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A Collection of Thoughts, Quotes and Experiences.     Page 7               

By Murad M. Khan MD, MRCPsych.
Associate Professor, Department of Psychiatry, The Aga University, Karachi, Pakistan

Any man's death diminishes me
Because I am involved in mankind.
And therefore never send to know
For whom the bell tolls
It tolls for thee'
- John Donne 1571-1631

Some things are meant never to be forgotten. Some things are meant to remain imprinted in one's memory long after the event has passed. Some things have such a profound effect on one that witnessing them changes one's life forever. Many years ago I was witness to such a happening. I have never forgotten it. It has remained imprinted on my memory. And- it changed my life forever....
Fate, it seems, conjures in all sorts of ways to place us in a certain place at a certain time. More than twenty years ago, fate intervened in my life and I found myself on the tiny island of Malta. You see, when I graduated from medical school in 1977 the Pakistan Army wanted me to serve in their ranks for two years. I thought otherwise. In Malta the island's doctors and the government were locked in a dispute in which the then government of Mr. Dom Mintoff wanted the doctors to sign some sort of a bond. The doctors thought otherwise. Not finding a way out of the dispute many of the doctors had left the island, others not permitted to work in the government hospitals. Only a small number were allowed to work at St. Luke's Hospital.
In Pakistan when I found out that Malta required doctors I was unaware of any problem on the island nor did I know the background to it. I only wanted to get out of Pakistan before the Army caught hold of me, put me in uniform and post me on some outpost on the foothills of the Himalayas! So when the opportunity to work in Malta came along I grabbed it with both hands.
Karin Grech was fifteen years old. She was the daughter of the Professor Grech- head of the department of Obstetrics & Gynecology at St. Luke's Hospital and one of the few doctors who retained his position at the hospital. Karin had been studying in England but had come home for her Christmas vacations. A few days before Christmas someone sent her father a parcel bomb. Karin happened to open it. In the middle of the ward round on the surgical floor we were told to rush down to the casualty..…..
Sitting alone in my room that night, going over the events of the day, I tried desperately to make sense of what I had witnessed. Try as I might, I could not. I was confused, angry, sad, depressed and numb. And I cried. I could not understand how one human being could inflict such horrific injuries on another. I wanted to erase from my mind's eye what I had seen. I wanted it to be as though nothing had happened. As though what I had gone through had been nothing but a bad dream from which I would soon wake up.
But the more I thought about it the more I realized that there had to be some purpose, some sense even in an apparently senseless and wanton act like this. After all, it was fate that had taken me from Pakistan, brought me to Malta and made me rush down to the casualty ward of St. Lukes Hospital on that fateful day. Surely it couldn't have happened all by chance or mere coincidence? But what was the moral, what was the lesson in this for me? Indeed, was there one?
Having spent the better part of the night thinking about the events of the day, the answer came to me in the early hours of the next morning. I had been a doctor only a few months. Yet, so early on in my career I had been witness to a young human being's suffering of the extreme kind. Rather than try and forget what I had witnessed, I had to make sure that it remained fresh in my mind so that at every turn, at every corner in my life I would be reminded- not of Karin's injuries or her suffering but of the frailty of human life, of man's inhumanity to man and of that vital, essential element of human existence we so often forget- that despite what we may think of ourselves, in the grand scheme of things human beings have but a tiny, insignificant part to play. I had to remember this for the rest of my life. As a doctor, who would deal with all kinds of sufferings I had to use this incident as a reference point in my life. I was to make sure that at least for one person this young girl's suffering would not be in vain.
The moment the realization dawned on me I decided to put down on paper what I had witnessed and experienced in the casualty ward the day before. The words are now more than twenty years old but even today when I read them it seems as though I wrote them only yesterday.
This is what I wrote.....
" You passed at a time when youth's morning was just touching it's evening. When I first saw you, you were just a tangled mass of blood, flesh and bones. Yet, a few minutes ago you must have been a happy, vibrant, full of life fifteen year old. What happened in those few minutes is now history. I never knew you, Karin, except when I stepped in the cubicle where they had placed you in. Yet in those few precious minutes I was with you, I developed a special feeling for you. I never spoke to you yet I knew through your soft moaning you were trying to reach out and tell me something. Your delicate hand now hanging so precariously by a few tendons and nerves must have picked many a flower or done many a beautiful drawing. Your pretty face now full of shrapnel wounds and so horrific to look at must have attracted many a young man. Your gentle blue eyes, now blood shot and moving lazily must have seen many a beautiful sunset. Your ear now missing from its place must have heard many a bird's song. Your beautiful body now lying lifelessly must have swayed to music at many a disco or a party Your tender legs now lying listlessly and looking so strange with needles and tubes sticking out from them must have run many a time after the spring air You lie there, Karin, moaning softly, moving slowly, each breath an agony, each heartbeat a challenge, as they try to fight off the inevitable ". 
    Karin was taken to the operating theater, although it was obvious from her injuries that she had no chance of surviving. The whole of her anterior abdominal wall had almost completed vanished from the intensity of the bomb blast. She was bleeding profusely- both from the inferior vena cava as well as the aorta, her abdominal organs just floating in a pool of blood. Incredibly though, she was alive- hanging on to life by the slimmest of chances. It was as if God wanted us - wanted me, to witness the specter, so that it may remain etched in my mind and change my life forever.
Karin remained alive long enough for us to take her to the operation theatre. Mr. Apap Bologna, Mr. Felice and I scrubbed for the operation. Dr. Azzopardi tried to anaesthetize her. But where was one to begin? What was one to do in such a situation? It was hopeless. Thankfully her agony ended within the next few seconds and Karin Grech passed into history.

Today, as I practice psychiatry in Pakistan, dealing with human suffering of a somewhat different kind, the time I spent in Malta seems a distant past. Yet I am frequently reminded of my brief, but fateful encounter with the brave young Maltese girl who in her death gave me a lesson for life.

PAKISTAN: Focus on growing problem of suicide 
An interview with Murad M. Khan MD and other experts....

ISLAMABAD, 9 August (IRIN) - Jamila will never forget the day she tried to take her own life. "I could not bear the suffering any longer, so I used razor blades to slit my wrists," she told IRIN. "They bled straight away, and I just sat in my bedroom until I 
became unconscious," she said. 
    But Jamila's attempt failed. "I woke up in hospital and was devastated that I was still alive," she said. Doctors said she was lucky to have survived, having lost a tremendous amount of blood. Asked why she had tried to kill herself, the 25 year-old said she had 
missed her family after getting married away from her home province. 
   Traditionally, the extended family system common in Pakistani society provides a comfort blanket for family members suffering from depression. But in this case it had been absent, resulting in an attempt that might never have been reported. 
  However, a prominent researcher, Professor Murad Khan of the Aga Khan University in Karachi, told IRIN that the extended family system could also be a factor influencing suicide. "It is very common for Pakistanis under pressure from the family or in-laws to 
feel suicidal." 
  Other reasons behind why people in Pakistan commit suicide are similar to those in the West. "For women, it usually boils down to relationship problems, while for men - unemployment and financial matters," Khan explained. 
Commenting on poverty-related suicides, Khan said: "Poverty is something that bothers us. Lack of jobs and no opportunities in the country are major factors in suicide cases." The official figure for unemployment in Pakistan stands at 25 percent 
  Khan also linked the international economic sanctions imposed on the country following nuclear tests to the rise in suicide rates by men. The economic downturn three years ago after the Islamic nation declared itself a nuclear power made it even more difficult for men to find work and provide for their families in this male-dominated society. 
  According to an observational study conducted by Khan, it is clear that most suicide victims in Pakistan are from the lower and middle classes of society. He maintains the root of the problem stems from the lack of knowledge about mental illness in the 
country, and the lack of adequate assistance available for the mentally disturbed. At the Islamabad psychiatric clinic, 30 percent of outpatients were suicidal, a psychiatrist, Dr Aftab Khan, told IRIN. He, too, believed that mental illness is the main cause of suicide cases. "There are a number of underlying reasons for people committing suicide," he said. "But if you are depressed you are more likely to kill yourself," he added. 
At least one out of 100 patients seen daily at the Institute of Psychiatry in Rawalpindi is suicidal. Statistics show that in 1999, some 129 male and 120 female suicidal patients were admitted. "These are only the patients that were able to visit the clinic," Dr Khalid Saeed, associate professor at the institute, told IRIN. "We fear the number of suicides in this area is more than double," he said. 
Saeed said it was vital to decide how serious each suicide case was, saying that when a patient walked through the doors of the institute, he or she was assessed on the frequency of suicidal thoughts. Doctors then tried to establish whether they had 
attempted suicide, and whether a serious method, such as firearms or other weapons, had been used. 
   According to Saeed, people from the lower income groups may not even realise they are getting depressed due to high levels of illiteracy, coupled with their financial situation, which makes them "highly unlikely to go and seek help". 
  Concerned about the acknowledgement of mental illness among rural communities, Saeed said there was an urgent need for integrating services for disturbed people in primary health care in Pakistan. Awareness and acceptance of the problem were 
As a starting point, the institute is arranging workshops to get the health data gathering centre to record mental illness by making people aware of how serious a condition it is and what it could lead to. "If we keep on pushing mental health issues 
under the carpet, and we know the serious repercussions, we are virtually pushing suicidal people over the edge," he said. 
The Human Rights Commission of Pakistan (HRCP) collects statistics based on newspaper reports of suicides. According to the figures, 2,000 suicides were reported between January and August last year. But according to studies by Khan, this figure is 
totally unrealistic in a population of 140 million. "Suicides are grossly under-reported in Pakistan," he said. 
Based on the HRCP method of collecting data, he estimated the figure for the entire year to be 3,000. He fears, however, that it could actually be much higher. "It may be eight to 10 times higher," he said. "We just do not know." 
Global figures arrived at by the World Health Organisation (WHO) show that in countries with a low incidence rate, eight to 10 people out of every 100,000 commit suicide every year, and in those with a high level, the number is more than double. 
"Pakistan's statistics do not even fall into the lowest category, so there is something seriously wrong with those [HRCP] statistics," Khan maintained. Compounding the problem is the country's central health data gathering system, which does not record suicide or mental illness as causes of death. Nor, like other developing countries, does Islamabad report mortality rates on suicide to the WHO. 
Khan has asked the government to conduct a comprehensive nationwide study on the issue, although he faces stiff opposition. Suicide is a taboo subject in Pakistan. In Islam, it is a sin to take one's life. Suicide is therefore a criminal offence in Muslim 
countries, carrying a jail sentence or a heavy fine, thereby deterring those who have attempted suicide from seeking help, he explained. 
"Muslims should not be committing suicide. It is haram [unlawful]," Amir Qazi Hussain Ahmad, the spokesman for the religious group, Jamaat-e-Islami, in the capital, Islamabad, told IRIN. "It is written in the holy book, and only God decides a Muslim's fate," he said. "This is our religion, and people know what the law is." According to Khan, however, Islam is no longer a strong deterrent. 
"Religion no longer prevents Pakistanis from committing suicide," he said. He argues that this is borne out by a dramatic rise in suicides over the last five to six years. 
Amin H. Karim MD, FACC, FACP, FRCP (Edin,), MRCP (UK).
Cardiovascular Diseases,
AngioCardiac Care of Texas P.A.
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Houston, Texas 77030-2706.
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