialogue process” in all but name on February 10. Worse still, the Mumbai carnage was reduced to a virtual footnote — just another terrorist incident — in the announcement. India has received unprecedented international support to deal with the perpetrators of 26/11. The Israelis have filed a highly publicised law suit in a New York court against LeT chief Hafiz Mohammed Saeed and ISI boss Lt-Gen Shuja Pasha for their role in the Mumbai attack. We have, however, shot ourselves in the foot thanks to some divisive and irresponsible statements by some of our politicians, voicing concern about “Hindu terrorism” in India. The damage caused by these irresponsible statements became evident when I recently met a group of distinguished Pakistanis, who averred that India had no right to insist on action against the perpetrators of the 26/11 terrorist attack on Mumbai, as it had taken no action against the “Hindu terrorists” responsible for the deaths of Pakistani nationals in the Samjhauta Express bomb blasts. Pakistan’s official spokesman accused India of lacking the resolve to act against “”Hindu terrorists”. Pakistan has also launched a campaign claiming that the Indian Army is full of “Hindu terrorists” like Lt-Col Srikant Purohit, now under arrest for involvement in the Malegaon blasts. The issue of “Hindu terrorism” was raised when Foreign Secretary Nirupama Rao met her Pakistani counterpart Salman Bashir in Thimphu. Irresponsible statements have resulted in India paying a high price internationally. India’s response to these developments has been weak and incoherent. Instead of asserting that terrorist acts allegedly executed by Indians (from SIMI and Abhinav Bharat) were exclusively in their own country, which cannot be equated with the 26/11 attack, carried out by Pakistanis crossing illegally into India, our government has appeared defensive and confused in handling the issue. This, in turn, has led to India now getting itself cornered and unable to keep up pressure to force Pakistan to bring the perpetrators of the 26/11 attack to book. India’s astute Foreign Secretary, who handled past negotiations with Pakistan with commendable skill, has urged people not to “lend any credence” to what Hafiz Saeed says. But is it prudent to forget that after vowing to raise the “Green flag of Islam” on the ramparts of the Red Fort, Hafiz Saeed masterminded terrorist strikes on the Red Fort in Delhi in 2001 and on Mumbai in 2008? Having been put on the defensive on Pakistan-sponsored terrorism, the government has only further weakened our position by agreeing to what, in effect, is the resumption of the “composite dialogue” with Pakistan. The result of this is going to be that Pakistan will divert attention from terrorism it sponsors to its “grievances” on issues like river waters, Siachen, Sir Creek and Jammu and Kashmir. While continuing engagement with a neighbour is imperative even in times of conflict, what we are now finding is that the terms of the dialogue, which effectively sideline the salience of terrorism it sponsors, are being set by Pakistan. Given the growing violence and religious extremism within Pakistan, it should be obvious that the weak civilian government headed by President Zardari lacks the authority to take any bold measures on issues like terrorism. The India-centric obsession of the Pakistan Army Chief, Gen Ashfaque Parvez Kayani, should also be kept in view. It is, therefore, astonishing that our government is prepared to resume the stalled dialogue with Pakistan on Siachen. Only a few years ago, the Prime Minister appeared agreeable to pulling out our forces from Siachen. He was forced to backtrack because of political and public opposition. Dr Manmohan Singh’s readiness to consider withdrawal from Siachen was not only opposed by the Army, but also reportedly by his colleagues in the government and the Congress party. Given General Kayani’s track record, it would be a perilous mistake to withdraw from Siachen in the belief that the Pakistan Army will keep its word and not move into areas vacated by us, as it did earlier in Kargil. Our Army has made it clear that if the Pakistanis walked into vacated positions we now occupy in Siachen, we would not be able to retake these positions, which we have held sacrificing the lives of scores of our officers and men. Do the sacrifices of our men in uniform count for nothing? New Delhi has already lost its trump cards in dealing with Pakistan-sponsored terrorism because of political leaders giving divisive, religious colours to terrorism and due to its diplomatic naiveté. Under directions from General Kayani, the Pakistan Government has returned to sterile rhetoric about Jammu and Kashmir and disowned the framework for a solution devised earlier with General Musharraf, which was based on the territorial status quo. Does our government seriously believe that talks between Foreign Secretaries will lead to General Kayani having a change of heart, or his restraining General Pasha from planning attacks on Indian territory and on Indian interests in Afghanistan? Moreover, Home Minister P. Chidambaram’s visit to Islamabad has established that the civilian government is unable and unwilling to rein in, or act against, ISI-backed terrorist outfits. In these circumstances, any pullout from Siachen has to be linked to a final settlement of the Kashmir issue, and India should neither forget not forgive the perpetrators and masterminds of the 26/11
attack.
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A figure of speech Being
rather old-fashioned, every time I hear a certain four-letter word spoken or appearing in print in a novel produced by one of our brilliant young writers, desi or foreign, I experience a sense of shock. But there is one four-letter word, not obscene, but with ramifications that spread far and wide, up and down. The word which has gained currency during the past 30 years or so is ‘seva’, ‘khidmat’ if you have declared Urdu as your mother tongue. It means serving or to be precise, “selfless service”. It is the ‘selflessness’ that seems to have undergone a complete reversal in its connotation over the years, so that it now stands for ‘service to self. Here are a few examples of how it works. Take the telephone man who comes to your house after repeated overtures to an inscrutable entity called ‘Complaints’. After he has rectified the fault in your telephone line he salaams you with a grin and asks ‘kutchh aur seva?’ This is the signal for you to hand over a fiver or tenner depending on the enormity of the fault. You thank him for his “takleef”! It is as you go up the bureaucratic ladder begging for public service that the word becomes a financial burden. Twenty-three years ago I had to obtain a mutation from the M.C.D office in respect of a flat I had bought in New Delhi. The application, together with supporting documents was submitted in the month of July. Without it, I couldn’t have the electrical and water connections changed to my name. Nothing happened till September despite half-a-dozen personal visits to the M.C.D office at the cost of much petrol. Eventually the inspector arrived to make sure that I had not made any external additions or alterations in the flat. I hadn’t. As he was about to leave I asked him how much longer I would have to wait for the mutation. ‘It depends’ was the cryptic reply. I got the message. As it happened, I was writing a weekly column at the time for a local eveninger and the latest piece I had done was on the growing official corruption in Delhi. So the next time I went to see the functionary concerned at the local zonal office I took a copy of the paper with me with the edit page on top and ‘inadvertently’ left it on the man’s desk. Two days later the mutation was delivered at my residence! The odd thing about this ‘seva’ is that it increases in direct proportion to the rank and designation of the official dealing with your case. Understandably so, as there are so many ‘middlemen’ collecting their
crumbs.
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Besides medical expertise, a physician has to be equipped with skills to cope with bad news,
treatment failures, patient suffering, medical futility and death The present medical curriculum, however, lays stress mainly on imparting the loads of medical knowledge only. Thus the medical students with top academic ranks have rarely interacted with the public life. A medical student usually enters the course at the age of 17, and finishes it at the age of 21 years. The period of 4.5 years is mostly spent in a similar environment thus restricting the overall maturity and development of the personality. Suddenly after the course, the medical student enters an environment which demands great responsibility, courteousness, communication skills and mature behaviour out of him.
Prepare them
n
Majority of the legal cases pertaining to medical profession can be avoided with optimum level of communication. Thus it is the need of the hour that short courses in developing the communication skills should be introduced into the medical curriculum When I entered the clinical environment as an intern, I was not prepared for the psychological trauma of life and death. I remember that during my first duty of internship in paediatrics, 25 years back, a two-year- old child visited the OPD in the lap of his mother with the problem of breathlessness. A prescription was handed over to the patient by the consultant after thorough examination and the patient was advised to take medicine at home. But the mother insisted on the child to be admitted because she had come from a remote village and she wanted her child to get well before she went home. The child was accordingly admitted. I was on night duty along with the junior resident and nurse. At midnight the child suddenly developed a bout of breathlessness and could not be revived. The scene was full of trauma and horror for me. The thoughts of conviction of the mother about the seriousness of her child resulting in hospital admission and the error of judgment on our part for treating the child as an outpatient were knocking my mind repeatedly. The question whether we took the disease of the child too casually resulting into some act of omission was haunting me. I almost cried and was consoled by the co- residents and the nurses explaining that it was a part of our career. It is a known fact now that the adverse events have significant impact on the behaviour of doctors. Terry Mizrahi from Hunter College School of Social Work, New York describes 3 'Ds' as a range of negative coping mechanisms employed by doctors in training when a mistake is made: n
'denial' - which involves redefining errors as nonerrors and may
even involve negation of the concept of error. These mechanisms are often unsuccessful; a finding confirmed by Baylis. With the unveiling of mistakes with time, the resultant emotional reactions as per the scientific studies can take the form of shame, doubt, fear, guilt, sadness, loss, frustration and panic. Furthermore, the situations of unfavorable outcome in spite of the best medical care are also a well recognised cause of emotional trauma. Tait Shanafelt, in his article "When Your Favorite Patient Relapses: Physician Grief and Well-Being" has described the grief of a physician due to sudden and unexpected bad outcome of a patient. Dr Frank L. Meyskens, in his poem "Tidal wave" has expressed the feelings of a physician as to how he feels powerless and overwhelmed by tidal waves of bad news, treatment failures, patient suffering, medical futility, and death. In a book, Trauma and Recovery, written by Dr Judith Herman, the author has emphasised that certain emotional traumas sustained by a physician during the course of his/ her career can manifest as a bona fide form of post-traumatic stress disorder. Furthermore, there are instances when even the dedicated and competent medical men have to face unwarranted circumstances like rude behaviour of patients, legal cases, and even interpersonal rivalries. Although, in due course of time they come out of the adverse situations, but during that time and for some time later on, the trauma and stress gets manifested in their behaviour affecting the performance of their work. I remember a colleague of mine who was slapped with a legal case when he operated upon a 90-year-old male patient for a hip fracture who developed thrombus in the legs on the tenth day of surgery that travelled to the lungs and ultimately the patient could not be saved. My friend went through a lot of mental stress during those days. He wasted a lot of time and energy to prove that the thrombus in elderly patients can occur after hip surgery in spite of the best care. In the present era of information technology, the patients need to be informed about the nature of their problems and the possible solutions and risks in their own language. The physician is supposed to have the skills so that he has the capability of communicating with the richest and the poorest, the elite and the down trodden, and the literate and the illiterate. Majority of the legal cases pertaining to medical profession can be avoided with optimum level of communication. Thus it is the need of the hour that short courses in developing the communication skills should be introduced into the medical curriculum. Dr John D Kelly in his article "Medical Student Education: Time for a Different Radical Change" has suggested that the knowledge of literature can also go a long way in enhancing the overall communication skills of the physicians to establish a life-giving emotional connection with patients. This will also help in accelerating the two-way flow of knowledge in the classrooms as well as writing their research projects and papers. Thus even a short stint of training in emotional crisis management will be helpful to the medical graduates not only in the well being of these caregivers but is also likely to go a long way in enhancing the performance of medical work. Therefore, it is essential that the medical curriculum should be revised with addition of some optional courses. The coaching should be provided for handling death, dying, litigation stress, and adverse events. Dr Kelly has also suggested many tools like cognitive behaviour therapy, support groups, and stress management techniques that most of the medical personnel are never exposed to. The experts have earlier suggested that development of medical men with wholesome and mature personalities can be enhanced by introducing the optional courses in humanities and arts to medical students. The pangs of medicine may be better tolerated by a soul nourished by an icing of art and literature on the cake of medicine than the one tasting only the monotonous medicine-laden cake. The subjects from nonmedical streams will not only facilitate the overall development of the medical students thus helping them dealing with untoward situations in a mature manner, but also can act as stress busters by relaxing their mind from the monotonous routine of medicine. Lastly, this is also an important fact that our mistakes and traumas tend to force us to carry the effect of our work place to our homes with a risk of even disturbing the family life and ultimately coming to work place with more frustration thus entering into a vicious loop of unending circle. Thus training of the physicians in acquiring the better communication skills, and handling the emotional trauma and adverse situations in a better way must be introduced into the medical curriculum in order to produce doctors who are themselves happy and are able to provide superior care, make fewer mistakes, and are sued less often. The writer is associated with Government Medical College and Hospital, Sector 32, Chandigarh
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