Comprehensive Allergy and Asthma Associates

Physicians:

1. CATHY WEISS GREEN, M.D.
Earned her degree with honors at the University of Southern California Medical School in Los Angeles. She achieved pediatric board certification in 1992 after completing residency and chief residency training at the University of Michigan Hospital and Cedars Sinai Medical Center. Awarded a UCLA clinical assistant professor title in 1996, academic achievements included the following: participation in the development of the Cedars Sinai hospital-wide pediatric asthma guidelines; development of a JHACO featured Pediatric Quality Assurance Program for the Cedars Sinai emergency department; and presentation of in-services, lectures, and case conferences to staff physicians, pediatric residents/interns, nurses and paramedics.

In 2000, as an integral part of fellowship training at Harbor-UCLA in allergy/immunology, she developed an asthma outreach program for the Torrance and Los Angeles Unified School District's nurses, health aids and educators in addition to participating as co-investigator in the Salmeterol Multicenter Asthma Research Trial.

After fellowship completion in July 2002, she was awarded an UCLA faculty position at Cedars-Sinai Medical Center as an allergist and immunologist. Her clinical responsibilities at Cedars Sinai were as follows: directing the allergy and immunology resident elective, presenting the resident allergy and immunology lecture series, and participating in clinical case conference and grand round presentations. In 2003, Dr. Green received board certification in adult and pediatric allergy and immunology. In 2005, she was awarded a UCLA clinical associate professor title for her academic achievements.

Dr. Green is a member of the American Academy of Allergy Asthma and Immunology, The American College of Allergy Asthma and Immunology, The Los Angeles Society of Allergy and Asthma, and The Los Angeles County Medical Association. Dr. Green is an allergist and immunologist who currently specializes in the evaluation of allergic and immunologic conditions for both adults and children. Dr. Green practices with Dr. Catherine Fuller for Comprehensive Allergy and Asthma Associates in West Los Angeles. Her previous experience as an allergist and immunologist includes Dr. Green's five year association with the Allergy and Clinical Immunology Medical Group in Santa Monica California. In addition, she was the Principal Investigator for the Omalizumab (Xolair) Excels clinical research trial. Dr. Green is an allergist and immunologist whose current areas of expertise include adult and childhood asthma, food allergy and anaphylaxis, allergic rhinitis and sinusitis, acute and chronic urticaria, atopic dermatitis, medication reactions, hymenoptera sensitivity, and immunodeficiency diseases

2. Catherine Fuller, M.D.
Earned her medical degree from the University of North Carolina At Chapel Hill. She completed her residency in Pediatrics at UCLA. Her fellowship in allergy and immunology was completed at Children's Hospital of Los Angeles. Dr. Fuller is an Assistant Clinical Instructor at the David Geffen School of Medicine at UCLA.

Dr. Fuller is a Diplomate of the American Board of Pediatrics and the American Board of Allergy and Immunology. She is a member of the American Academy of Allergy and Asthma, the American College of Allergy and the Joint Council of Allergy and Immunology. She is in private practice in West Los Angeles.











3. Staff

(Top) Dr. Green; Dr. Fuller; Tessa; (Front) Karen; Lilia; Michelle

Michelle Geelhoed is a Certified Physician's Assistant whose primary goal is to provide top quality care to our patients. She received her Masters in Physician Assistant Studies from the University of Southern California (USC) in 2005. She has been a member of the Phi Kappa Phi honor society since 2004. Prior to joining Comprehensive Allergy and Asthma Associates, Michelle worked as a physician's assistant for a family practice clinic in Los Angeles. In addition, she worked for four years as a medical assistant in an allergy practice. She also worked as a research specialist at Children's Hospital of Los Angeles where she studied white blood cell movement and sickle cell anemia. Michelle is certified in cardiopulmonary resuscitation, advanced cardiac life support, and pediatric advanced life support.

Lilia Yumul is a dedicated career nurse who puts patients first. She has been a licensed vocational nurse (LVN) since 1984 and a registered nurse (RN) since 1994. She has sixteen years of experience in the field of allergy and immunology and has had additional experience in the fields of cardiology, urology and gastroenterology. She also worked as an ER/express care nurse for seven years. Lilia has certification in cardiopulmonary resuscitation (CPR), advanced cardiac life support (ACLS) and pediatric advanced life support (PALS).

Karen Ariola is a recent graduate of UCLA and hopes to pursue a career in the field of medicine. She has worked as an allergy office assistant for two years. Karen is cheerful and available to help facilititate patient care. She has experience with allergy skin testing and allergy shots as well as a wide range of administrative duties.
Conditions:
Atopic Dermatitis (a form of Eczema):
Atopic eczema also known as atopic dermatitis is a skin rash that is made worse by allergies. The rash is dry and itchy and most commonly occurs in infants and young children but can occur at any age. Food allergies and certain environmental allergies can trigger outbreaks of Atopic Dermatitis. Allergy Skin Testing and sometimes ImmunoCAP IgE blood testing are used to identify allergens that are triggering the dry itchy rash outbreaks. Treatment includes environmental control, dietary intervention and topical anti-inflammatory creams to help treat the rash.

Allergy will cause flare-ups of atopic dermatitis. Therefore, measures to reduce allergen exposure help to minimize the need for anti-inflammatory creams. This preserves skin integrity by minimizing medication use.

Staphylocccus Aureus is a bacteria that lives in the skin. When itchy skin inflamed by atopic dermatitis is scratched, overgrowth of the "Staph" bacteria occurs. This particular bacteria further inflames the dry itchy skin making the rash worse. In addition to anti-inflammatory creams, it is important to treat inflamed skin with topical antibiotic therapy to help further control the inflammatory cycle. When atopic dermatitis with "Staph" overgrowth is severe, oral antibiotics to treat the "Staph" bacteria may be required to calm the inflammatory reaction

Effective treatment of atopic dermatitis is a must to prevent progression. A comprehensive treatment plan which begins with identifying the allergens underlying flare-ups, allergen avoidance, medication use and environmental control is imperative in order to control atopic dermatitis.

Bronchial Asthma:
Bronchial Asthma is a condition that is commonly related to allergies. Symptoms of asthma include shortness of breath and wheezing, chronic cough, and wheezing with exercise. These symptoms can be caused by exposure to allergens in an allergic individual. The more severe the asthma, the more likely allergies are playing a role. At least 80% of children and 50 - 80% of adults with asthma have allergic asthma. Common allergens that flare the symptoms of asthma include pollens (grasses/trees/ weeds), dogs, cats, dust mites, molds and foods.

Allergy skin testing identifies those allergens that are likely making the symptoms of asthma worse. In addition, allergy skin testing identifies how severe of an allergy exists to these allergens.

Allergic asthma can be successfully treated with medication; however, identifying the allergens which make asthma worse is important in instituting a more comprehensive treatment plan. In addition to medication, this treatment plan would include environmental control measures, dietary intervention, and allergen immunotherapy (allergy shots). Allergy shots are indicated and are a successful treatment for allergic asthma in adults and children.

Food Allergies:
Research shows that children and adults currently have more food allergy than at anytime in the past. Symptoms of severe food allergy include hives, swelling and shortness of breath. These symptoms can be life threatening. Children and adults with severe food allergy commonly require emergency room treatment and can require admission to the hospital for treatment. In addition, less severe food allergy can worsen underlying conditions such as asthma, atopic dermatitis and sinus allergies. It can also cause heartburn, diarrhea and bloating.

Food allergies are diagnosed with specialized diagnostic testing which includes ImmunoCAP IgE blood testing and/or food allergy skin testing. Food allergies can be mild or severe. ImmunoCAP IgE blood testing and allergy skin testing as well as the symptoms you are experiencing help to define the severity of your food allergy. Testing is also used to identify the specific foods which are causing symptoms.

After specific food allergies are diagnosed, a treatment plan which includes dietary intervention, medications and at times other methods is instituted to alleviate symptoms caused be ingestion of the allergenic foods that are identified.

Hives and Swelling:
Hives or urticaria can be caused by allergies. Symptoms of hives include red blotchy patches that come and go and are often associated with welts. Hives often itch. They can progress to swelling of the deeper tissues. This is a more serious condition known as angioedema and is often painful.

Hives can be acute, lasting a period of days to weeks, or chronic, lasting months. Common allergens that cause hives acutely are medications, certain foods, latex, and bee stings. High level inhalant allergy to environmental like pollens, dogs, cats dust mites and mold can also cause hives and often leads to more chronic symptoms. Hives are not always caused by allergy and thus a comprehensive evaluation is often required when hives do not resolve easily after treatment with medication.

It is important to determine the cause of hives in order to effectively treat them. A blood work-up and allergy skin testing are methods to help identify their cause. Hives must be treated with rapid intervention which includes avoidance of allergen triggers, and treatment with appropriate medication in order to control symptoms and prevent progression. If hives are due to a condition other than allergy, this must be identified in order to effectively treat the underlying cause of the hives.

Recurrent or persistent hives are best evaluated by an allergist/immunologist in order to best diagnose their underlying cause. In most cases, hives can be effectively managed when their cause is accurately identified.

Honey Bee, Yellow Jacket, and Wasp Allergy:
Allergy to bees and wasps can be life threatening. An adult or child with any reaction to a bee sting that is more than mild and localized should be evaluated by an allergist. Local swelling is defined as swelling that does not progress beyond the part of the body that is stung. Any reaction other than a local reaction may indicate allergy to bee venom that may be serious. Even hives after a bee sting may be a sign that there is danger of a much more serious reaction if you were to be stung again.

Specialized blood testing and venom allergy skin testing are methods that are used to determine the severity of bee sting allergies and the need for further treatment. Venom allergy shots are effective for the treatment of potentially life threatening bee sting allergies. Treatment with venom allergy shots (venom immunotherapy) is at least 5 years and is instituted when there is a risk of a life threatening reaction to a subsequent bee sting. Injectable Epinephrine also is used to provide additional protection.

Identification and treatment of severe bee sting allergy before the next sting can be life saving. Therefore, it is imperative that rapid evaluation by an allergist be performed and treatment be instituted when indicated in all cases of systemic (full body reactions) to bee stings.

Immunodeficiency Conditions:
Immunodeficiency conditions present with recurrent infections. The severity and the frequency of these infections generally reflects the severity of the underlying immunodeficiency condition.

Most immunodeficiencies are mild; however; there are immunodeficiency conditions that are severe and present with severe infections such as recurrent pneumonia and meningitis. The most common immunodeficiency condition is IgA deficiency. Recurrent respiratory infections are associated with this deficiency. Blood tests which assess immunoglobulin levels, specific antibody levels, specific lymphocyte counts and other immune function will diagnose immunodeficiency conditions. Blood tests can also determine which part of the immune system is affected. In additon, an evaluation for the presence allergy is typically useful since allergic conditions are often associated with recurrent less severe infections. Allergy is most commonly diagnosed by allergy skin testing and ImmunoCAP IgE blood testing when indicated.

Once an immunodeficiency condition is diagnosed, treatment will help to boost the deficient portion of the immune system to better fight infection. The most common therapies include vaccination with Pneumovax and Intravenous Immunoglobulin; however others are available.

Nasal, Sinus and Eye Allergies:
Nasal allergies (allergic rhinitis) and sinus allergies (allergic sinusitis) are common. Symptoms of nasal allergies include nasal congestion, sneezing and itching of the nose. These symptoms are sometimes associated with itchy, watery eyes known as allergic conjunctivitis. Common sinus allergy symptoms are sinus pressure, headache, post-nasal drip and cough. Nasal and sinus allergies are often associated with recurrent sinus infections. Children with these allergies can also have recurrent ear infections.

Common allergens that cause nasal sinus and eye allergies include pollens (grasses/trees/weeds), dogs, cats, dust mites, molds and various foods. Allergy skin testing is used to identify the allergens that cause these symptoms. A typical panel of 72 allergens will identify many of the common allergens that are responsible for your symptoms.

Medications, in addition to environmental control measures and dietary intervention (when indicated), successfully control symptoms of nasal, sinus, and eye allergies. When symptoms are year round or more severe, allergen immunotherapy (allergy shots) are a very effective therapy for adults and children with these conditions.

Allergy shots are not a medication but contain allergens that produce immune tolerance to the allergens that cause your allergic symptoms. The course of allergen immunotherapy (allergy shots) is typically 3-5 years. Studies show that allergy shots will decrease symptoms and medication use for patients with nasal, sinus and eye allergies.

Pet Allergies:
Animal dander (skin shedding or epidermal scales of animals) is an important cause of allergic reactions to pets. Exposure to the saliva, fur, and the urine of pets can also result in allergic symptoms. Many people have beloved pets in their household and despite allergy to them, do not realistically want to get rid of these pets. In cases of mild sensitivity, keeping your pet outside the home and removing your pet from the bedroom will likely improve your allergic symptoms. It is important to remember that even if a pet is completely removed from the home, it often takes several months until the animal dander is no longer a problem.

Allergic conditions like allergic asthma, nasal and sinus allergies, and eye allergies are often made worse by a pet in the home. HEPA filters and HEPA vacuums can help remove animal allergens from the air and carpeting. Cats are typically more allergenic than dogs and the cat allergen called Fed-D1 will attach to clothes and furniture. It is important to keep the cat?s litter box away from the home. Washing and brushing your pets at least once weekly can also help to decrease your allergic symptoms.

Allergy to dogs, cats, rabbits and other pets can be diagnosed by allergy skin testing. When high level allergy is identified, environmental control measures, medication, and allergy shots may help to alleviate symptoms caused by your pet. If the allergy is severe enough and a more severe allergic condition such as asthma has developed, there are times when pet removal from the home may be the most reasonable option. However by working with your allergist and instituting the steps outlined above, removal of your pet from the home in most cases can be avoided.

Control Measures:
Dust Mite Control Measures:

Dust mites are microscopic creatures that live in the skin. These mites collect most commonly in bedding, mattresses, stuffed couches and pillows, carpets and stuffed animals. Certain people are allergic to dust mites and when this occurs, dust mite allergy will worsen underlying allergic conditions such as asthma, atopic dermatitis and allergic rhinitis. Dust mite allergy is most commonly diagnosed by allergy skin testing.

Dust mite control measures are important in minimizing exposure to this allergen when dust mite allergy is present. Common dust mite control measures include mattress pillow, duvet, and box spring covers, HEPA filters for the bedroom and living areas, flooring instead of carpeting, and HEPA vacuums for all carpeted areas. Additional measures include minimizing stuffed animal exposure and washing all bedding once a week in very hot water. HEPA filtration systems can also be installed in the heating and air conditioning systems in your home.

Dust mite control measures when instituted in their entirety will decrease indoor exposure to dust mite allergens. Decreasing exposure to these allergens is important in controlling allergic conditions.

Mold Control:
Mold is an indoor allergen and grows wherever there is moisture. The best way to control mold is to keep the environment clean and dry. Plumbing leaks are common causes of water intrusion in the home and will lead to mold growth. When mold spores are present in the air, allergic conditions such as asthma, hives, and nasal allergies can develop or worsen.

Allergy skin testing can detect allergy to mold. A panel of mold allergens can be placed on your back. If after placing the mold panel welts and/or redness develop, this indicates mold allergy.

There are two types of molds. Wet molds like Penicillium and Aspergillus which are typically found indoors with water intrusion (i.e. plumbing leaks) and dry molds like alternaria which are typically found outdoors. Dry molds will blow in from the desert with the dry Santa Ana winds.

If mold is present in your home, it should be remediated to prevent a flare of your allergy symptoms. If remediatation is not possible, leaving the home may be necessary to prevent worsening of allergy symptoms. In addition, dehumidification may be somewhat effective in decreasing mold growth.

Diagnosis/Treatment:
Allergy Skin Testing:
Allergy skin testing is the most common method used by allergists to determine which allergens will likely play a role in flaring allergic conditions. Common allergens include pollens from grasses, trees, weeds, and indoor allergens such as dust mites, mold, and animal allergens. Food allergens are also usually tested.

Skin testing is initially performed by superficial methods where the skin is pricked or scratched with common allergens. Injection of small amounts of allergens into the skin is then performed to confirm the negative results. This assures that allergy skin testing is not falsely read as negative.

Allergy skin testing is performed in the allergist's office and cannot be performed if a patient has taken an antihistamine (i.e. Benadryl, Zyrtec, Claritin or Allegra) typically within 7 days. Thus, it is recommended that prior to a scheduled initial consultation, patients check with the office regarding their medications.

Allergy Shots & Allergen Immunotherapy:
Allergy shots (Allergen Immunotherapy) are a very effective method used to treat certain allergic conditions. They are approved for the treatment of bronchial asthma, allergic rhinoconjunctivitis, and stinging insect allergy. Allergy shots are efficacious for both adults and children.

Allergy shots contain allergens and are not a medicine. They induce an immune tolerance so that the body becomes less allergic. They have been used by allergists since 1911 when it was discovered that by giving injections of allergens little by little, allergic symptoms did not occur when the allergens (i.e. grass pollens) were inhaled.

Allergy shots are almost painless. Shots are given once to twice weekly during the buildup phase (typically 6 months) and then once every 2 - 4 weeks. The course is typically 3 to 5 years. Studies have proven that allergy shots effectively decrease medication use and symptoms for certain allergic conditions.

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Women's Health Problems in Pakistan

Women's Health Problems in Pakistan

Dr Manzoor Ahmed Butt,
General Medical Practitioner, Researcher& Trainer,
Maqbool Clinic, Research & Training Centre,
Dhoke Kala Khan, Shamsabad,
Rawalpindi-46300, Pakistan.

A Brief Background

Ours is a male dominant society where only very few females enjoy full rights and have
access to opportunities of even very basic human needs. This is even more true in the
health sector, where unfortunately there is a great lack of female doctors combined with a
large number of female 'quacks' in the country and the situation is at its worst in
Shamsabad where there is only one or two qualified female doctors. The female doctors
are neither easily available nor easily affordable and women do not prefer to be examined
by male doctors.

There are a lot of government hospitals which provide free or low fee treatment to
women but those are not preferred because of:

-The casual and offhand behaviour of doctors
- More than one male doctor examining the patient at one time
- The fear of crowds of medical students present at time of examination
- The fear that doctor may misuse this opportunity for some evil deed

Right from the beginning of my career, I have had very strong intentions to organize the
primary health care system in my area and to make my clinic a model for others. Towards
this end, I was very fortunate because I became involved with two very useful people, Dr
Christopher Rose, PhD, Ex. Executive Director, Action in International Medicine (AIM) ,

London,UK and Dr Barry H. Smith, MD, PhD, Director of Dreyfus Health Foundation (
DHF ) , New York, USA. The two organizations were jointly operating a very famous
Programme called CCI-Programme.


CCI Programme Training Workshop

Dr Rose visited Pakistan twice, in 1998 and 1999, at my request. We had identified the
Top Ten Health Problems of Shamsabad List during his last visit. Women's health
problems were on the top of the list. (The term Women's Health Problems is strictly used
to indicate only those health problems, which are specific to women).

Dr Christopher and I had decided to address these problems through the CCI-Approach,
but this was not possible due to lack of funds because of the collapse of AIM. We did not
receive any funds, from any organization.

I was left with three choices:
a) Continue searching for the funds from other sources
b) Quit the mission
c) Continue the mission with my own personal resources at a very small scale through my
clinic.

The first two were not possible for me due to many reasons, therefore, I decided to act on
the third option and hence started to follow the PSBH1 - approach in my clinic.

Dr Barry H. Smith is an eminent neurosurgeon, development scientist and social work
expert. Dr Christopher Rose is a renowned scientist, development & social work expert
from Glangors, UK. Although the CCI-Programme does not exist anymore these two
gentlemen are kind enough to consistently provide their moral support and guidance for
our work.

Before starting the work, it was necessary to have some insight into the prevalence and
magnitude of the most pressing health problems of women living in Shamsabad.
Therefore, all the women attending my clinic for any reason were questioned about their
(women's) health problems for one month and the following most pressing women's
health problems were identified.

Later, some conclusions were drawn, from this data, in a very crowded free camp held in
my clinic on the second Sunday of July, 2000.
The main problems were:
1) Vaginal discharge
2) Unwanted pregnancies in married women
3) Breast Problems
4) Malnutrition
5) Menstrual disorders

Strangely, only a few indicated the lack of facilities for Antenatal care and problems
caused by childbirth by traditional birth attendants who are uneducated and lack training.
To make the list more real and practical, the problems were re-numbered as follows:
1) Lack of facilities for antenatal care and childbirth
2) Vaginal discharge
3) Unwanted pregnancies in married women
4) Breast Problems
5) Malnutrition
6) Menstrual disorders



Defining the Problem: The women's health problems were discussed during different workshops in Shamsabad which were attended by cross section of the community and the
following were identified as aggravating factors:

Lack of medical facilities,
Ignorance,
Lack of nutritional facilities,
Prevalent social environment,
Psychological factors,
Unemployment and Poverty

How we are addressing the problems?

The Logistics

Maqbool clinic, a General Practice clinic, has been owned and operated by myself since
1986. It is situated in Shamsabad, Dhoke Kala Khan, Rawalpindi very close to
Islamabad. The surrounding area is densely populated (approximately, some 100,000)
where a number of Afghan and Pashtoon refugees of Afghanistan live among local mix
urban, suburban and rural population.

Mrs. Rahila Manzoor (my wife) is a locally trained health technician who can perform
vaginal examination and take HVS and Pap smears. She is playing a vital role in this
work. The clinic always has at least one nurse capable of dealing with women. It was
decided that Mrs. Rahila would first examine the patients and if she found something
requiring examination by a doctor, the patient would be given a choice to either have a
pelvic examination by myself but if she refused, referral to hospital female doctor with a
full personal reference from us. I had already trained and upgraded my skills in obstetrics
and gynaecology via further training from friend Gynaecologists, and via the internet and
audio-video aids. The necessary skills were then taught to Mrs. Rahila .It was decided
that expenses for the women's health project would be met from income of our clinic's
other routine activities and all income from this project would be utilized to add facilities
for enhancement of our activities.

There was no pathology laboratory near my clinic. There was a great need for a
laboratory that could provide quality results at low price for our "Women's Health
Project", especially those essential during antenatal period. I was already doing blood
sugar testing, urine sugar testing and pregnancy tests in my clinic from my own
resources; but there was an immense need to initiate the following very important tests:
Blood grouping, Haemoglobin Estimation, ESR, urine screening for sugar and
albuminurea, urine routine examination, screenings for Hepatitis-B, Hepatitis-C and
HIV/AIDS.

I had some savings from my clinic's income for this purpose. I used that money to buy
the essentials. We have a part time laboratory technician. I had already refreshed my
pathology knowledge and skills and undertook training in these tests. I have been
performing these tests since 2002. I have kept the rates at a level which is affordable for
all patients and I do these free for the very poor. I am using Standard Control Technique
to prevent false results. Our patients have benefited not only via the affordabe costs, but
also get quality results without going very far. To keep it self sustainable, all income
from the laboratory is being reinvested to buy the diagnostic reagents and material.

What was the main obstacle?

The main obstacle was that no-one could imagine that women would have an
examination by a GP who is operating a clinic right near their homes. The following were
identified as restraining factors:

* The concern as to how they could face this person again
* What if my husband finds out?
* The fear that someone may peep in during examination
* The fear that the staff of clinic would disclose this information to my
neighbors/relatives.


How we overcame these problems

First of all, I established an all day help line (from 06am to 01 am) which provided free
advice and guidance for medical and social problems of patients. I am proud to inform
you that I have saved lives of many innocent girls who were at the point of committing
suicide because of their social circumstances. My clinic is more of a social welfare office
and we are available for everyone regardless of faith and religion.

I respect every patient, especially women. I always reassure our reluctant patients that
having a physical examination is not a sin on their part nor any opportunity for me to do
some evil. I inform them that a doctor is fully aware of the human body and when he
examines private parts of a female, it is for benefit of women and not for satisfying his
evil feelings. Right from the start, I referred to patients as relatives, such as sister,
daughter, and aunt so that they should understand I do not have any evil feeling for them.
To overcome other difficulties, we took the following steps:

1) The examination room of my clinic permits complete privacy
2) During examination, my wife or a female nurse is always present
3) Patient is allowed to bring in one of her relative or friend into examination room
during check up, if she likes.
4) All information regarding a patient's examination and disease is kept fully confidential,
even from the husband if the woman demands. If she is suffering from some serious
problem, we always encourage her to take the husband into confidence.


To address the problem of lack of awareness among women about the importance of
Antenatal care and complications of childbirth by non-qualified, non-trained midwives,
the following question was formulated:

Question
Will a Programme of motivation and awareness about the importance of antenatal care
and childbirth by a trained and qualified midwife/hospital staff whether at home or in
hospital, organized at Maqbool Clinic, Dhoke Kala Khan by Dr Manzoor, Mrs. Raheela
Manzoor, Miss Sobia , Miss Shabana & Miss Sajida (local volunteers) for one year, for
pregnant women of Dhoke Kala Khan, create awareness at least in 30% of those
attending the clinic?

The activity was initiated formally on 01-05-2000. All pregnant women attending our
clinic were informed about the presence of Antenatal centers in the city and they were
encouraged to visit such free government centers for antenatal booking and delivery.
They were informed about the importance of:
(a) Diet during Pregnancy
(b) Regular Blood pressure checkups
(c) Regular weight measurements
(d) Regular fundal height checkups
(e) Hb % determination
(f) Blood /Urine Sugar determination
(g) Blood group determination
(h) Determination of foetal well being through ultrasound examination
(i) Immunisation against Tetanus and Hepatitis

During 2001, this activity was performed with about 700 women . The outcome was
greater than expected. Many women now come to us for antenatal checkups. Their
number is at least five times more than those who were coming to us previously.


It was realized that the following activities are urgently needed to augment this effort:
a) More organised Antenatal checkup facilities including basic relevant tests at our clinic
b) More advocacies for ultrasound examinations and hospital delivery
c) The most important of all is the availability of resources for training of local midwives
who are already popular among women.


We are already performing pregnancy tests, blood sugar measurements, and urine sugar
/albumin measurements and immunization against tetanus.
To address the problem of vaginal discharge in married women, the following question
was formulated:

Question
Will a Programme of "health education and affordable facilities of pelvic examination,
HVS study, Pap Smear test, specific treatment of infections and, referral of difficult-totreat
cases to a gynaecologist" at Maqbool Clinic, Dhoke Kala Khan organized by Dr
Manzoor, Mrs. Raheela Manzoor, Miss Sobia (clinic nurse), Miss Shabana & Miss Sajida
(local volunteers) and other supporting persons/organizations for one year for women of
Dhoke Kala Khan reduce the incidence of vaginal discharge by 25% in those coming for
guidance and treatment?

The activity formally started on 01-05-00. Although the clinic had been operating since
1986 the following had to be arranged from the clinic's own financial resources;
A gynae-examination table, examination lights, examination instruments especially
vaginal speculums, sterilisation equipment, disposable plastic gloves, sterilised
disposable gloves, sterlisable gloves, accessories for pap-test and HVS and regular supply
of relevant medicines
During 2001, about 390 females came for examination. Out of these, 85 were virgins and
305 were married.



a) The virgins were only examined by naked eye and 35 out of these 85 were only having
a watery discharge. These women were reassured and provided with advice for better
personal hygiene; the other 50 were having monilia infection, confirmed by discharge.
They were given advice and treatment.

b) Out of 305 married women , one patient complained of foul smelling discharge after
birth. She came to the clinic on the 25th day postpartum. On examination, there was a
hole in her posterior fornix and there was lot of pus and bloody discharge coming out of
it. She was sent to hospital for admission but they sent her back. The next day, I used
personal resources to get her admitted to the Gynaecology ward. She died there on the
third day after admission.

- One patient was having VVF, she was referred to hospital for an operation.

- Thirteen patients were having third degree utero-vaginal prolapse with ulceration of the
cervix. They were referred to hospital for care.
- Fifty seven patients had second degree utero-vaginal prolapse. They were also referred
to hospital for care.

- Twenty patients were actually having stress incontinence, they were also guided to
hospital.

- Ninety were only having uncomplicated monilial infection. They were given treatment
and advice re better personal hygiene

c) The rest of the 123 women out of 305 had moderate to severe infections. They were
advised for HVS. Only 25 agreed and were later treated according to the laboratory
report. The rest of the 98 women were given treatment for two weeks; 70 responded very
well to treatment and were followed up successfully.

d) Our real problem was the remaining 28 women who were having very severe pelvic
infection and cervical ulcers. They were asked to have a Pap test. 15 did not come back, 2
went to hospital for this test with our reference, and 11 agreed to have a test at the clinic.
The laboratory report indicated that two were having borderline dyskaryotic changes.
They are being closely watched.

It was realized that there is a great need for health education regarding personal hygiene
and sexually transmitted diseases (STDs). The following very important observations
were recorded;

- Almost no women take a bath during menses (5 to 7 days)

- Almost no women take a bath before intercourse; they only bathe after intercourse and
at least 4 to 6 hours after the act

- Most women use pieces of old bed sheets during menses as a sanitary pad; only a few
use cotton and none were using sanitary pads.

- The majority of women do not wear suitable under clothes

To address the problem of unwanted pregnancies in married women, the following
question was formulated:

Question
Will a programme of "health education and affordable facilities for family planning for
married women of Dhoke Kala Khan at Maqbool Clinic, organized by Dr Manzoor, Mrs.
Raheela Manzoor, Miss Sobia, Miss Shabana & Miss Sajida and other supporting
persons/organizations for one year reduce the incidence of unwanted pregnancies by
10% in married women?

This activity was started at random in October of 1999 but we started to keep records
formally from 01-05-00. It is actually a joint venture with the Government of our
province, Punjab, and a very resourceful NGO called Green Star. The Government and
the NGO provide us with very cheap supplies of family planning medicines and
accessories and we in turn provide our non-profit service to the women of area. The NGO
has also organised training workshop for us.

During 2001, about 275 women came to us for advice regarding family planning. All of
these were briefed about available facilities and especially about "Emergency Family
planning". About 55 never came back for advice or services. 25 preferred an IUD and
were guided to nearby centres for insertion of the device as we do not yet have this
facility. Out of the remaining, 30 selected condoms, 117 started injections with us and 48
preferred pills.

Unfortunately, only 15 out of 117 took regular injections at an interval of two months for
one year. Only 10 out of 48 on pills came for a second month's dose because they were
reluctant to take the pill daily.

This activity was more of a failure because;

a) Women do not understand the importance of timing in the menstrual cycle

b) They have a lot of misbeliefs regarding medicines

c) Women do not have sex education knowledge

d) There are a lot of 'quack' medicines available in the market, which claim effectiveness
for one year if taken once a year.

There is a great need for health education, counseling and group discussions regarding
this problem

To address the problems of Breast disorders, the following question was formulated:

Question
Will a Programme of "health education and facilities for free training for Breast Self
Examination (BSE)" and affordable Breast examination, by Dr Manzoor and Mrs.
Raheela Manzoor at Maqbool Clinic, Dhoke Kala Khan for one year for women of Dhoke
Kala Khan reduce the incidence of breast problems by 20%?

The activities were formally started on 01-05-00 and till now only consist of examination
by me or my wife as well as referral of problem cases to hospital. I trained my wife with
the help of the Internet and via patient examinations.

During 2001, about 142 patients attended our clinic.

a) Fifty five were lactating women with acute infection; 29 were referred to hospital for I
& D, the rest were successfully treated with antibiotics and other supportive measures.

b) Thirty were young girls who complained of strange things palpable in breast.
Examination revealed no abnormality but normal glands. They were advised, reassured,
and given supportive treatment

c) 1 girl presented with sinus in the left breast following acute infection. She was also
successfully treated and is now receiving follow-up treatment by us as well as a surgeon
in hospital.

d) 1 woman was eighty years old with a hard mass in breast. She was referred to hospital
where carcinoma was diagnosed and the breast was removed. She comes to us for regular
follow-up.

e) 4 were discovered to have a lump in the breast and were referred to hospital where
biopsy had revealed benign tumor. These have been reassured and given supportive
treatment and advice for frequent follow-ups.

f) One unmarried woman of 33 years C/O discharge from nipple. She was referred to
hospital for biopsy which revealed nothing. We are following her up by taking a smear
from the discharge and we get it examined by a Pathologist every six months.

g) The rest of the women did not have any abnormality. They are advised to do "Breast
Self Examination" every month and come here for a check up after every six months.

The major problem in this sector is that women present very late because of their shyness
and the only answer to it is training of Breast Self Examination. We have purchased a
Pentium-111 multimedia computer from the clinic's own resources and we have begun
this training in groups.

To address the problem of Malnutrition, the following question was formulated:

Question
Will a Programme of " health education and facilities of affordable health supplement" at
Maqbool Clinic, Dhoke Kala Khan organized Dr Manzoor, Mrs. Raheela Manzoor, Miss
Sobia, Mr. Mumtaz (male nurse in the clinic), Miss Shabana & Miss Sajida (locak
volunteers) and other supporting persons/organizations for one year for child-bearing
women of Dhoke Kala Khan reduce the incidence of anaemia and malnutrition by 20%?

To address the very common problem of anaemia and malnutrition in women of
childbearing age of Shamsabad, we joined the Vitalet Project for Better Health. The
activity formally started on 28-11-00. I took training about nutrition supplements on 03-
10-00 from a very resourceful NGO named Social Marketing Pakistan.

It mainly consists of health education and facilities of affordable health supplements,
which comprise multi-vitamins, and essential micro and macro minerals product whose
market price is an 80-Pakistani rupee for one-month course. We get the supply of this
supplement from the NGO on a regular basis at the rate of eight rupee per pack and
provide our every registered malnourished patient at rate of ten rupees for one month for
the maximum of four months.

To generate more awareness about the importance of a balanced diet, we arranged a
general meeting of 35 women with a nutrition expert from an NGO in our clinic on 24-
03-01 and thereafter-another special meeting of 30 pregnant/lactating women with the
same expert on 21-05-01 in our clinic.

During these meetings, the women showed a lot of interest in the topic and we intend to
keep up these activities in future. During the year 2001, a total of 360 women and 5 men
were provided this supplement. Out of 360, some more than two dozen women were
identified as grossly malnourished. These needed more attention and extra effort. We
planned an initial three week diet programme for each of these which generally consisted
of:

- Half a litre of milk daily at the clinic for 21-days
- Ten multi-vitamin injections/or infusions at the clinic on alternate days
- High energy candies daily at the clinic for 21-days
- High energy biscuits daily at the clinic for 21-days

Every patient attended our clinic very regularly and at the end of the three week course,
each was provided with this health supplement free of charge for four subsequent months.
All costs of milk, injections, infusions, disposable syringes, candies, biscuits and the
health tablets was borne by the clinic. In addition, we provided about three hundred and
fifty rupees each to two patients for laboratory investigations. One of our patients was a
tailor and was unable to operate her hand driven machine. We provided her with a motor
and all accessories to convert her machine to a motorised sewing machine.

Menstrual disorders
A number of patients attend our clinic with menstrual problems. They can be divided into
two main groups.

Group-1 consists of girls aged between 12 to 25 and,

Group-2 consists of women above 25.

In Group-1, most girls presented with dysmenorrhoea, amenorrhoea, oligomeno- rrhoea,
and polymenorrhoea. These are provided reassurance, guidance and supportive treatment.

There is an increasing number of cases of young unmarried girls who present with
generalized hirsutism accompanied with either amenorrhoea or oligomenorrhoea.
Unfortunately, we are not capable of handling such cases because these require hormonal
investigations and need an expert in hirsutism. Hirsutism is not only destroying their
social lives but also inducing suicidal trends in these girls because they cannot afford
very expensive laser therapy.

In Group-2, most of the women presented with dysmenorrhoea, amenorrhoea,
oligomenorrhoea, and polymenorrhoea. These were provided reassurance, guidance and
supportive treatment. There are certain patients who require hormonal assays, diagnostic
D & C and other measures beyond the scope of this clinic. Therefore, at present we are
only providing guidance to such patients.

Our results generally
In the beginning only 5 % women consented for a pelvic examination by me.

Our efforts have seen gradual improvement. Most patients now prefer me to examine
them and this includes the very rich women who can afford expensive treatment by
women doctors, elsewhere. An important result is that now many husbands bring their
wives to us and they convince their wives to get a check up. Most women have
permission from their husbands or mothers in law.

Women have also seen that my attitude has not changed after examining them and now
they bring their mothers, grandmothers and relatives and tell them that they have been
examined by me. I always remember that I am a GP and not a gynaecologist, therefore, I
do not hesitate to refer patients to hospitals or gynaecolgists if I feel it necessary.

I am pleased to report that our women's health project is continuing quite successfully. I
have performed more than seven hundred pelvic examinations on record since it began.
Now I perform 2 to 3 pelvic examinations daily under strict hygienic conditions and
about 1 to 2 breast examinations.

We have been able to generate awareness about many issues including health education
and feminine personal hygiene (especially during menses and personal relationship with
husband); general health issues; vaginal discharge and pelvic diseases; family planning
both regular and emergency); sexually transmitted diseases; Breast examination;
(especially the importance of early diagnosis of lumps) and antenatal, intranatal and
postnatal care. A lot of work is still to be done but our pace is satisfactory, if not good.

We are also committed to help increase women's income.

I have introduced the concept of breast self examination in this community and there is
increasing awareness about the importance of early detection and management of breast
lumps. Towards this end, I have diagnosed five cases of carcinoma of breast during this
year. I referred a real sister with one of these cases for prophylactic mammography which
turned out to be another case of carcinoma at so small a size it could not be palpated. We
always refer the suspected or high-risk patients to relevant government centres for further
check ups and mammography or scinti-mammography.


My greatest wish for the program is to provide organised training of female health
workers, female health visitors, nurses, and other women health care providers who are
licensed (e.g., homeopathic female doctors, traditional or eastern medicine health
providers) to work, but lack adequate training and skills. It has always been my dream to
initiate and establish an institution that could provide basic and recent training to health
professionals, especially paramedics.

I have reduced my expenses, forgone all leisure pastimes and have not traveled overseas
for the last eight years. I now have most of the required training materials. I have
gradually purchased a computer, printer, scanner, and digital web camera entirely from
my personal income. Towards this end, I have devised short courses for training and
ways of examining candidates who complete training.

What further help is needed?
We are looking for collaboration with individuals and organizations that could be of help.
We are trying our best to address women's health problems and some of its contributing
factors. We intend to train a lot of female school teachers and married women in personal
hygiene, safe motherhood, hazards of STDS and their prevention, and emergency family
planning .The most important of all is the training of traditional birth attendants as most
women here still prefer them.

Unfortunately, we are unable to do much to address the most aggravating factors,
unemployment and poverty. We intend to help transform women's lives with all possible
support including provision of small items of help in the form of paying off their bills for
repairing of sewing machines, small accessories and motors for sewing machines and small financial aid to start work. We also want to arrange healthy competition among
female artisans to improve the level of their skills and to help them find suitable work.

Dr Manzoor Ahmed Butt,
General Medical Practitioner, Researcher& Trainer,
Maqbool Clinic, Research & Training Centre,
Dhoke Kala Khan, Shamsabad,
Rawalpindi-46300, Pakistan.

HEALTH AND WELFAREHEALTH AND WELFARE

In 1992 some 35 million Pakistanis, or about 30 percent of the population, were unable to afford nutritionally adequate food or to afford any nonfood items at all. Of these, 24.3 million lived in rural areas, where they constituted 29 percent of the population. Urban areas, with one-third of the national population, had a poverty rate of 26 percent.

Between 1985 and 1991, about 85 percent of rural residents and 100 percent of urban dwellers had access to some kind of Western or biomedical health care; but 12.9 million people had no access to health services. Only 45 percent of rural people had safe water as compared with 80 percent of urbanites, leaving 55 million without potable water. Also in the same period, only 10 percent of rural residents had access to modern sanitation while 55 percent of city residents did; a total of 94.9 million people hence were without sanitary facilities.

In the early 1990s, the leading causes of death remained gastroenteritis, respiratory infections, congenital abnormalities, tuberculosis, malaria, and typhoid. Gastrointestinal, parasitic, and respiratory ailments, as well as malnutrition, contributed substantially to morbidity. The incidence of communicable childhood diseases was high; measles, diphtheria, and pertussis took a substantial toll among children under five. Although the urban poor also suffered from these diseases, those in rural areas were the principal victims.

Despite these discouraging facts, there has been significant improvement in some health indicators, even though the population grew by 130 percent between 1955 and 1960 and between 1985 and 1990, and increasing from 50.0 million in 1960 to 123.4 million in 1993. For example, in 1960 only 25 percent of the population had purportedly safe water (compared with 56 percent in 1992). In addition, average life expectancy at birth was 43.1 years in 1960; in 1992 it had reached 58.3 years.

Maternal and Child Health

The average age of marriage for women was 19.8 between 1980 and 1990, and, with the rate of contraception use reaching only 12 percent in 1992, many delivered their first child about one year later. Thus, nearly half of Pakistani women have at least one child before they complete their twentieth year. In 1988-90 only 70 percent of pregnant women received any prenatal care; the same proportion of births were attended by health workers. A study covering the years 1975 to 1990 found that 57 percent of pregnant women were anemic (1975 to 1990) and that many suffered from vitamin deficiencies. In 1988 some 600 of every 100,000 deliveries resulted in the death of the mother. Among women who die between ages fifteen and forty-five, a significant portion of deaths are related to childbearing.

The inadequate health care and the malnutrition suffered by women are reflected in infant and child health statistics. About 30 percent of babies born between 1985 and 1990 were of low birth weight. During 1992 ninety-nine of every 1,000 infants died in their first year of life. Mothers breast-feed for a median of twenty months, according to a 1986-90 survey, but generally withhold necessary supplementary foods until weaning. In 1990 approximately 42 percent of children under five years of age were underweight. In 1992 there were 3.7 million malnourished children, and 652,000 died. Poor nutrition contributes significantly to childhood morbidity and mortality.

Progress has been made despite these rather dismal data. The infant mortality rate dropped from 163 per 1,000 live births in 1960 to ninety-nine per 1,000 in 1992. Immunization has also expanded rapidly in the recent past; 81 percent of infants had received the recommended vaccines in 1992. A network of immunizations clinics--virtually free in most places--exists in urban areas and ensures that health workers are notified of a child's birth. Word of mouth and media attention, coupled with rural health clinics, seem to be responsible for the rapid increase in immunization rates in rural areas. By 1992 about 85 percent of the population had access to oral rehydration salts, and oral rehydration therapy was expected to lower the child mortality.

Health Care Policies and Developments

National public health is a recent innovation in Pakistan. In prepartition India, the British provided health care for government employees but rarely attended to the health needs of the population at large, except for establishing a few major hospitals, such as Mayo Hospital in Lahore, which has King Edward Medical College nearby. Improvements in health care have been hampered by scarce resources and are difficult to coordinate nationally because health care remains a provincial responsibility rather than a central government one. Until the early 1970s, local governing bodies were in charge of health services.

National health planning began with the Second Five-Year Plan (1960-65) and continued through the Eighth Five-Year Plan (1993- 98). Provision of health care for the rural populace has long been a stated priority, but efforts to provide such care continue to be hampered by administrative problems and difficulties in staffing rural clinics. In the early 1970s, a decentralized system was developed in which basic health units provided primary care for a surrounding population of 6,000 to 10,000 people, rural health centers offered support and more comprehensive services to local units, and both the basic units and the health centers could refer patients to larger urban hospitals.

In the early 1990s, the orientation of the country's medical system, including medical education, favored the elite. There has been a marked boom in private clinics and hospitals since the late 1980s and a corresponding, unfortunate deterioration in services provided by nationalized hospitals. In 1992 there was only one physician for every 2,127 persons, one nurse for every 6,626 persons, and only one hospital for every 131,274 persons. There was only one dentist for every 67,757 persons.

Medical schools have come under a great deal of criticism from women's groups for discriminating against females. In some cities, females seeking admission to medical school have even held demonstrations against separate gender quotas. Males can often gain admission to medical schools with lower test scores than females because the absolute number for males in the separate quotas is much greater than that for females. The quota exists despite the pressing need for more physicians available to treat women.

The government has embarked on a major health initiative with substantial donor assistance. The initial phase of an estimated US$140 million family health project, which would eventually aid all four provinces, was approved in July 1991 by the government of Pakistan and the World Bank, the latter's first such project in Pakistan. The program is aimed at improving maternal health care and controlling epidemic diseases in Sindh and the NorthWest Frontier Province. It will provide help for staff development, particularly in training female paramedics, and will also strengthen the management and organization of provincial health departments. The estimated completion date is 1999. The second stage of the project will include Punjab and Balochistan.

In addition to public- and private-sector biomedicine, there are indigenous forms of treatment. Unani Tibb (Arabic for Greek medicine), also called Islami-Tibb, is Galenic medicine resystematized and augmented by Muslim scholars. Herbal treatments are used to balance bodily humors. Practitioners, hakims, are trained in medical colleges or learn the skill from family members who pass it down the generations. Some manufactured remedies are also available in certain pharmacies. Homeopathy, thought by some to be "poor man's Western medicine," is also taught and practiced in Pakistan. Several forms of religious healing are common too. Prophetic healing is based largely on the hadith of the Prophet pertaining to hygiene and moral and physical health, and simple treatments are used, such as honey, a few herbs, and prayer. Some religious conservatives argue that reliance on anything but prayer suggests lack of faith, while others point out that the Prophet remarked that Allah had created medicines in order that humans should avail themselves of their benefits. Popular forms of religious healing, at least protection from malign influences, are common in most of the country. The use of tawiz, amulets containing Quranic verses, or the intervention of a pir, living or dead, is generally relied upon to direct the healing force of Allah's blessing to anyone confronted with uncertainty or distress.

Smoking, Drugs, and AIDS

Smoking is primarily a health threat for men. Nearly half of all men smoked in the 1970s and 1980s, whereas only 5 percent of women smoked. Twenty-five percent of all adults were estimated to be smokers in 1985, with a marked increase among women (who still generally smoke only at home). The national airline, Pakistan International Airlines (PIA), instituted a no-smoking policy on all its domestic flights in the late 1980s. In an unusual departure from global trends, PIA reversed this policy in mid1992 , claiming public pressure--despite no evident public outcry in newspapers or other media. Men also take neswar, a tobacco-based ground mixture including lime that is placed under the tongue. Both men and women chew pan, betel nut plus herbs and sometimes tobacco wrapped in betel leaf; the dark red juice damages teeth and gums. Both neswar and pan may engender mild dependency and may contribute to oral cancers or other serious problems.

Opium smuggling and cultivation, as well as heroin production, became major problems after the Soviet invasion of Afghanistan in 1979. The war interrupted the opium pipeline from Afghanistan to the West, and Ayatollah Ruhollah Khomeini's crackdown on drug smuggling made shipment through Iran difficult. Pakistan was an attractive route because corrupt officials could easily be bribed. Although the government cooperated with international agencies, most notably the United States Agency for International Development, in their opium poppy substitution programs, Pakistan became a major center for heroin production and a transshipment point for the international drug market.

Opium poppy cultivation, already established in remote highland areas of the North-West Frontier Province by the late nineteenth century, increased after World War II and expanded again to become the basis of some local economies in the mid1980s . Harvesting requires intensive labor, but profits are great and storage and marketing are easy. The annual yield from an entire village can be transported from an isolated area on a few donkeys. Opium poppy yields, estimated at 800 tons in 1979, dropped to between forty and forty-five tons by 1985, but dramatically rose to 130 tons in 1989 and then 180 tons in 1990. Yields then declined slowly to 175 tons in 1992 and 140 tons in 1993. The area under opium poppy cultivation followed the same pattern, from 5,850 hectares in 1989 to 8,215 hectares in 1990. It reached 9,147 hectares in 1992 but dropped to 6,280 the following year. The caretaker government of Moeen Qureshi (July to mid-October 1993) was responsible for the reductions in production and area under cultivation; the succeeding government of Benazir Bhutto has perpetuated his policies and declared its intent to augment them.

Use of heroin within Pakistan has expanded significantly. The Pakistan Narcotics Control Board estimates that although there were no known heroin addicts in Pakistan in 1980, the figure had reached 1.2 million by 1989; there were more than 2 million drug addicts of all types in the country in 1991. This dramatic increase is attributed the ready availability of drugs. There were only thirty drug treatment centers in Pakistan in 1991, with a reported cure rate of about 20 percent.

Acquired immune deficiency syndrome (AIDS) has not yet been much of a problem in Pakistan, probably as a result of cultural mores constricting premarital, extramarital, and openly homosexual relations. The effect of poor quality control on blood supplies and needle sharing among addicts is undetermined. The government has been slow to respond to the threat posed by AIDS. Cultural and religious restrictions prevent official policies encouraging "safe-sex" or other programs that would prevent the spread of the disease. State-run radio and television stations have made no attempt to educate the public about AIDS. In fact, the government has minimized the problem of AIDS in the same way that it has dealt with potentially widespread alcoholism by labeling it as a "foreigners' disease."

The Ministry of Health, however, has established the National AIDS Control Programme to monitor the disease and to try to prevent its spread. During 1993 twenty-five AIDS screening centers were established at various hospitals, including the Agha Khan University Hospital in Karachi, the National Institute of Health in Islamabad, and the Jinnah Postgraduate Medical Center. AIDS screening kits and materials are provided free at these facilities. By early 1994, approximately 300,000 people in Pakistan had been tested.

A center for AIDS testing has also been established at the Port Health Office in Keamari harbor in Karachi. Another is expected to open during 1994 at Karachi Airport. Beginning in 1994, all foreigners and sailors arriving in Pakistan will be required to have certificates stating that they are AIDS-free. Certificates of inspection are already required of Pakistani sailors. All imported blood, blood products, and vaccines must also be certified.

Zakat as a Welfare System

Social security plans were first introduced in the 1960s but have never achieved much success. Traditionally, the family and biradari have functioned as a welfare system that can be relied on in times of need based on reciprocal obligations.

In 1980, as a part of his Islamization program, Zia introduced a welfare system, known as the Zakat and Ushr Ordinance. Based on the Islamic notion of zakat, the aim was to forge a national system to help those without kin. The Zakat and Ushr Ordinance combined elements of the traditional Islamic welfare institution with those of a modern public welfare system. The ordinance's moral imperative and much of its institutional structure were directly based on the Quran and the sharia.

As a traditional religious institution, zakat involves both the payment and the distribution of an alms tax given by Muslims who enjoy some surplus to certain kinds of deserving poor Muslims (mustahaqeen). The traditional interpretation by the Hanafi school of religious law stipulates that zakat is to be paid once a year on wealth held more than a year. The rate varies, although it is generally 2.5 percent. Ushr is another form of almsgiving, a 5 percent tax paid on the produce of land, not on the value of the land itself. Both zakat and ushr are paid to groups as specified in the Quran, such as the poor, the needy, recent converts to Islam, people who do the good works of God, and those who collect and disburse zakat.

The Zakat and Ushr Ordinance set broad parameters for eligibility for zakat, which is determined by local zakat committees. Priority is given to widows, orphans, the disabled, and students of traditional religious schools. Eligibility is broad and flexible and presumes great trust in the integrity, fairness, and good sense of the local zakat committees. Although the program initially focused on providing cash payments, it gradually has moved into establishing training centers, especially sewing centers for women. By 1983 the zakat program had disbursed more than Rs2.5 billion to some 4 million people. The program, however, has come under a great deal of criticism for the uneven manner in which funds are disbursed.

Shia have vociferously criticized the program on the basis that its innate structure is built around Sunni jurisprudence. Shia leaders successfully have championed the right to collect zakat payments from members of their community and to distribute them only among Shia mustahaqeen.

Problems Deteriorating Education in Pakistan

Various research studies have indicated the psycho-social problems of the students, teachers, planners and managers working in the public and private sector of education in Pakistan. These problems can be studied under in three domains i.e. home-centered problems, community-centered problems and school-centered problems.

Although, the Quaid-e-Azam, Muhammad Ali Jinnah, in his message delivered in the first Education Conference 1947, categorically stressed on taking practical steps in reshaping the whole education system of the country, yet the situation regarding the education sector of Pakistan has been very uncertain and critical till yet. The commissions and policies till the recent years have beautifully worked out various strategies and plans for enhancing and changing the curriculum, giving quality education, preparing standard textbooks, resolving the problem of medium of instruction, streamlining the planning and management of the institutions, but due to the policies and reforms without implementation, the mismatch in public and private systems, the teaching of languages only and the polarization and existence of pressure groups have weakened not only the whole education system of Pakistan but the other institutions and organizations also.

Moreover, it is a fact that the attitudes of teacher, the response of student and the behavior of manager do have a crucial role in making the personality of the individuals and social progress, but in addition to this some physical problems that still exist here are the overcrowded classrooms, inadequate teaching materials, poor staffing, absence of equipped libraries and laboratories, and lack of physical facilities like playgrounds, drinking water, washrooms, recreational, common, medical and retiring rooms and furniture etc. This alarming situation has caused an awkward backwardness of the education system in the country.

Furthermore, besides the system problems as observed, it is obvious that the teachers' problems of insecurity, accommodation, remuneration, political exploitation life threats and deprivation prevent a teacher to play the role of an implementer, prompter, director, guide, counselor, manager, organizer and instructor inside the school and also halt him/her to work outside in the society as a good social.

Unfortunately, due to the lack of professional growth and leadership, teacher in Pakistan evidently faces a hurdle in the way toward lifelong and quality education. Most of the teachers are virtually literate and have regressive trends. However, the one room affair, the schools without boundary walls and the negligible participation of community also deteriorate the smooth process of education in Pakistan.

The broken homes, the social status of parents, poverty, orphanage, divorced families, crowded homes, sibling rivalry problem, family educational background, inferiority complexes, harsh discipline and child labour are also persistently showing their virulent fangs to tear down the learners in our country.

Teachers' Status in the Educational institutions of Pakistan:

Teacher is considered the most central source in putting all the educational reforms into practice at all levels. In Pakistan teachers' access to their democratic rights seems to be denied or not practiced properly according to the Policy Document of Pakistan which guarantees the realization of their democratic rights . The alarming aspects of their concerns are how to think up a plan of action that may facilitate them to have proper access to their democratic rights inside their institutions and in society as well.

Teaching is a very decent profession and a holy job. It uplifts and brings up the individuals as a responsible nation. The society has a lot of hopes from the teachers whom with the young generations have direct contact. Every nation desires excellent and fine production from schools and colleges. The learners imitate, identify and follow their teachers as model. The important part of our society is the educators who play revolutionary roles in the making of a nation. Their duty is plausible as they educate a child, the father of man, and a useful citizen of future.

Responsibilities and rights go together. Above and beyond performing a noble duty, the teachers have certain rights too. They have the right to live a respectably happy life in all aspects i.e. personal, social, cultural, religious, economic, and democratic aspirations, relations, affiliation and beliefs and practices in a proper manner. Teaching is a less attractive job in Pakistan, because the teachers face financial and economic hardships and they have to live within their limited resources. There is lack of the needed support from government and community is to facilitate them with respectable and happy life.

Due to the undemocratic administration here in Pakistan, a teacher faces problems of unreasonable and inappropriate work load. It halts to improve the quality of education and also makes the field unattractive to the new comers.

Educating children for quality and lifelong learning is very essential for the development of active citizenship, indispensable for their active part in a democratic society; and vital to promoting democratic culture. The role of teachers in promoting democracy learning through active and participatory approaches is essential. The Parliamentary Assembly and the Committee of Ministers of the Council of Europe (1997) suggested inclusion of the courses of human rights in all school curricula. In its further recommendation (2002), it was stressed upon that the initial training of teachers in education for democratic citizenship is mandatory for which various steps like lifting up the level of professionalism of teachers and introducing new measures important today are to be taken.

The challenges like cultural deviation and nationalism, worldwide threats to security, expansion of new technologies of information and ecological harms do demand the new caliber from a teacher. In addition to them are the problems of the population movements, emergence of the once repressed people and the increasing demand for individual independence and new forms of equality. Further more, the weakening of social makeup and unity among people , doubts about conservative political institutions, types of governance and political leaders, increasing political, economic and cultural interconnectedness and interdependence are persistently intensifying the increasing pressure on educators and teachers to prepare and pace with the new century..

The curses of globalization, internet hazards, radioactivity of the nuclear developments, greed for power over the weaker nations, immoral and unethical attitudes of the world powers, the genetic decoding, the tussles of civilizations and cultures also require teachers to be well-equipped. The prevailing social and moral evils demand the new roles of teachers. So, for their innovative roles and effective performance, the realization and recognition of teachers' democratic rights is very necessary. It is the need of the day to acknowledge and realize their democratic rights and assure their accessibility.

The rapidly changing world increases the need for an active, informed and responsible community which resultantly demands commonly accepted aim of education and role of teachers. In other words, the responsibility of teacher as a universal leader is greater. A teacher must be prepared for promoting forms of education and training at a time of increasing interconnectedness and interdependence at regional and international level.

Dürr and Martins (2000) suggest that the new form of education is to prepare the learners for actual involvement in society. To provide such teaching presents important challenges for the teaching profession. A teacher is meant to learn the new forms of knowledge, develop new teaching methods, find new ways of working and create new forms of professional relationships. Teaching should be enhanced with current affairs, critical thinking and skill teaching. .

Researches on the problem indicate clearly that problem in the realization of and access to the democratic rights of teachers in Pakistan still exists though the Constitution and Civil Laws of Pakistan contain their recognition and provision. In some cases the private educational managers in particular and public managers in general have been violating the democratic rights of teachers. Researches show that the situation in private and female teachers is alarmingly worse. It is because of the lack of their significant leading role and struggle for the realization of their rights.

The cause of this disparity is not only the community or government or educational managers but the teachers themselves so as they are not effectively performing their job and do not struggle for their rights. Consequently, this deprivation has disturbed the personality, competence and family and social life of teachers in Pakistan

Most of the teachers do have the caliber of management and leadership, like university teachers, but lack to actively participate in the struggles for the realization their democratic rights.

Article Source: http://EzineArticles.com/?expert=Mir_Alam_Said

PROBLEMS OF EDUCATION IN PAKISTAN

1 here was a time, when India sub-continent was noted all over the world as a glorious
centre of education and culture where students from all parts of the globe used to pour in
the educational and cultures Nalanda, Tax.la and Prayag attracted students from the
places, as far as Egypt, Greece, China, Sri Lanka and Indonesia. It was 'an ideal system of
education, which apart from disseminating sweetness and light, infused into the minds of
the pupils a spiritual urge for coming in contact which the kingdom of the Absolute. But
now when we look at the present state of affairs in our country, the change shocks us
deeply and we cry out in the language of Wordsworth.

"Whiter is fled the visionary gleam? Where is it now, the glory and the dream "400

for Prospective Headmasters

It is asserted with great regret by persons of almost every shade of opinion that our
educational system has not undergone any change with the change brought about by
political independence. It bears no imprint of freedom and appears to be as listless and
academic as it used to be during the days of slavery. Our universities still remain
anchored to the pattern that had been introduced a century ago by our British rulers to
serve their administrative needs. The imperfection of that pattern are now keenly felt and
there is a universal cry for introducing a radical change in the educational system - a
change that will touch not merely the methods and curricular but the very objective and
ideology of education, in accordance with the needs of the new social, economical and
political set-up in the country. Passive and Mechanical System

The crowing defect of our existing educational system that requires the immediate * and
earnest consideration of all those who are interested in the welfare of the country, is its
excessively passive and mechanical character. The students play no active role in the
attainment of knowledge. His entire education is passive and mechanical. Things are
loaded or his mind which he cannot digest, which he only crams and therefore they never
become his own. They remain floating on his mental surface a mere matter of idle
inquires; they never sink deep to become entwined in the mental texture, to help to
constitute a distinct intellectual and spiritual personality. Our educational system in the
words of Dr. Annie, is just 'cramming the boy's head with a lot of disjointed facts poured
into the head as into a basket, to be emptied out again in the examination room, and the
empty basket carried out again into the world."

This is the reason why a student who succeeds so well in his college examination fails so
miserably in the examination of life. The best product of our examination system is an
owlish looking, boy, a veritable bookworm who knows nothing of the world beyond the
world books. He is physically poor, intellectually blank and morally insolvent. He has no
proper grasps and assimilation, no views and visions of his own. He is determined to no
acts, has no desire to form convictions, arrives at no conclusions and his will seems to be
suspended, asleep, diseased or dead. He simply covers the window of his mind with the

pages of books and the plaster of book phrases sticks into his mental skin, making it
ineffective to all direct touches of truth. The present system of our education, therefore,
makes of the students dumb-driven cattle rather than enlightened citizens, bookworms
rather than creative thinkers, machines rather than ideal men. Our students, "act ,as
performing animals and animated dolls. Their souls are regimented and their faces are
without feature."

Theoretical Nature of the System

The existing system of our education is predominantly academic and theoretical. It is
theoretical as a rule and practical by chance. As Maulana Azad observed, "There is no
adjustment between the system of our education and the needs of our life. The student is
taught lesson from books but not lessons from life. In other words, he is provided
with^knowledge, but not with wisdom. He is obliged to know the history of Greece of
2,000 years ago, but he knows more about the English Country councils, than about own
municipality of his own town. He is so busy in leaning about "great and distant things
that he has little interest in life's little thing around him, he ,mmits to memory the
character - sketch of Hamlet some other imaginary person described in his book, but he
cannot read the character of his own friend or relative. He can recite the poems of Shelley
or the Gazals of Ghalib, but he does not know in what ways he can server his community
or nation. Want of Moral and Cultural Education

Now, we come to the question of moral and cultural development of our students. What
do our universities do for their character building? Do they strive to make them honest,
upright the truthful? Or, does their function finish only with imparting to them bits of
information? We have to admit sadly that today their function does finish with imparting
them bits of stimulating their imagination and feeding to their emotional life. They do not
inculcate in them a love of virtue and righteousness, a sense of selfrespect and personal
dignity. In the past, a student was taught to be God-fearing, to love and practice the rules
of religion, to obey his parents and respect his teachers. But today the false glamour of
western civilization has led our students astray and they have forgotten the noble ideals
and traditions of their past culture.

Our schools and colleges still run on those antinational lines that were laid down by
Macualay more than a century ago with a view to perpetuating the hold of British rule
and the domination of western culture. Their courses of study and text books do not
breath the air of freedom hardly feel of being the citizens of Pakistan, endowed with a
rich cultural heritage. In the name of secular education our schools and colleges have
become so colourless and un-Pakistani that their students do not feel any sense of
patriotism. The students of today are governed and guided wholly by worldly values.
They have no passion for the worship of the true, the good and the beautiful. They have
no love of learning for its own sake and even no sense of respect for the teacher.

The old pious bond of reverence and gratitude between the teacher and the taught has
been supplemented by unnatural, economic and official relationship. The teacher is
nothing more than a paid servant or the college or the university. The personal spiritual
relationship between the teacher and the taught has disappeared and consequently acts of in discipline and hooliganism have become deeds of daily occurrence with our student
community. The problem of growing indiscipline among the students is something which
reflects seriously on our educational institutions and which proves that they have been
totally incapable of producing youths of sound moral calibre, character and culture. Want
of Physical Training

Our students are poor not only intellectual but physically too. Their unsound minds live
in unsound bodies. Hordes of pale, spectre-thin youths meet the eyes at the portals of
colleges and universities. This is so because there is hardly any provision in our colleges
and universities for systematic physical training, games and sports and such other extra-
curricular activities. The want of physical training leads the students to lose in other ways
also. They do not learn the dignity of labour. They begin to shun labour of every kind,
physical or intellectual. They become idle, ease loving and extravagant. Jinnah deeply
mourned this neglect of physical work in our system of education. He advised the
educationists of the country to see that Pakistan's system of education is so modified that
the tremendous manpower of the nation is fully exploited for the progress and prosperity
of the people. The handful of Japanese is reported to have said that they can "live by the
tips of their fingers". Therein lies a great lesson for the students of Pakistan. The
Expensiveness of the Prevailing System

Considering the general standard of living in the country, it is definite that our system of
education is highly expensive. Even for the upper middle class people higher education in
our country has become a white elephant. The education of a student at the collegiate
level costs the community approximately one thousand rupees a year. This does not,
however, take into amount the cost of maintenance which is likely to amount to another
six hundred rupees a year. University education is thus drawing heavily upon the national resources of an impoverished community. A Pastime Luxury

In a way, our education has been a sort of pastime luxury, a form of amusement like many other modern thing of entertainment such as science has invented for us. Students go to schools and colleges more for the sake of amusement than instruction. Our classrooms have an appearance almost of a cinema hall, well furnished with chairs and electric fans and the blackboard which can be compared to a screen on the background of which the teacher stands more or less like an actor trying to please his audience by his saucy remarks, pleasant stories and a copious display of antics. He is on the stage and has to play his allotted part very wisely and wittily. Such actors appear before the huge audience of the students one after another and if any actor fails even a little in this dramatic performance, the audience get out of control and raises strange catcalls of all kinds to rectify the part of the actor, just as it happens in a theatre house. They have no love of wisdom, no thirst of knowledge, but only a desire to get * certificates and diplomas which may serve them as passport to white collars services. Want of Vocational training

The commonest criticism against our educational system, which is not, however, without justification, is that it does not fit us for earning our bread. Our colleges and universities are like factories that produce graduates in quick succession just as machines issues forth Pins and needles one after another on a mass scale. Every year thousands of graduates are turned out from these factories that wander into the wide world in their vain efforts to find employment. In life there is no demand for these university product. The result is that the more our education expands, the more the ranks of the educated unemployed swell. In the last few years, there is no doubt; our education has improved greatly but only quantitatively not qualitatively.

But, as an eminent educationist observes, "What the nation requires is not merely more
education, but also better education, and what will ultimately, count in the progress of the
race is not the quantity alone but also quality of our education as well". At present, our
students hold degrees which are pompous in name but poor in worth. A student holds the
degree of M.A. without knowing even a single art, simple electric switch or repair a
watch or a radio set His degree serves him only for delight and ornament, not for ability.
Much of the misery and frustration among the educated classes in our country man,
therefore, be attributed to this defective aspect of our education. Our schools and colleges
do not impart to their students any technical vocational instruction. There are no provisions for any training in practical manual labour, industry, mechanism, handcraft, trade or a profession. And this accounts largely for the problems of poverty and unemployment in a country like ours, which has vast treasure house of natural resources. Conclusion

In view of the foregoing defects and shortages, our system of education calls for a radical
change. One of the first and most stupendous tasks that face us today is to overhand and
reconstruct our educational machinery that the regeneration of the nation depends. We
have to devise as early possible a comprehensive national scheme of education which
seeks to bring about a complete and harmonious development of all the factors of human
personality. Our ideal pattern of education would be that in which emphasis is shifted
from the development of memory to the enfoldment of personality, from more intellectual entertainment to sound moral instruction. It would instil in the minds of youth healthy attitudes of cooperation the dignity of labour, and the values of constructive work it would stimulate their intellect and imagination for clear views and visions, and make to
them, not mere book worms and job hunters, but intelligent citizens and ideal that the
State Government as well as the managements of private educational institutions should
take early steps to give Pakistani colour to our schools and colleges and make them living
centres of productive activities on the lines of education as required by the nation.