‘Help. Life. Hope. SIUT. Words that make a world of difference. Use your Zakat & Donations to reach out to those who can’t afford to live.’

These are the words on the banner before me as I wait for my flight to board at Quaid-E-Azam International Airport. When I landed in Karachi eight days ago, little did I know that I was embarking on a life changing journey that would allow me to see just how these contributions literally breathe life into the poor ill.

I thought I was going to CBEC SIUT to give a presentation on the ‘corporate physician’ and bio-ethical dilemmas in the global arena, and gather data for a research paper on the interactions between doctors and the pharmaceutical industry in Pakistan. I was actually about to be educated in emerging ethical issues in the biomedical arena from world-class presenters – and learn a lot more about humanity.

The view from the rooftop terrace outside CBEC will haunt me forever. I talk incessantly, but for once I was speechless. Men, women, children, babies in makeshift tents were waking up on the pavements below me. There were so many of them living on the streets, making breakfast in non-existent kitchens; some still sleeping in the littered lanes. I couldn’t quite believe that among them were patients being treated at SIUT, who were possibly waiting for kidney donors or needed dialysis or follow up treatments on a daily basis. The others were with their families, who had travelled from afar to be by their sides. I wondered how it was possible to work for a hospital surrounded by such pain and suffering and witness this heart-breaking existence every day. It all became clear when I was taken on a tour of the hospital and was told everywhere:

‘This isn’t a hospital; this is a phenomenon.’ ‘This is the only hospital in the world where you can be treated with dignity if you are poor.’ ‘Welcome to our hospital.’

It was in the paediatric nephrology department that I was overcome with emotion as a mother of a young child sobbed, and another grasped her son and asked me to check his files with urgency. I was surrounded by sick children and felt completely useless. The only thing I could do was nod and smile. They all smiled back.

Faced with the stark reality that the majority of the patients at SIUT (perhaps more than ninety per cent) are below the poverty line, it’s hard to imagine how any individual or company could do anything to harm them further and it is this sentiment especially that I take back with me to Scotland. My research interests lie in investigating how commercial interests impact on public health policy making – sometimes to the detriment of public health. There is evidence that pharmaceutical regulations put in place to protect the interests of patients may be ineffective and can be circumvented. Ineffectual rules or industry self-regulated codes of conduct may exist to create a veneer of respectability in developed economies, but are virtually non-existent in the developing world where multinationals flock to conduct clinical trials at a fraction of the cost.

In exchange, countries like Pakistan get ‘gifts’ in the form of corporate social responsibility – pharmaceutical companies plant trees in community gardens, which display their logos, instead of subsidising medicine for the poor. These promotional activities are often classed as philanthropy, but it’s only when you witness genuine altruism that you realise what the art of giving – without flashing the label of charity – is all about.

I’m grateful to everyone at SIUT and in particular those affiliated with CBEC for reminding me that there are very good people in this world, and reigniting my passion for research in bioethics. I am now convinced that there can be happiness and hope even for those who can’t afford to live.

In a presentation given at CBEC on 22^nd December 2017 entitled “Big Data: Losing Control of your Digital-Self” [1], I lamented about the ease with which companies have surreptitiously amassed a wealth of knowledge about us. Us as in the individual – you or I, not an aggregate sum. This data is being used in a multitude of ways and even where not malicious its use may cause harm.

Our world is changing. Behind all the apps, all the smart devices, and all modern digital comforts, there is one impetus – collect all the data all the time. The most valuable commodity in the digital world is not a crypto-currency but in fact our data. Even in the physical world data is more valuable than oil [1]. Everything we do leaves a digital footprint. Landing on a webpage creates a trail of evidence of our activities, both on our own devices (in the form of cookies) and on the servers running the website (in terms of access logs). The advertising eco-system that now drives the Web 2.0 and e-Commerce world, in fact exposes our data to hundreds of other entities without us knowing the extent or giving explicit consent.

While we consider this a necessary evil of the digital world, the ubiquity of digital devices means that this phenomenon of data harvesting translates to the physical world as well. As we walk through a public place – or any place – we leave traces of our presence. The signals (WIFI, GPRS, Bluetooth) emitted by our devices are detected and logged. Should you be so inclined, your home router can be converted to spy on the comings and goings of your neighbour¹ or their income level by counting the number of smart devices. Linking these detector systems with CCTV, loyalty cards, other smart devices (bulbs, home assistants, device finders) allows organisations to create rich models of ‘us’.

These rich models are the new commodity of the surveillance capitalism era. A term coined by Shoshana Zuboff in 2015 [2], surveillance capitalism is a new economic order that claims human experience as free raw material for hidden commercial and security practices [3]. The addictive nature and reward schemes of cyber (e.g. Snapchat), and cyber-physical (Pokémon Go) apps has led experts to estimate that we touch our mobile devices anywhere between 80-2000 times a day [4-5]. Through this constant use of our devices, the phone manufacturers and the app designers are able to collect data on us passively. Sensors within the device such as Accelerometer, GPS, App Census and Usage, 3G/4G signal strength, available WIFI Connections and device specific information sensors [6], allow the data collectors to infer¹ our age, gender, income, level of education, sexual identity, activity and preferences, political leanings, eating habits, friendship groups, and health [7]. The common retort to learning of the nature and scale of the data acquisition is, “What’s the harm? So, what if they personalise my ads?” However, the full context, circumstance and extent of the data use are not fully understood.

Understanding the problem from a Nicomachean lens [8] we can question the problem using the 5 W’s. Why is our data being collected? Possibly, this is the easiest of the five questions to answer. Our data is being collected to feed a process known as data-driven development. Computer scientists, engineers and domain experts the world over are building wonderful futuristic things, such as medical diagnostic tools, transport and logistics solutions, new business models, tools and services, and revolutionary urban infrastructure planning, to name a few. These developments have led to new commercial opportunities and a whole sector of pay-as-you-use services. This ‘servitisation’ first seen in the computer infrastructure world through cloud computing has spread to vehicle ownership (through ride share apps), books, films and music (through streaming services), to tourism (through accommodation sharing apps). The provision of these services and the entire business models is both reliant on our data and generates further data about the human experience.

What data is collected and what is it used for? While the first half of this question was answered in the preceding paragraphs, finding a complete answer to the latter half is problematic. At face value our data is used by those we give it to, to provide us a service, and to determine new products, services, or marketing opportunities. While a benign sounding outcome, new products, services, or marketing opportunities can span the design of a new screw-driver [9], all the way to a targeted campaign to influence elections [10]. Further, as we see in the next questions, when and where the data enters the security apparatus is completely obfuscated from us – the data subjects.

When was the data collected and when will it be used? Rightly or wrongly, many a famous personality find themselves in trouble for comments made 10-15 years ago because in some archive there is an errant tweet or post. While we may believe we have deleted a mis-informed tweet as soon as humanly possible, there are data aggregators that are automatically farming our activities in real-time. It is not just large organisations, anyone with a Twitter account can collect and store Twitter activity using the public interfaces.  Posts and tweets are not necessarily deleted from these archives. This information (known as a firehose) is then sold on to anyone with a credit card. It is foreseeable that an alternate Equifax-LinkedIn hybrid emerges the allows employers to get a moral, ethical or expected performance score of existing or potential employees that is based on their historical data footprint. The young adults (Gen-Z) of today (ages 20 and below) have lived their entire lives under the auspices of surveillance capitalism. The full impact of the data their parents and they themselves have shared about themselves is yet to be seen.

Where is our data being kept? This is where things become murkier. Our data has been collected over the last two-decades through different online and physical services by organisations who have changed names and owners hundred times over.  Technology evolves every 18 months and companies are constantly cycling deprecated (in the process of being replaced by new technology) equipment. So, what happened to the hard drive holding our biodata when we registered with a website, hotel, or conference in 2009? Is the hard drive still floating between offices? Was it dumped in the trash when the computer stopped working? Did someone else recover that information? Was the data sold on? Is the data still with the organisation? Do they keep it in the cloud? Is it secure? Before Hotmail/Outlook and Gmail cornered the email market, think of all the email accounts we had created in the nineties and noughties. Did we delete all the emails, pictures and information from our Supernet or Cybernet accounts? Did it disappear from their backups? Did we delete all our information and pictures from early social media e.g. Orkut and MySpace?

Who has our data? The final question for which no one can realistically give a complete answer. As is already clear from the other four-W’s, we don’t know the full extent of Why our data was collected, what all was collected (beyond what we put in a web-form) and what it will be used for, how far back does the data collection go, or what the data is now. The European Union’s Regulation on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (also known as General Data Protection Regulation: GDPR) tried to make a first stab at solving the Who problem [11]. On the 25^th of May, 2018 when the regulation went into effect we got a brief glimpse into the scale as many responsible organisations informed the data-subjects that their data was being held and what it was being used for [12]. However, the data subject either blindly clicked accept to the new terms and conditions or completely ignored the emails [13].

General attitudes in Pakistan tend to either be that Pakistan and Pakistani society is technologically so far behind Silicon Valley that the implications of these technologies are inconsequential, or that it does not matter if the pictures posted on Facebook or Instagram are processed by some algorithm. But the pervasiveness of digital technologies should not be underestimated. A look at Google’s Play Store [14] and Apple’s App store [15] usage shows that the vast majority of applications downloaded and used by Pakistani’s are made and designed by non-Pakistani entities. We are inadvertently surrendering our digital identities to foreign companies. The models they generate to represent us may have inherent biases that are can be seen affecting people of colour in the West [19-22]. The new tools and services built on these models will inevitable find their way into the Pakistan (banking KYC and loan assessment software, student performance evaluation software, etc.)

We may never know the full extent of who has our data or whether it will come back to bite us in an Orwellian, or Huxley-ian, or Gasset-ian dystopia. The general consensus is that it will be a dystopia.

[1]A demonstration of these techniques and their effectiveness were covered in a seminar by the author, a recording of which can be found on the CBEC Facebook pages.

References:

1. https://www.economist.com/leaders/2017/05/06/the-worlds-most-valuable-resource-is-no-longer-oil-but-data
2. Zuboff, S. (2015). Big other: surveillance capitalism and the prospects of an information civilization. Journal of Information Technology, 30(1), 75-89.
3. Zuboff, S. (2019). The age of surveillance capitalism: the fight for the future at the new frontier of power. Profile Books.
4. http://time.com/4147614/smartphone-usage-us-2015/
5. https://blog.dscout.com/mobile-touches
6. http://www.surveyswipe.com/passive-data-collection.html
7. https://theglassroom.org/glassroomlondon/exhibits
8. Sloan, M.C. (2010). “Aristotle’s Nicomachean Ethics as the Original Locus for the Septem Circumstantiae”. Classical Philology. 105: 236–251. doi:10.1086/656196
9. Chandra A. and Chandna, P. (2011) “Ergonomic design of hand tool (screwdriver) for Indian worker using comfort predictors: a case study” International Journal of Advanced Engineering Technology, vol. 2, no. 4, pp. 231-238
10. Cadwalladr, C., & Graham-Harrison, E. (2018). The Cambridge analytica files. The Guardian, 21, 6-7.
11. http://support.gnip.com/apis/firehose/overview.html
12. https://dev.twitter.com/
13. https://eugdpr.org/
14. https://www.bloomberg.com/news/articles/2018-05-25/blocking-500-million-users-is-easier-than-complying-with-gdpr
15. https://thenextweb.com/eu/2018/12/27/gdprs-impact-was-too-soft-in-2018-but-next-year-will-be-different/
16. http://xyologic.com/
17. http://appannie.com/
18. https://atlantablackstar.com/2016/01/31/study-racial-discrimination-in-mortgage-lending-continues-to-impact-african-americans-with-a-black-name-lowering-ones-credit-score-by-71-points/
19. https://www.theguardian.com/inequality/2017/aug/08/rise-of-the-racist-robots-how-ai-is-learning-all-our-worst-impulses
20. https://www.forbes.com/sites/bernardmarr/2019/01/29/3-steps-to-tackle-the-problem-of-bias-in-artificial-intelligence/#51fc08297a12
21. https://www.mortgagebrokernews.ca/news/technology/ai-needs-a-lot-more-work-before-it-can-be-safely-used-in-mortgage-253820.aspx
22. Morstatter, F., Pfeffer, J., & Liu, H. (2014, April). When is it biased?: assessing the representativeness of twitter’s streaming API. In Proceedings of the 23rd international conference on world wide web (pp. 555-556). ACM.

“It takes the whole of life to learn how to live, and – what will perhaps make you wonder more – it takes the whole of life to learn how to die.”

– Seneca, 65 CE

The quest to defy death is as old as humanity itself, perhaps older. In the Abrahamic scriptures, including the Quran, the first human, Adam, is deceived by Iblis (Satan) into eating the forbidden fruit of paradise to acquire immortality (Quran 20:120). The avoidance of death and the quest to prolong life is a pattern repeatedly woven into the tapestry of human stories. In a Greek myth,^[1] Eos, the goddess of dawn, asks Zeus to grant her lover Tithonus (the prince of Troy) immortality but forgets to mention eternal youth along with it. A tragic end follows when Tithonus reaches a “hateful old age,” getting to a point where he is not able to even lift his limbs. Finally, Eos locks him into a chamber where he babbles endlessly. In another Greek myth, the Cumaean Sibyl (a Greek priestess) asks the god Apollo for a thousand-year life, but forgets to mention enduring youth. In the end, she too becomes the “prey of a long old age” and shrinks until she is confined to a jar, whispering, “I wish to die.”

The Roman Stoic philosopher Seneca remarked that it is not only difficult to learn how to live but that “it takes the whole of life to learn how to die.” A few thousand years down the road, humans have not yet succeeded in evading death but medical advancements in the last century are pushing back the boundaries, raising new questions about what kind of life is worth living and what it means to die well. In one of Plato’s dialogues (The Republic, Book III), Socrates says that Herodicus, regarded as the tutor of the Greek physician Hippocrates, tormented himself as well as others “by the invention of lingering death.” Herodicus, who had a chronic disease, spent his life trying to cure himself. Since recovering from that disease was impossible, he used his skills in medicine and therapy to keep himself going till he reached old age. Plato criticizes Herodicus for practicing such coddling medicine and argues that Aesculapius (the god of medicine) did not teach such medical practices – not out of ignorance but because Aesculapius was concerned about society’s functionality. In a well-governed society, according to Plato, there is a function specific to each member of that society, and no one has “leisure to be sick” and doctor himself all his days.

Whether we agree with Plato’s rather stern viewpoint about a useful life or not, it is hard to deny that medical advancements that are making it possible to live longer, are changing the ways in which we die. In traditional narratives of death in many societies, an old parent would die in his bed after having distributed inheritance and attended to his responsibilities. Death in a familiar environment, surrounded by loved ones, fulfilled the dying person’s psychological and emotional needs without involving many healthcare professionals. Death was deemed imminent and faced with patience and confidence. This was a constant in history across cultures. Prophet Muhammad’s companion Bilal bin Rabah on his death bed, sang, “Tomorrow we shall meet with our beloved ones, Muhammad (peace be upon him) and his companions.” The Sufi ascetics embraced death gladly, viewing it as a means of union with God. Ibn Qayyim al-Jawziyya explained that death was a way of union with God, saying, “Every lover yearns for the meeting with his beloved.”^[2]

In fifteenth century Europe, Christian texts titled Ars moriendi (the art of dying) were well known. These texts provided guidance on the proper rules and procedures for facing death in the best way. For those who gladly accepted it, death was not only a natural process but also had a spiritual and ‘other-worldly’ aspect. Dreams and the presentiment of death were common, even among ordinary people. French historian, Philippe Ariès, quotes from the history of Europe, the last words of kings, knights, saints, common people – even children – calmly facing death. “I shall not live two days,” “I see, and I know that my end has come,” “I feel that death is near,” “My death is at hand, that’s what it is,” were common phrases near death.

Despite the fact that people in earlier times prepared themselves for dying well, death did not ask before coming – nor could it be turned away. With the rapid scientific advancement in the last century, death has become less adventitious, at least, in technologically advanced societies where a large cohort of the population dies after going through the regular phases of life (education, marriage, career, and children) and reaching old age. Death no longer seems as unpredictable as before, but something has been lost: The presentiment of death has become rarer.

According to a well-known quote by Ivan Illich, “In every society, the dominant image of death determines the prevalent concept of health.” Death in our times has been medicalized. From an inevitable natural phenomenon or a call by God, death has transformed into the effect of an identifiable cause (disease) which it is possible to get the better of. The categorization of death into natural and unnatural/abnormal/accidental supplements this perception. Along with this, the idea of ‘savior’, formerly invested in the physician’s persona, has now materialized in the form of the healthcare institution and we turn to the hospital to save us from death. The resultant medicalization of society elevates the ‘power over death’ perception to a new level. Death feels optional. Consequently, people spend massive amounts of money on healthcare in the last few days of life. While this does not eliminate death it does create the most rational and normal form of death – a hospitalized death under the supervision of medical experts.

Some contemporary writers, especially from the medical fraternity, have also started focusing on this topic. Atul Gawande, in his essay, ‘Letting Go’, writes that anxiety about death is increasing in modern society. According to Gawande, until the actual declaration of death, there is often a state of denial regarding impending death by both the patient and the family. Possibly, the denial stems from this relatively new, institutionalized image of death as something that can be controlled, circumvented, defeated – or even chosen. As a result, the modern, hospitalized death often follows extraordinary efforts to ‘do everything’ to prolong life – regardless of the quality of that life. For those who are engaged in healthcare provision, a BMJ editorial asks a thought provoking question: “Would you like to die the way your patients do, doctor?”^[3] As Seneca wrote, the question of how to die is perhaps connected to the question of how to live –  the other side of the same coin.

[1] Homeric Hymn to Aphrodite

[2] Ibn Qayyim Al Jawziyya, Madarij Al Salikeen (Ranks of the Divine Seekers: A Parallel English-Arabic Text) Trans. Ovamir Anjum (Brill, 2020), Vol 2, 620.

[3] Enkin, Murray, Alejandro R. Jadad, and Richard Smith. “Death can be our friend” (2011). BMJ; 343.

The Centre of Biomedical Ethics and Culture turned ten in October 2014. We celebrated our first decade the way we know best – by creating more work for ourselves! As reported in the previous edition of the Bioethics Links, (accessible at:  http://www.siut.org/bioethics/Newsletter%20June,%202014.pdf), CBEC faculty decided that the Centre needed to be reviewed by an international group of peers so that we could get an unbiased opinion regarding our accomplishments, our shortcomings and our future trajectory. The fact that such a review of a bioethics centre had never been reported in English language literature did not deter us; we are quite used to inventing our own wheels. Our reviewers were also brave to accept the challenge of the unknown and take up the onerous task of doing something they had never done before. Their commitment lasted much longer than the four days they spent on campus; it consumed several weeks thereafter during which the eight willing academics visited CBEC, toiled hard to make sense of what they observed, and to put it all in a report that was submitted to the SIUT Director in June 2014.  Their findings resonated with those of three external evaluators who had submitted their analyses based on their experience with CBEC and its activities and a faculty report that had been sent to them.

Our reviewers found the academic programs to be rigorous, interactive and challenging. Commenting on the course work they said, “The quality and topic range of the modules are world class.” Regarding the impact of the programs, they opined that CBEC’s “bioethical influence has extended beyond its office walls to other medical and also non-medical institutional settings …”

The review team found several distinctive features of CBEC which set it apart from other bioethics centres around the world. In the opinion of one reviewer, among CBEC’s most distinguishing characteristic(s) was the “inclusion of the term and concept of ‘Culture’ in its name” and the attention given to religion as a source of ethics. Another commented that, “CBEC’s conception of ‘culture’…   attempts to link ‘particularism’ and ‘universalism’ through its recognition of the ‘commonalities’ along with the dissimilarities that persons who belong to different societies and cultures bring to a moral life … This kind of multi-faceted and knowledgeable perspective on culture(s) is one of CBEC’s most distinctive attribute. It is a perspective that is minimized or marginalized, if not largely ignored by many other bioethics centres.”

Reviewers noted that an important feature of the teaching is “how well grounded instruction is in the clinical realities that students face in their professional lives. A fine balance is struck between didactic teaching and exposure to conceptual bases of bioethics … many programs in the West and elsewhere, fail to find this balance.”

The review team also appreciated the formal inclusion of literature, poetry and humanities in formal educational sessions. They were particularly pleased with the way CBEC faculty keep in touch with the alumni and facilitate them in their various bioethics related activities. The efforts made to keep the network of alumni engaged in bioethics, years after their graduation was also noted.

While acknowledging the Centre’s achievements at national and international levels, the reviewers however felt that the small core faculty could eventually “burn out” if faculty and support staff were not increased, strongly recommending an increase in their numbers. While impressed by the research output from CBEC over the last decade reviewers recommended that we devise a research agenda and appoint faculty specifically trained in research to be able to use our potential to the optimal. Dr. Adib Rizvi, SIUT’s Director, knows how to consolidate his successes. Based on the review recommendations, he has asked CBEC to embark upon an immediate expansion of its programs.

Needless to say, CBEC faculty was delighted with the report! We also found the review process to be a learning experience providing us new insights into ourselves, while also helping us to chart our future directions.

It is a routine Tuesday morning with my usual cup of tea in the solace of my room at work. This hour of tea is my time to kindle my thoughts: sit at the computer, check my mail, and meet some deadlines before the day begins. It’s Tuesday and I have a theatre case, a mastectomy on a breast cancer patient. It’s mundane, it’s routine but I know from all these years of practice that for the patient it is a life changing day, I know there is hope for cure for which she lays her life in my hands.

Let’s not dwell on these frills, it was a usual theatre morning where I go and the activities begin. Operation theatres have an exclusive atmosphere where there is the chitter chatter with residents and colleagues, pulling each other’s leg as hardcore work is done. The theatre is like a charm bracelet, you love it without really knowing why. It is the same ring you wear every day, but if you forget to wear it on a particular day you feel incomplete. For some hardcore coffee drinkers, it is a freshly brewed shot of hot coffee and for the book lover a novel you would love reading again and again: there is no argument about the intensity of the relationship of a surgeon and her theatre.

Where was I? Yes, in theatre and I have just finished my breast case and enjoyed my second cup of tea when I receive a call from my registrar reminding me that it’s my call day. There is a young woman with a gut perforation most likely due to typhoid. She is prepared for the standard emergency laparotomy and I have her shifted immediately to the theatre and the elective cases must go on waiting. Waiting, yet another classical experience in the OR – when will they shift the patient? Just as I decide to check, a female resident comes to the surgeons’ room and says the patient is refusing surgery. My male colleagues, with sarcastic humour, goad me to go and speak to the patient with compassion and empathy, which they believe are female traits, to convince the patient for the inevitable surgery.

I walk into the theatre and see a young woman who is supposed to be twenty-five years of age but looks no more than eighteen, beautiful in her simplicity, insisting that she will be fine. She does not want surgery. I begin to explain what is wrong in a language (Urdu) which I believe she understands. I explain that her life is of value and attempt to explore her fears but all I get is refusal and that she will become OK. I emotionally blackmail her: she has six children who need her and this is a routine surgery. I reinforce that she should trust us. There is no shift, instead she asks me if I believe in God and when I acknowledge this I am told, “For the love of God I don’t want surgery, it does not matter if I die.” I walk out of OR flustered and upset wondering how this mother of six can be so stubborn. I doubt her comprehension, and am willing to deceive her and have her anaesthetized with absolutely no moral discomfort. Controlling my frustration and anger I decide to call her husband who had consented for her surgery. My colleague, observing the drama, teases me that this paternalism goes against the ethics of care I am known to talk about.

My patient is in a state of emergency, in sepsis, kidneys going into failure with a pathetic nutritional status. Her husband, gowned, comes to the operating theater to speak to her. A cute couple, he patiently tries to explain to her that it is for her good, she argues with him and says you deceived me into coming to the big city, just take me back, I don’t want this surgery. Others in the room are viewers of the communication but the couple is oblivious to everyone. Some intervene and try to make her see the light. Her husband and a technician switch into their local dialect, and between her half “yes” and half “no” and the husband by her side with his arms around her, she is anaesthetized and the operation is underway.

Routine typhoid perforation, contamination that requires a thorough washout and a stoma (temporary opening made in the intestine) for she is nutritionally depleted and her parameters would not take anything else. Registrars do a good job and she is shifted to a step-down ICU and does well.

The next day her parameters improving, she is talking. Her stoma is a little slow to function but that is expected after such a surgery. She demands food which most of us believe is a good sign of recovery. However, her husband is told that only sips of water are allowed. I believe that within the next twenty-four hours she can take fluids and suck on sweets for taste; feel pleased at seeing her expression when she sips packaged mango juice, savoring the flavor she wants to gulp it down fast. Smiling, I ask her to take it slow and to drink more after a while. She changes her role and becomes a friend, complaining about her husband not giving her anything to eat or drink. I tell her, he is just carrying out doctors’ orders. Humorously, I tell the husband that your wife though delicate, is a headstrong woman, and I take my leave feeling happy. Tomorrow is another day, should one not feel happy or satisfied?

I see her once in the morning when all is well, her stoma functioning and labs normalizing, but as the minutes turn to hours the picture has changed. By the end of the day there is something not right, she is restless and drowsy all in one, her urine is concentrated. Am I missing something, what can it be? I tell my registrar to keep a watch and make sure he evaluates her again before he leaves at the end of the day. The next I hear of her being shifted to intensive care because of tachypnoea (fast breathing) and being electively ventilated with the expected need of ionotropic support. Why for the life of me I ask, her chest was clear, her parameters were near normal, why, just why? It becomes a downhill ride from there on, she starts to get acidotic, we stand by the bedside and look at her head to toe, we debate her re-exploration, has she perforated again, there is a septic focus somewhere. The resuscitation goes on, the labs get repeated to no avail and we discuss and explore in search of a reason for sepsis. We remove the double lumen placed, we check the chest, to find no answers anywhere. The much-needed CT scan cannot be done for her condition would not allow that kind of movement.

Then begins a feeling of impending doom that most surgeons have experienced. The conversation becomes another set of routine sentences: Ph is acidotic, urine output is only 12 ml in the last hour, she cannot be dialyzed because her pressures are not being maintained, dose of inotropes have been increased but BP still low. Nothing, just nothing gets better and finally the call that always makes you feel you failed comes and the saga ends. Aptly said in such circumstances: “man proposes and God disposes”; as mere humans we cannot fight fate.

Later in the day I ponder: where did I go wrong, what did I miss, I should not have forced the surgery. However, deep down I know if another such case came I would do the same thing, in the hope that this one would make it. I see her face and it is still painful, it is too soon to closet and move on. My eyes blur to say no more.

Oh My Blog!
Beenish Syed

As a PGD student, my life became a roller coaster ride of never ending assignments, readings, and end of module tests.  But posting on the monthly “Blog” was my most daunting task. Before acquiring an “ethical lens” I was unable to see the ethical issues embedded in my daily routine as a doctor. So I decided to write about these on the Blog. To my delight, my postings generated lively discussions among my colleagues and the faculty.

Challenging My Own Beliefs
Atif Mahmood

When I first started my PGD journey, the hardest thing to do was to tackle morally dubious subjects. Having to navigate through difficult moral conundrums made me more aware of subtleties that exist outside textbooks and made me question my beliefs. However, this discomfort helped me grow, giving me a better knowledge of other people’s viewpoints and forming my own moral compass.

From Reels to Ethics
Saima Saleem

After years of working as a filmmaker and media person, embarking on my PGD journey in CBEC felt like a genre shift. Initially, I felt lost amongst the medical jargon but for me the most challenging part was to unlearn my own biases. In stark contrast to the hero-doctor image depicted in media, I realized the ethical tightrope medical professionals walk daily.

The Prejudice of Certainties
Arsalan Khan

Enrolling in PGD bioethics, entrenched in scientific facts and anchored in religion, I stumbled into the grays of uncertainties. The once clear “facts” blurred, exposing unexamined biases. Graduating from the one year program, I now recognize the paramount challenge: understanding other points of view, untainted by the distorting hues of personal opinion.

Refaat Alareer was born in Gaza City in September 1979 during the Israeli occupation of the Gaza Strip. He was killed on December 6, 2023 by an airstrike in northern Gaza during the present invasion underway of the Gaza Strip by the Israeli army.

Alareer was a poet and an activist, and professor of world literature and creative writing at the Islamic University of Gaza. He considered the power of storytelling as an important form of resistance and co-founded the organization “We are not Numbers,” a mentorship program for Palestinian writers. He was editor of Gaza Writes Back: Stories from Young Writers in Gaza, Palestine (2013), and Gaza Unsilenced (2015).

While sheltering in a UNRWA school, Alareer had received multiple death threats stating that the Israeli army knew his location. He sought refuge in his sister’s apartment which was subsequently bombed killing him together with his brother and nephew, and his sister and her three children.

Alareer wrote his poem “If I Must Die,” a few days before he was killed and it has been widely circulated and translated into over 40 languages since then. It was inspired by Black poet Claude McKay’s 1919 poem “If We Must Die,” a passionate denunciation of racism and all forms of oppression, and a call for resistance against such practices.

If I Must Die
Refaat Alareer (November 1, 2023)

If I must die,
you must live
to tell my story
to sell my things
to buy a piece of cloth
and some strings,
(make it white with a long tail)
so that a child, somewhere in Gaza
while looking heaven in the eye
awaiting his dad who left in a blaze —
and bid no one farewell
not even to his flesh
not even to himself —
sees the kite, my kite you made, flying up above,
and thinks for a moment an angel is there
bringing back love.
If I must die
let it bring hope,
Let it be a story

In 2011, more than 12000 Palestinian children flew kites on the beach of the Northern Gaza Strip during a summer camp organized by the United Nations Relief and Works Agency (UNRWA). They achieved the Guinness World Record for the largest number of airborne kites at a given time. During the event, the children also carried the portraits of 66 Palestinian children who had been killed in the Palestinian enclave by Israeli airstrikes during a previous conflict.

Credit: UN Photo/Shareef Sarhan https://www.flickr.com/photos/un_photo/6029204185

The Ethics and Culture Hour (ECH) is an event that CBEC hosts for a wider audience at periodic intervals. Revived after a hiatus of two COVID inflicted years, the focus of this particular ECH was to look at the life and work of the Pakistani poet, Ada Jafarey, regarded as the First Lady of Urdu Poetry through the prism of her autobiography “Jo rahi so bekhabari rahi.“

The catalyst for the event was the recently released translation of the autobiography from Urdu to English, titled “A World of Her Own” by her son and CBEC faculty, Dr. Aamir Jafarey with his daughter Asra. As the translated work states, “this autobiography is the tale of an ordinary girl, and a woman from a traditional household … The girl was a captive of the loneliness that filled her heart, became the woman, who despite being confined to four walls wandered the expanse of her imagination freely.”

For Aamir, the initial motivation to embark on this challenging project was to make his 8-year-old daughter comprehend her grandmother’s story. As years went by, Asra joined as a formal collaborator in the translation while she pursued her graduate degree in English literature. During the event, Asra theorized the limitations of translated works, capturing her dissatisfaction with the product by stating “Almost there, but not quite.”

Nida Wahid Bashir, CBEC part time faculty, who had played a key role in the planning of the event, also served as the moderator for the evening. Dr. Moazam welcomed the guests and spoke about the centre. She also introduced Aamir Jafarey and invited him to talk about the translation. The two guest speakers were prominent poets of Pakistan, Mohtarma Zehra Nigah and Professor Pirzada Qasim, who spoke about Ada and her poetry. The evening ended with a ghazal performance by renowned singer Salman Alvi. Bushra Shirazi closed the session by giving a vote of thanks to all the people who were involved in making the ECH a success.

In October 2023, the Pakistan Association of Urological Surgeons (PAUS) invited me to give a State of the Art Lecture in their international conference held in Karachi. As a female surgeon, I chose to speak about the continuing challenges for women wishing to train in and practice surgery subtitling my talk Hunooz Dilli Dur Ast (Delhi is still far away). This famous phrase, traced to 14th century Sufi Nizamuddin Auliya remains, I believe, an apt metaphor for women wishing to pursue surgical careers.

During the 1970s and 1980s while training in general and pediatric surgery in the USA, I was the sole female trainee in surgical programs, and subsequently the only female surgeon for a decade I spent as faculty in an American university. I was constantly reminded how tough it was to become a surgeon, that “even men do not make it through training,” that surgery “requires a man’s temperament, women are too soft, emotional,” and given backhanded compliments that I “worked like a man.”

One could argue that matters have changed since then for women wishing to become surgeons. However, studies published within the last five years indicate that for many women Dilli dur ast remains the reality. The global increase in females graduating from medical colleges over the last three decades (now 50% to 65% of graduating classes) does not reflect a proportionate increase in women trainees/consultants in surgical specialties (excluding gynecology).

Due to lack of indigenous research, this information is unavailable from Pakistan but I suspect the numbers may not be too dissimilar. I conducted an informal, pre-talk survey of the three top healthcare institutions, all with sought after surgical training programs, that had organized the PAUS conference. Between them, they had well over 200 surgeons on staff of which roughly, 20 were women. Majority of female surgeons held junior positions and merely two women had made it to full professor.

A comprehensive scoping review about the experiences of female surgeons from 26 countries (Human Resources for Health, 2020) reveals several factors that continue to serve as hurdles for women. Among the most pernicious is the persistence of stereotypical gender roles, the old canard that “biology is destiny.” Notions that women are less courageous than men, emotional, less rational, are voiced as jokes and jibes directed against female trainees and surgeons. Such perceptions often translate into gender based discrimination against women in surgery with less opportunities in the Operating Room (OR), and emotional and physical harassment by male surgeons.

The scoping study specifically identifies lack of mentorship as an important global impediment reported by women trainees and younger surgeons. Sociological studies indicate that having female surgeons on the faculty can encourage young women to consider surgical careers. This pattern of a dearth of mentorship for women trainees, also surfaces during my conversations with younger female surgeons in Pakistan. Curiously, I also hear from some criticism of women who do “make it in surgery” yet remain unsympathetic to experiences of younger colleagues.

As a woman mentored by male surgeons, I believe it is important that we work towards not perceiving surgery as a war between the sexes. Experienced surgeons, female and male alike, can be effective mentors, tough but fair irrespective of the sex of trainees and younger colleagues.

The Spanish poet Antonio Machado writes, “Traveler, there is no path; the path is made by walking.” Female and male surgeons in Pakistan, and globally, have to walk together to make this path.

When I think of spaces in Karachi, places where I can go alone or with my female friends, I think of being enclosed within four walls. Spaces and places are the same here. They consist of the same four walls, with the limited activity Karachi offers. The only aspect that changes is their interior design. Because spaces for women in Karachi are confined to four walls, a sample book on aesthetics, yet claustrophobic.

The term ‘walkable cities’ is the utopia I envisioned growing up, but it’s a bit of a buzz-word now. It’s an easy win in any argument when a relative asks me why I want to go abroad, what’s so special about Chicago. “Why don’t you stay in Karachi with your family?” ask my relative aunties. “Walkable cities, Aunty.” I reply with a smile, nod and walk away knowing there’s no response they could possibly give to this.

***

In Phadke’s book “Why Loiter” (2011), she talks about how it’s not only unfriendly people that make a place unsafe, but also unfriendly spaces. Design choices that make public spaces obscure and private feed into the notion that the public street is dangerous, and solidifies the gendered distinction that public spaces are to be occupied by men, and the ghar (house) is the only safe spot for women.

While conducting a research study conducted with a colleague in 2020 that involved online surveys with hundreds of women, a rough list of factors affecting the safety of a place for women emerged. The prominent ones included lighting, openness, visibility, security, walk-path, public transport and gender disparity. All these factors are essential when designing a space; after all, who doesn’t think of them when designing a space for public use? However, these metrics are rarely applied within the context of public spaces in Pakistan.

The crux is that the elimination of female comfort when designing public spaces is not taken into account reflecting a deliberate disregard in order to maintain a patriarchal equilibrium, to keep women out of public spaces not meant to be theirs.

***

I’ve spent the last five months walking on the streets of

Chicago. The Institute I attend is in the middle of the metropolitan overlooking Millennium Park and the Art Institute of Chicago. My lovely, small apartment that I share with my friend is almost a 40 minute commute from there. Twenty minutes of that commute is a walk, and the rest is by the train.

The idea of walkability is so novel to everyone I know in Karachi that my stories of the Chicago Transport System will be met with awe. No one in Chicago bats an eyelid when I say that in my circle of fifteen in the city, nobody owns a car despite being in their mid-twenties. This is so because for Chicagoans, cars are not a necessity since for the most part the city is walkable, filled with at least 11 different train tracks and thousands of buses. You can get from the suburbs to downtown without needing a car. You can walk to the grocery store without fearing for your life. You can cross the road and have cars stop for you without fearing someone driving over you. All of which is utopian for someone from Karachi.

***

I am back in Karachi for my winter break. Somehow after spending a few months in Chicago, my automatic response of walkable cities to aunties does not roll off my tongue so easily now. It’s because I realize that I would not be caught dead using the underground subway after 10pm in Chicago, I recheck the train schedule five times before I descend down into the station, and I use the ten-minute walk between stations to call someone because the streetlights are still too dim to feel safe. The metrics of safety for women are not perfect in Chicago either. There is a stark difference in security and lighting once you leave the Downtown Loop and enter the rest of the city. I am realizing that my bar for freedom of mobility for women has been so low that Chicago seemed a utopia to me, but only because it does provide a bare minimum for women which Karachi fails to do.

Here in Karachi, I drive my beat-up white Mira to pick up my friends Ariba and Mariyam because driving them around is safer than calling an Uber. We cruise the city in the hours between noon and maghrib (sunset), we dodge calls from our mothers when we cross the timestamp of 5 p.m., we hop from one cafe to another, and we end up at V.M Sanctuary, an indoor space to work.

We raise our cups of mediocre chai (tea), and we laugh about how we are the awara (wayward) girls in our families. The so-called progressives who have traded the four walls of our homes for the four walls of these cafes.