She Slapped Me in 1985 – It Still Hurts

Partner Content

I joined the Department of Community Health Sciences at the Aga Khan University Medical College (AKUMC) in 1983 as its first Preceptor. The other faculty members included Dr. Pierre Tousignant (Acting Chairman), Mehtab Karim (Demographer), Fozia Qureshi (Pediatrician), and Samia Altaf (Public Health Specialist).

We began our community programs by conducting a baseline household survey in Orangi Town, located in the northwestern part of Karachi. With an estimated population of 2.4 million, Orangi was often described as the world’s largest slum or Katchi Abadi. Life there was a daily struggle against poverty, disease, and despair.

The rapid, unplanned growth of the settlement created acute environmental challenges that were severely affecting the health and quality of life of its residents. Narrow, congested lanes were lined with open drains carrying wastewater, often clogged and overflowing, creating breeding grounds for mosquitoes and flies. Solid waste collection was irregular, and heaps of garbage were piled along streets and vacant plots, emitting foul odors. The shortage of clean drinking water had forced many households to rely on unsafe sources, increasing the risk of waterborne diseases. Poor ventilation in densely packed housing, coupled with inadequate sanitation, absence of green spaces, and healthcare, amplified the struggle of people, making survival itself an unrelenting daily challenge.

Years of undernutrition and chronic illness were etched into the physique of the adults: lean, sinewy frames with tired, weathered faces, prematurely aged by hardship. Many children appeared stunted, with thin limbs, protruding ribs, and dull, listless eyes, their growth and vitality hindered by poor diet and frequent bouts of disease.

Coming from a privileged family, living in a posh area of Karachi and working at the most expensive health facility in the country, the Aga Khan University Medical College and Hospital, Orangi Town was a new world for me. The sights, surrounding scenes, and interactions with the community shocked me, as I had never seen or imagined such existence.

To bring change to this unsanitary, dilapidated, and deplorable environment, the Orangi Pilot Project (OPP), a research and action institution, was established in 1980 by Akhtar Hameed Khan. He was a leading social scientist and a pioneer in participatory rural development. The major aim of OPP was to address the sanitation issues faced by the Orangi settlers. His efforts for building soak pits for each house in the lane, on a collective-help basis, were gaining recognition and rapid acceptance in the community.

In 1984, the Department of Community Health Sciences (CHS), Aga Khan University, joined hands with the OPP to provide limited medical coverage in Circle 125 of Orangi Town, where the average number of people per household was 7.7.

We began by collecting data through a baseline household survey to obtain quantitative information about the demographics, income, and morbidity and mortality patterns in the households of the selected cluster. The data showed high mortality in the last year, with 70% of deaths occurring due to diarrhea, malnutrition, infectious diseases, and preventable birth-related causes.

In 1985, based on the results of the survey and in response to the healthcare needs of the women and children, the CHS Department established a small clinic, which operated three days a week from 10 am to 2 pm. Alongside, we trained some women of the area as community health workers (CHWs). Each CHW was assigned a certain number of households. Their role was to conduct growth monitoring of children to identify malnourished children, provide ORS to children with diarrhea, give antenatal and postnatal care advice, and provide health education regarding the immunization of children and pregnant women, as well as general cleanliness.

The CHWs started working enthusiastically and energetically, which played an important role not only in identifying health-related issues at the household level but also in encouraging women to seek care for themselves and their children.

I managed the clinic with medical students. One day, a woman in her early thirties walked in, cradling a two-year-old boy with diarrhea. The sight of him stunned me. He was more bone than flesh: sunken eyes, wrinkled skin, his body limp with exhaustion. He was not only severely dehydrated but also suffering from marasmus, a cruel form of malnutrition where hunger eats away both flesh and spirit. He was so emaciated that he could not even sit.
 

The child not only needed urgent intravenous infusions to counter his severe dehydration and loss of salts, but also careful nutritional rehabilitation and medical support to gradually restore proper nourishment and prevent complications. To save his life, we rushed him to Aga Khan University Hospital.

He was admitted to the ward of the Paediatrics Department and was provided care with extra attention. Within a week, he started showing signs of significant improvement. By the second week, he was able to sit and eat semi-solid foods like khichri, banana, etc. He was discharged at the end of the third week as he was gaining weight and was on the road to recovery.

The mother was instructed with care: feed him eggs, yogurt, khichri, bananas, keep utensils clean, boil water. She nodded, but with a strange blankness that we did not understand.

We, the staff of the Orangi clinic, rejoiced at this achievement. It felt like saving a life against all odds, but it did not last long. Only a few weeks later, the mother returned to the clinic with the child in the same pitiful condition as when he was first brought to us.

My heart sank, but instead of pausing, I lashed out, blaming the mother for her ineffective and negligent childcare. I made statements about her disregard for the amount of effort the hospital staff had made in saving her child, the cost we had incurred on his treatment from the charity funds, and her indifference towards following our advice regarding feeding and nutritional care. She had not fed him any of the foods that we had advised. My words were sharp and accusatory. Despite my harsh tone, she remained calm, her eyes downcast, her face unreadable, and waited for me to complete my diatribe.

Then, in a voice soft yet steady, she looked at me and said:

“Doctor Sahib, you are telling me I am a bad mother, that I do not care for my child. You ask why I did not give him eggs, khichri, yogurt, bananas, etc. Do you know why?”

I did not hesitate and demanded, “Why?”

Her reply was like a thunderclap:

“Because we are poor. So poor that for the last two days my family has eaten nothing but chai aur papay (tea and rusks).”

Her words struck me harder than any physical blow. I felt as though she had slapped me across the face, harshly, painfully, but truthfully. It hurt, as I realized how much my words had hurt her. I could not find words to apologize. In that moment, I realized my ignorance. Despite years of education, lectures on determinants of health, and theoretical knowledge about poverty, I had never truly understood. She, an uneducated, impoverished mother, had taught me in a few sentences what no textbook ever could.

That day changed me. Since then, that lesson has remained with me and has guided me to understand the needs of the underprivileged — the have-nots.

As I continued working in Orangi, the chasm between the lives of the “haves and have-nots” grew clearer. The reality was more discernible when I attended wedding events or parties at the hotels over the weekends. The extravaganza of dresses and décor, halls shimmering with crystal and silver, resplendent tables laden with culinary treasures became appallingly disturbing.

Every time, while approaching the banquet tables with a sumptuous spread, where every platter glittered with indulgence and abundance, the voice of the woman from Orangi echoed in my mind:

“For last two days my family had not eaten anything but chai aur papay.”

Each uneaten morsel abandoned on plates, each dish wasted, became unbearable. The extravagance of those halls stood in violent contrast to the emptiness of Orangi’s homes.

Almost four decades have passed, but even today, often the voice echoes while approaching the resplendent tables of lavish banquets. It draws my attention to the waiters moving swiftly to serve the guests with the sumptuous spread. With 44% of the population in Pakistan below the poverty line, it makes me wonder what their children have eaten today at home. Chai aur papay?