The new medical paradigm

Atul Gawande in his commencement address at Harvard Medical School lays out the challenges facing the medical profession of the future. And it is not technology he focused on but rather the ability to work in teams to provide patient care. He argues against the prevailing culture of the specialist and the super specialist and instead offers the view that medicines complexity has exceeded our individual capabilities as doctors and there is need to shift to a different paradigm in the coming years. A thought provoking piece….

“ We are at a cusp point in medical generations. The doctors of former generations lament what medicine has become. If they could start over, the surveys tell us, they wouldn’t choose the profession today. They recall a simpler past without insurance-company hassles, government regulations, malpractice litigation, not to mention nurses and doctors bearing tattoos and talking of wanting “balance” in their lives. These are not the cause of their unease, however. They are symptoms of a deeper condition—which is the reality that medicine’s complexity has exceeded our individual capabilities as doctors."

"The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. One needed only an ethic of hard work, a prescription pad, a secretary, and a hospital willing to serve as one’s workshop, loaning a bed and nurses for a patient’s convalescence, maybe an operating room with a few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. "

It was calculated that in 1970, 2.5 full-time equivalents of doctors were required to look after a patient. By the end of the nineteen-nineties, it was more than fifteen. The number must be even larger today. Atul continues “Everyone has just a piece of patient care. We’re all specialists now—even primary-care doctors. A structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care.

We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need."

He argues that we need "to understand how to provide what society most needs: better care at lower cost. And the pattern seems to be that the places that function most like a system are most successful. By a system I mean that the diverse people actually work together to direct their specialized capabilities toward common goals for patients. They are coordinated by design. They are pit crews. To function this way, however, you must cultivate certain skills which are uncommon in practice and not often taught.

For one, you must acquire an ability to recognize when you’ve succeeded and when you’ve failed for patients. People in effective systems become interested in data. They put effort and resources into collecting them, refining them, understanding what they say about their performance.

Second, you must grow an ability to devise solutions for the system problems that data and experience uncover. When I was in medical school, for instance, one of the last ways I’d have imagined spending time in my future surgical career would have been working on things like checklists. Robots and surgical techniques, sure. Information technology, maybe. But checklists?

They turn out, however, to be among the basic tools of the quality and productivity revolution in aviation, engineering, construction—in virtually every field combining high risk and complexity. Checklists seem lowly and simplistic, but they help fill in for the gaps in our brains and between our brains. They emphasize group precision in execution. And making them in medicine has forced us to define our key aims for our patients and to say exactly what we will do to achieve them. Making teams successful is more difficult than we knew. Even the simplest checklist forces us to grapple with vulnerabilities like handoffs and checklist overload. But designed well, the results can be extraordinary, allowing us to nearly eliminate many hospital infections, to cut deaths in surgery by as much as half globally, and to slash costs, as well.

Which brings us to the third skill that you must have but haven’t been taught—the ability to implement at scale, the ability to get colleagues along the entire chain of care functioning like pit crews for patients. There is resistance, sometimes vehement resistance, to the efforts that make it possible. Partly, it is because the work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.

These values are the opposite of autonomy, independency, self-sufficiency. Many doctors fear the future will end daring, creativity, and the joys of thinking that medicine has had. But nothing says teams cannot be daring or creative or that your work with others will not require hard thinking and wise judgment. Success under conditions of complexity still demands these qualities. Resistance also surfaces because medicine is not structured for group work. Even just asking clinicians to make time to sit together and agree on plans for complex patients feels like an imposition. “I’m not paid for this!” people object, and it’s true right up to the highest levels.”

.....

The problems of making health care work are large. The complexities are overwhelming governments, economies, and societies around the world. We have every indication, however, that where people in medicine combine their talents and efforts to design organized service to patients and local communities, extraordinary change can result.”

Leadership in the twenty first century

Different people have different views on what constitutes real leadership and what are its inherent traits. For years the major styles of leadership have been characterized as authoritarian, democratic or laisse-faire. But at the heart of real leadership are some basic values that transcentd both gender and geography.

The following piece from Bob Gates, the retiring defence secretary, provides a simple, compelling case for the real basis of leadership:

“ real leadership is a rare and precious commodity, and requires qualities that many people might possess piecemeal to varying degrees, but few exhibit in total.

As you start your careers as leaders today, I would like to offer some brief thoughts on those qualities. For starters, great leaders must have vision – the ability to get your eyes off your shoelaces at every level of rank and responsibility, and see beyond the day-to-day tasks and problems. To be able to look beyond tomorrow and discern a world of possibilities and potential. How do you take any outfit to a higher level of excellence? You must see what others do not or cannot, and then be prepared to act on your vision.

An additional quality necessary for leadership is deep conviction. True leadership is a fire in the mind that transforms all who feel its warmth, that transfixes all who see its shining light in the eyes of a man or woman. It is a strength of purpose and belief in a cause that reaches out to others, touches their hearts, and makes them eager to follow.

Self-confidence is still another quality of leadership. Not the chest-thumping, strutting egotism we see and read about all the time. Rather, it is the quiet self-assurance that allows a leader to give others both real responsibility and real credit for success. The ability to stand in the shadow and let others receive attention and accolades. A leader is able to make decisions but then delegate and trust others to make things happen. This doesn’t mean turning your back after making a decision and hoping for the best. It does mean trusting in people at the same time you hold them accountable. The bottom line: a self-confident leader doesn’t cast such a large shadow that no one else can grow.

A further quality of leadership is courage: not just the physical courage of the seas, of the skies and of the trenches, but moral courage. The courage to chart a new course; the courage to do what is right and not just what is popular; the courage to stand alone; the courage to act; the courage as a military officer to “speak truth to power.”

In most academic curricula today, and in most business, government, and military training programs, there is great emphasis on team-building, on working together, on building consensus, on group dynamics. You have learned a lot about that. But, for everyone who would become a leader, the time will inevitably come when you must stand alone. When alone you must say, “This is wrong” or “I disagree with all of you and, because I have the responsibility, this is what we will do.” Don’t kid yourself – that takes real courage.

Another essential quality of leadership is integrity. Without this, real leadership is not possible. Nowadays, it seems like integrity – or honor or character – is kind of quaint, a curious, old-fashioned notion. We read of too many successful and intelligent people in and out of government who succumb to the easy wrong rather than the hard right – whether from inattention or a sense of entitlement, the notion that rules are not for them. But for a real leader, personal virtues – self-reliance, self control, honor, truthfulness, morality – are absolute. These are the building blocks of character, of integrity – and only on that foundation can real leadership be built."

A marriage in the family

One of the questions I was constantly being asked in the eight years I was in Vietnam, was whether I would allow my only son to marry a Vietnamese. And my answer was always the same- he is a free man and he can marry whomever he wants!

And last month, my son decided to challenge my beliefs- he told us that he wanted to marry his long term girl friend who was a Vietnamese. Needless to say my wife and I were both thrilled and excited by his choice. It also gave us another opportunity to visit our favourite country, Vietnam! And to learn about its traditions and customs as well.

To my relief , the Vietnamese weddings are rather simple affairs in comparison with the four day Indian marriages.

Preparations for the traditional Vietnamese wedding first begins by choosing a date and time for the marriage ceremony. This is decided by a Buddhist monk, Spiritual leader, or, if you can believe it in a communist country, a fortune teller.

The wedding itself consists of an extensive set of ceremonies: asking permission to receive the bride, receiving the bride at her house, and bringing the bride to the groom's house. At the end of the ceremonies, there is an elaborate wedding reception for the two families and guests.

Before the wedding day, the groom's family would make a trip to the bride's home with a gift of betel nuts to officially ask permission to receive the bride. At this time, the bride's family would confirm the wedding and further proceedings would take place.

On the morning of a wedding in Vietnam, the groom's mother visits the bride's family and offers them two gifts. The first is a special plant, that represents respect, and the second is pink chalk, which is the color of happiness.

On the day of the wedding itself, the procession of the groom's family is led in specific order. The first person would be the representative of the groom's house followed by the groom's father, the groom, then the rest of his family and close friends. In the past, the groom's mother might not take part in the procession as a sign that she would not be a threat to the future bride; she would even "hide" for a short period upon the bride's welcoming to the groom's home. However, this practice has long been abandoned. The number of people participating in the groom's procession varies but is usually restricted to a smaller number (20 or so) to make it easier on the bride's family, which must receive all the guests.

In the procession, the groom, his family and friends bear elaborately decorated lacquer boxes, covered in red cloth. Inside these boxes are gifts representing the wealth that the groom's family will bring to the bride's family. Gifts are betel, fruit, cakes, a roast pig, fabric, and an abundance of jewelry for the bride. Usually, the number of gift boxes varies between 6 or 8, but never 7 or 9 since it is seen as bad luck. The gifts are covered by the red color paper or cloth. In Vietnamese beliefs, the odd number and the red color will bring luck to the young couple.

Upon arriving at the bride's home, the procession lights fireworks to alert the bride's family, who then lights its own round of firecrackers to welcome the groom's procession. The groom's family would introduce themselves and ask permission for their son to marry his bride. The Master of the Ceremony (usually a respected person among the bride's relatives) instructs the bride's parents to present their daughter. The bride then follows her parents out. She is in Vietnamese traditional wedding Ao Dai, which is usually in red. The wedding ceremony starts in front of the altar. The bride and the groom would kneel down and pray, asking their ancestors' permission to be married, also asking for blessing on their family-to-be. The couple then turns around and bow down to the bride's parents to say thank for raising and protecting her since birth. They then bow their head to each other, which means to show their gratitude and respect toward their soon-to-be husband or wife. The Master of the Ceremony would gave the wedding couple advices on starting a new family. The groom and the bride's parents would take turn to share their experience and give blessing. The groom and the bride then exchange their wedding rings. The parents will give the newly wedded value gifts such as golden bracelets, ear rings, necklace.

A formal tea and candle ceremony along with speeches follows. While tea has always been an essential part of Vietnamese life,the Vietnamese tea culture is not as complex or ritually rigid as its counterparts in China, Japan or Korea. The bride and groom, in front of all their guests, will serve tea (or wine) to their parents. Each parent will then give advice about marriage and family to the couple. A candle ceremony will follow, symbolizing the joining of the bride and groom and the joining of the two families. The groom's gift boxes filled with jewelry will be opened by the groom's mother, who will then put each piece on the bride for good fortune.

As the procession arrives back at the groom's house, the groom's family members that did not take part in the procession but remained at home will light firecrackers in celebration. The newlyweds will be brought to the groom's ancestor altar, where another ceremony takes place and the bride is introduced to the groom's relatives. Finally, the bride is brought to the couple's room and shown their marriage bed.

Following the ceremony at the groom's house, all of the bride and groom's family and friends are invited to a reception that traditionally takes place at the groom's house. The number of guests in attendance at these modern-day receptions is large, usually in the hundreds. Elaborate 7 to 10 course meals are served, often starting with cold platters then followed by hot dishes such as seasoned lobster, seafood hot pot, and other Vietnamese delicacies. Guests are expected to bring gifts, and it is traditionally in the form of money in an envelopes usually between $100–$200 USD. Immediate family, usually gives more money to the bride and groom. At one point during the reception, the bride and groom will go from table-to-table to thank guests for their blessings and sometimes collect the envelopes. Most couples however leave a box at the sign-in table for guests to drop in their envelopes and cards. In modern weddings, brides usually change into three different gowns during the reception. Her dresses are usually composed of the Western white wedding gown, a second Western dress to be worn at the end of the evening during the dancing, and a third traditional Áo dài to be worn during the traditional table visits to personally thank the guests for coming.

Traditional and modern symbols of marriage are often featured during Vietnamese marriage ceremonies as decorations on the wedding umbrellas, lacquer gift boxes (or the red cloth that covers them), or even the decorations in the homes of both the bride and groom. They usually include lanterns, doves, initials of the couple, among other things. However, one symbol that is indispensable is the character 囍 and the words "song hỷ." This phrase also appears means “double happiness” and shows the joy for the both families.

Our man Akhil

The MIT factor

I was at MIT in 1962, straight out of IIT, Kharagpur. In the one year that I was there, I was able to get a Masters degree and work with some of the brightest minds in a consultancy company set up by three MIT professors ( one of whom recruited me) to help NASA solve problems that nobody else could solve.

It was a learning experience that I never forgot.

And this article on the MIT factor- 150 years of maverick genius- captures perfectly the ambience and spirit of MIT.

"People often asked me to compare the quality of education that I had received at IIT Kharagpur, MIT and at Berkeley.(Straight from the heart) I would tell them that the IIT education provided the best grounding an engineer could hope to have, with its rigor and sheer hard work. It taught us that all problems have a solution if the fundamentals are sound. MIT, on the other hand, taught me how to think. Perhaps one episode from my Cambridge days would encapsulate this best.

During the summer vacations, I was asked by one of my professors to work in his consulting company. Simpson, Gumpertz and Heger was a consulting company formed by a group of three MIT professors to be advisers to NASA, which was preparing to land a man on the moon. They were set up to solve problems that NASA’s own experts could not. One of my first assignments was to work on the design of a model test for the project Apollo module as it headed to the moon. We needed to simulate the dynamics of the module as its weight and pull changed in its journey to the moon due to its consumption of fuel. NASA was waiting for our recommendations, but I was stuck and for two weeks could seem to find no solution to the problem. I decided to go to Dr Simpson, the head of the company, to tell him that he had better allocate this work to someone more competent. Dr. Simpson was to teach me a lesson that has stayed with me all my life.

“Do you think this problem has an answer?” he asked me.

“Yes” I replied. “There has to be an answer, but I have researched all the relevant books and articles and found no answers in them.”

“Well,” he smiled, “that is because this answer has not yet been found. When we founded this company, it was to work on problems that nobody else could solve. That is why NASA sends all their complex problems to us.”

“You will not,” he continued, “find the answer in any book or article. Rather, when you find the answer, you will be the one writing the article or the book.”

“Do not,” he added, “assume that someone somewhere else knows the answer. You must find it yourself, starting from first principles. You are, after all, the graduate of the finest engineering school in the world and we have picked you as one of the best in your batch. So go back and find the answer and see me next week.”

I went back, filled with renewed purpose, and over the next week met many experts to try and search for the elusive answer. And just as Dr Simpson had predicted, it was there and I did find it.

The education at Berkeley education was similar to that at MIT but with a difference. If MIT taught you to think, Berkeley taught you to think creatively and, in today’s parlance, “out of the box.” It taught you how to take knowledge and your understanding of it to create new knowledge. In the summer of 1967, I was spending my summer working as a research assistant to Professor Penzien. He had just been given an assignment to ensure that the latest multi storied building in San Francisco, the Alcoa Building, could withstand an earthquake. Of course, the designers of the building had already analyzed the structure but the owners wanted to make sure that it would withstand an earthquake which San Francisco expected in the near future. We wondered what we could do beyond the analysis that had already been done.

“Let’s shake the building,” said Joe Penzien, “and see how it will really react during an earthquake”.

“Shake the building”, I thought, “How does one shake a forty story building which was already constructed to find out what would happen during an earthquake?”

But that was exactly what we proceeded to do. We found a machine that had been recently invented by another University of California professor which rotated two weights counterclockwise and which could be calibrated to induce a horizontal force. We installed this machine floor by floor and shook the building, measuring the response on each of the other floors, using accelerometers. We could then combine the individual waves to simulate the earthquake and thus determine how the entire building would perform during the intense movement of the earthquake. It was an interesting and creative approach to a problem that many in the industry had left only to computer analysis.

I was fortunate to have been trained at all the three schools but it was only much later that I realized what and how much I had learnt!"

The Mumbai massacre- reverbrations

As many of my readers know, my wife and I were held hostage in Oberoi Trident hotel during the Mumbai massacres in November of 2008. I had written about our experiences in my earliest blogs and in my book " Reflections of a curious mind". That episode and its aftermath were brought to my mind both by the killing of Osama Bin Laden and the importance of the court proceedings in Chicago of the perpetrators of the Mumbai massacre.

We had returned safely from our sojorn to Mumbai in November 2008 but did not quite realize that the incident had reverbrations that still rattle. It all started with a visit from the FBI about four months after the massacre with a phone call from the FBI fixing a meeting at a neighbourhood coffee shop.

We were excited at this first meeting with the FBI having been fed on a plethora of TV programs. May be we would finally get to meet one. But when I mentioned this phone call to my ever watchful and concerned daughter, she was alarmed and angry. How do you know they were the FBI? Why did they call you? How did they locate you? How do you know it is not some scam? Why do they want to meet at Starbucks? Are they trying to involve you in some court case?

I had no answers for her. But her concern was legitimate—after all it had been four months since the terrorist incident in Mumbai in which we were held hostage. Why now?

Goaded by her concern, I decided to call the number the caller had given me. The FBI office at Maryland had not heard of this gentleman. This left us even more alarmed. In the evening I decided to call again. This time the receptionist said that perhaps he was a consultant hired by the FBI on terrorism and connected me to the consultants office. There was only a voice mail there and I left a message postponing our meeting thus hopefully compelling him to call again when I could raise all the issues Shibani had raised.

There were no calls the next day but on Thursday morning, came a call again. My wife took the call. The FBI agent said that his team was at Starbucks and waiting for me. So we decided to go and meet with them at our neighborhood Starbucks.

When we reached there, we found the FBI team had corralled a private room in Starbucks. There were three of them. Joseph… was clearly the leader of the team. He was big and beefy and looked the image of an FBI lawman. He was accompanied by his partner,….and an African American lady who was introduced as a trauma counselor.

They wanted to know of our experience during the terrorist incident in November. Ena had mentioned to them that I had written a detailed blog of our hostage experience and we handed them a copy of the blog. What was the purpose of this meeting? I asked. We are only trying to keep our records complete. How did they locate me? We had copies of all the guests at the hotel where you had given your US address. Is there any court case linkage? No, he assured me, this was primarily an effort to complete their records. But it had been four months since the incident. That was my fault, he said, I should have contacted you sooner.

We spent the next hours describing our experiences during the incident. They had a number of questions but most of their focus was on whether we had seen any of the terrorists or their accomplices. We told them that fortunately we had been inside our hotel room during the entire period and only emerged after the hostages had been killed. There was really nothing we could do to help them in terms of personal contact with the terrorists. In retrospect, I think this was the real reason the FBI had contacted us just in case we remembered or had seen some suspicious accomplices that we could identify.

As we were leaving, the trauma counsellor asked my wife whether we had been traumatized by the incident. She was a trauma counselor and was available at all times to help deal with the aftermath of such an incident. She gave Ena a form and asked her to fill it in case she needed any counseling or grief management in the future. I was impressed with the detailed followup, albeit a trifle delayed, from the FBI particularly since no one from the Indian police service had even made an effort to contact me. But there was more..

A few months later, I received an email from the Department of Justice in Chicago informing me that since I was a victim of the terror attack I would be kept fully apprised of the developments in the prosecution of the masterminds of the massacre. Since then they have remained true to their word and every once in a while information is sent on the prosecution efforts and the case.

The latest developments are best captured in this article.

Again it was an instructive period in our lives. We had narrowly escaped the massacre more by chance than anything else-- I was in the lobby perhaps thirty minutes before the massacre began, we had changed our mind at the last minute from dining at the restaurant downstairs which was the scene of a major tragedy, we had evaded being taken hostage even after our names were on a TV ticker for a brief while- and it was a relief to find that at least some investigating agencies had not given up on tracing the masterminds of this tragedy and to bring them to justice.

Old age blues II

“Whatever poet, orator, or sage

May say of it, old age is still old age.

It is the waning, not the crescent moon;

The dusk of evening, not the blaze of noon;

It is not strength, but weakness; not desire,

But its surcease; not the fierce heat of fire,

The burning and consuming element,

But that of ashes and of embers spent,

In which some living sparks we still discern,

Enough to warm, but not enough to burn. “

And yet Longfellow says, “nothing is too late

Till the tired heart shall cease to palpitate.

Cato learned Greek at eighty; Sophocles

Wrote his grand Oedipus, and Simonides

Bore off the prize of verse from his compeers,

When each had numbered more than fourscore years,

And Theophrastus, at fourscore and ten,

Had but begun his Characters of Men.

Chaucer, at Woodstock with the nightingales,

At sixty wrote the Canterbury Tales;

Goethe at Weimar, toiling to the last,

Completed Faust when eighty years were past.

These are indeed exceptions; but they show

How far the gulf-stream of our youth may flow

Into the arctic regions of our lives.

Where little else than life itself survives.”

In any case, what choice do we have as old age approaches?

“Shall we sit idly down and say

The night hath come; it is no longer day?"

Or shall we say instead that

" the night hath not yet come; we are not quite

C"ut off from labor by the failing light;

Something remains for us to do or dare;

Even the oldest tree some fruit may bear;

Not Oedipus Coloneus, or Greek Ode,

Or tales of pilgrims that one morning rode

Out of the gateway of the Tabard Inn,

But other something, would we but begin;

For age is opportunity no less

Than youth itself, though in another dress,

And as the evening twilight fades away

The sky is filled with stars, invisible by day. “

From Henry Longfellow's Morituri Salutamas

SAlso see my blogs on Old age blues and why women dont have old age blues

The death of Osama and soul searching in Pakistan

The death of Osama has led to considerable soul searching among at least some of the intelligensia in Pakistan. Here are three pieces which capture the angst..

An editorial today in Pakistan's The Daily Times newspaper:

EDITORIAL: The game is up

The joint session of parliament on May 13 was nothing short of a historic turning point in civil-military relations. The in-camera briefings given by the military top brass to the parliamentarians in order to explain what happened in the Abbottabad raid is a new precedent. Before this incident, it would have been unimaginable to think that the ISI chief could ever answer scathing questions from the politicians for many hours. In the face of trenchant criticism for their obliviousness to Osama bin Laden’s presence near a military academy, our armed forces finally decided to brief the parliamentarians. Only time will tell whether the decision to do this was a tactical retreat by the military or reflects a real mind change. One thing is clear though: the ‘game’ is up. Pakistan’s military cannot afford to play its usual double game anymore because the world’s, and particularly the US’s, patience has finally run out. Despite their denials and having confessed to incompetence and an intelligence failure, disbelief lingers that Osama was living in a compound near Kakul and yet no one in the army or the ISI was aware of his whereabouts.

US Senator John Kerry, who is considered a friend of Pakistan, made it clear during his visit to Afghanistan that the US will “consider all its options” if Taliban leader Mullah Omar is found to be present on Pakistani soil. “We obviously want a Pakistan that is prepared to respect the interests of Afghanistan, and to be a real ally in our efforts to combat terrorism,” said Senator Kerry ahead of his visit to Pakistan. Even though the Obama administration has so far maintained that Washington wants to keep working with Islamabad, there is strong resentment in the US at being manipulated by Pakistan since 9/11. “People who were prepared to listen to [Pakistan’s] story for a long time are no longer prepared to listen,” said a senior US official according to a report published in The Washington Post. This certainly points to tough times ahead for Pakistan. Many analysts had been warning the military of the repercussions of its dual policies and how the shelf life of such tactics had ended long ago but clearly no one in GHQ paid any heed to these warnings. Unless the military aligns its new policy with Pakistan’s, the region’s and the world’s best interests, there is no guarantee that our territorial integrity would not be violated again. It seems that the mindset of our military is set in stone but the only way to change is if all civilian political forces come together and stand up to their monopoly on policies critical to the survival and progress of Pakistan.

On Saturday, Mian Nawaz Sharif demanded that our intelligence agencies “should work within their constitutional ambit” instead of “subverting the constitution, toppling governments, running parallel administrations and strengthening one political party at the cost of others”. The PML-N chief opined that it was about time the foreign policy should be formulated by the civilian democratic government and demanded that the army and intelligence agencies’ budgets should be presented in the National Assembly. There is merit in Mr Sharif’s demands. The PPP and its coalition partners should avail this historic opportunity of tilting the balance of power in favour of civilians. The PPP should not make the same mistake as their leader, Zulfikar Ali Bhutto, who wasted a golden chance to trim the military’s power back in 1971. Civilian supremacy will not only set our future in the right direction but will help improve Pak-US relations as well. The military’s game is over bar the shouting; our politicians must take charge now. *

Mother of all embarrassments

Ayaz Amir (Ayaz Amir is a renowned Pakistani journalist, and is a newly elected Member of National Assembly in Pakistan's Parliament.)

For a country with more than its share of misfortunes and sheer bad luck, we could have done without this warrior of the faith, Osama bin Laden, spreading his beneficence amongst us. He was a headache for us while he lived, but nothing short of a catastrophe in his death. For his killing, and the manner of it, have exposed Pakistan and its security establishment like nothing else.

To say that our security czars and assorted knights have been caught with their pants down would be the understatement of the century. This is the mother of all embarrassments, showing us either to be incompetent – it can’t get any worse than this, Osama living in a sprawling compound a short walk from that nursery school of the army, the Pakistan Military Academy and, if we are to believe this, our ever-vigilant eyes and ears knowing nothing about it – or, heaven forbid, complicit.

I would settle for incompetence anytime because the implications of complicity are too dreadful to contemplate.

And the Americans came, swooping over the mountains, right into the heart of the compound, and after carrying out their operation flew away into the moonless night without our formidable guardians of national security knowing anything about it. This is to pour salt over our wounds. The obvious question which even a child would raise is that if a cantonment crawling with the army such as Abbottabad is not safe from stealthy assault what does it say about the safety of our famous nuke capability, the mainstay of national pride and defence?

Barely 24 hours before the Osama assault General Kayani, at a ceremony in General Headquarters in remembrance of our soldiers killed in our Taliban wars, was describing the army as the defender of the country’s ideological and geographical frontiers. For the time being, I think, we should concentrate on ideology and leave geography well alone, the Abbottabad assault having made a mockery of our geographical frontiers.

Every other country in the world is happy if its armed forces can defend geography. We are the only country in the world which waxes lyrical about ideological frontiers. To us alone belongs the distinction of calling ourselves a fortress of Islam.

In the wake of the Raymond Davis affair a certain sternness had crept into our tone with the Americans, as we told them that they would have to curtail their footprint in Pakistan. I wonder what we tell them now. It is not difficult to imagine the smile on American lips when we now speak of the absolute necessity of minimising CIA activities.

With whom the gods would jest, they first make ridiculous. The hardest thing to bear in this saga is not wounded pride or breached sovereignty but our exposure to ridicule. Osama made us suffer in life and has made us look ridiculous after his death. Around the tallest mountains there is the echo of too much laughter at our expense.

Consider also the Foreign Office statement of May 3, “As far as the target compound is concerned, ISI had been sharing information with CIA...since 2009....It is important to highlight that taking advantage of much superior technological assets, CIA exploited intelligence leads given by us to identify and reach Osama bin Laden.” This is hilarious. If we were aware of the compound and had suspicions about its occupants what ‘superior technological assets’ were required to go in and find out?

But what takes the cake is the stern warning attached: “This event of unauthorised unilateral action cannot be taken as a rule. The government of Pakistan further affirms that such an event shall not serve as a future precedent for any state, including the US.” We can imagine the CIA trembling in its shoes. My son burst out laughing when he read this. If the Americans get a clue to the whereabouts of Ayman al-Zawahiri or Mullah Omar will they ask our permission before sending their SEAL teams in?

The CIA chief, Leon Panetta, has rubbed the point in: “It was decided that any effort to work with the Pakistanis could jeopardise the mission. They might alert the targets.” That’s about the level of trust we seem to inspire.

Anyway, trust Prime Minister Gilani to put it best, that the failure to find Osama for so long was not just Pakistan’s failure but that of intelligence agencies around the world. This is really cool, absolving ourselves of all responsibility even when Osama is discovered within walking distance of PMA Kakul.

We have some funny notions of sovereignty and national honour. The CIA spreading itself wide in Pakistan is a breach of national sovereignty, and rightly so. And American boots on the ground, as in Abbottabad, are totally unacceptable. But when it comes to Al Qaeda using Pakistan as a base, Sirajuddin Haqqani and the rest of the Taliban holed up in North Waziristan and Taliban elements in Quetta, we somehow can’t work up the same outrage.

We already had a tough job on our hands convincing the world of our bona fides. After the Osama operation it gets that much tougher.

In an ideal world this should be a wakeup call for Pakistan, an opportunity for some honest introspection and a hard look at some of the bizarre notions underpinning our theories of national security. Must we spend so much on defence? Is the world engaged in a conspiracy to undermine our foundations? Aren’t our nuclear weapons enough to give us a sense of security? Hasn’t the time come to curb some of our zest for nurturing and sustaining jihadi militias? And isn’t it time we stopped fretting so much about Afghanistan and made internal order and prosperity the principal focus of our endeavours?

But we do not live in an ideal world and our capacity for self-deception should not be under-estimated. Shaken as we may be by the Osama operation, we can safely assume that we won’t take this as a wakeup call. As the Foreign Office statement vividly shows, we’ll hunt for lame excuses and hide behind false explanations, convinced of our ability to fool the world when the only thing fooled will be ourselves.

So we will keep talking about strategic assets and good and bad Taliban, and about protecting our interests in Afghanistan, and we’ll keep subscribing to theories of Indian hostility and encirclement, because these are the foundations on which stands the peculiar national security state we have constructed, forever threatened and insecure.

If the separation of East Pakistan was not a wakeup call, if Musharraf’s adventure in Kargil wasn’t that either, it is too much to expect that Pakistan’s comprehensive exposure in this saga, the Islamic Republic without its clothes, will lead to any radical departures in national outlook.

Our ruling establishment is too set in its ways and, sadly, the roots of national stupidity run too deep.

And perish the thought of anyone taking responsibility and throwing in his papers. That’s just not the Pakistani way.

But there should be no escaping the fact that from now on we will have to be more careful. All the signs suggest that this may prove to be a milestone of sorts, a dangerous turning point, in that our friends, let alone our enemies, become more sceptical of our pronouncements and increasingly less willing to put up with our hidden and double games.

We will be asked some tough questions and the time for bluster or a show of righteous indignation may have passed."

Something has changed (in Dawn newspaper)

Something has changed ( in Dawn newspaper)

TWO weeks after Abbottabad, the jury’s still out on Pakistan. Who knew? Who didn’t? And does anyone at all feel bad about the whole thing?

While international journalists and US lawmakers continue to ask these questions, Pakistan observers are at pains to point out that the answers matter little given that nothing has changed — the status quo has been maintained.

Their cynical stance alludes to the civil-military power dynamic in Pakistan; the oscillating nature of the US-Pakistan relationship; military strategy in Afghanistan; and the overall shape of global terrorism. On this point, however, the observers are wrong. Something has changed. Thanks to the unilateral raid of Osama bin Laden’s house, Pakistanis have glimpsed a potential future when the world’s policies towards their country shift from engagement to containment. Not surprisingly, they do not like what they see.

Recently, a prominent local talk show host caused an international stir by pointing out the historic, gargantuan flaws in Pakistan’s national security strategy and demanding change. His harangue did not reverberate in isolation. Across the country, the slow grumble of accountability is finding voice. Pakistanis want to know exactly what is going on, why their country is the biggest haven for terrorists, and how it’s going to work out in the end.

Bin Laden’s killing is not in itself a game-changer. But the circumstances of his death crystallise the challenges Pakistan will face when it finally reckons with military thinking that sees militant groups as ‘strategic assets’ that can be deployed as proxies against enemies. If one considers how Pakistan might begin to evolve beyond this strategic posture, it quickly becomes apparent that there are no good options.

Let’s start with the no-change-in-strategy option. In the short-term, particularly as the US plans a valid endgame in Afghanistan, international patience with militant safe havens will wane. Under increasing domestic pressure to reduce defence expenditure and facilitate troop withdrawal, it is possible that the US government may opt to take military action against Pakistan-based militant groups.

Such interventions would no doubt cause a breakdown in the bilateral relationship, and spell equal trouble for both parties.

The US would certainly find its task in Afghanistan more challenging. But the consequences for Pakistan would be far more devastating, as cessation of foreign assistance could precipitate an economic collapse.

In a more dramatic scenario, a terrorist attack against foreign targets, perhaps in the US or India, might be traced back to Pakistan. Depending on the nature and scale of the attack, the affected country would be compelled to take retaliatory military action. Even if the reaction were restrained, it would necessitate a belligerent Pakistani response and thus spur Islamabad’s diplomatic isolation. More troublingly, in the event of a more severe or widespread response, Pakistan could
find itself embroiled in a contained conflict, or, in a worst-case scenario, war.

Taking a longer view, if Pakistan allows militant groups to proliferate and seek sanctuary within its borders, it will lose whatever credibility it has left and find itself banished to the margins where rogue states languish. Trade treaties and diplomatic relations will be less forthcoming, as nations will hesitate to establish ties with a state that is seen to sponsor terrorism. Unilateral strikes against militant havens would also probably become more frequent.

In all these eventualities, Pakistan would find its sovereignty violated, its armed forces cornered or compromised, and its diplomatic relations degraded from engagement to containment, causing this already fragile state to edge ever closer to failure. On the other hand, the Pakistan Army cannot neatly solve the ‘strategic asset’ dilemma by reversing its decades-old policies and taking military action against formerly state-supported militant groups. Action against militant leadership would no doubt result in a severe backlash leading to devastating civilian casualties. Attacks such as the horrifying suicide bombing at a paramilitary training centre in Charsadda on Friday would become commonplace. (Granted, that attack was probably not a direct retaliation to the killing of Bin Laden, but the fact that the Pakistani Taliban has claimed it as such indicates what direction the group’s future activities will take).

The fact that Pakistanis die and Pakistan suffers no matter what course of action our establishment adopts with regard to homegrown militant groups is sobering.

It also explains why the leadership’s responses to the Abbottabad fiasco have involved so much navel-gazing. Army chief Gen Kayani has been visiting garrisons, hell-bent on asserting his authority; the PPP-led coalition government has been issuing pro-US and pro-army statements by turns in an effort to ensure its longevity; and the PML-N has taken this opportunity to curry further favour with the judiciary, while hitting out against the government. This petty politicking hardly counts as crisis management, but it begins to make sense once one realises that a more profound discussion only brings bad news for Pakistan.

In this context, parliament’s decision on Friday to revisit national security strategies is disappointing because of its focus on foreign relations (particularly the bilateral relationship with the US). What will it take for Pakistan to contend with the reality that its greatest threats are internal rather than external?

The time has never been riper for a parliamentary review of security policies to tackle head on the challenges outlined above. But it seems unlikely that the establishment will be forthright about where the trouble really lies. Pakistanis can therefore anticipate more unanswered questions and nothing but bad choices.

The writer is the Pakistan Scholar at the Woodrow Wilson Centre in Washington.

huma.yusuf@gmail.com

The IIT brand - the hidden impacts

In recent years, IIT seems to have caught the public eye.I say recent years because IIT started over 60 years ago and it is only now that the world and India have learned of the superb brand it has become over the years. In any other place,the country would be touting it with some respect and pride for its manifold achievements. It is good to know that not only has IIT put India on the world map of technology and innovation but that IITians have also learnt to give a helping help to the less prieveleged. Here are two stories that are heartwarming examples:

Patna: A poor waiter in Patna has become a celebrity of sorts after his son cracked the IIT entrance exam this year. The overjoyed man gives full credit to I-Desire - a small group of former IITians in Bihar who coach underprivileged kids and provide them study material.Mani Bhusan Singh and his parents are getting privileged treatment in their neighbourhood after the 18-year-old cleared the Indian Institute of Technology Joint Entrance Examination (IIT-JEE)."I am now one of the most sought after people in my workplace and also my neighbourhood," says a proud Lallan Singh, Mani Bhusan's father."I got to know about I-Desire through a friend. They agreed to help my son prepare for IIT-JEE. It wouldn't have been possible if I-Desire had not helped us by providing coaching, study material and a proper guide," said Lallan Singh, a waiter in Hotel Maurya here.Lallan Singh, in his 40s, said his son could not appear for the Central Board of Secondary Education (CBSE) exams in Class 10 and 12 due to financial constraints."My son wanted to appear for the CBSE exams but due to lack of money I forced him to appear for the Bihar Examination Board exams," said Lallan Singh, who lives in a one-room rented house in Mandiri, a densely populated lower middle class area.There are 15 other students from underprivileged families here who have made it to IIT thanks to I-Desire.The former IITians have been funding I-Desire, which provides free coaching for a year and counseling by IITians, explained Grijesh Jha, coordinator of I-Desire and a former student of IIT Kanpur."As many as 16 of the 35 boys selected by us cracked the IIT exam this year," Jha said.I-Desire, a brainchild of Sushil Kumar, another IIT Kanpur product, was set up three years ago to provide help and support to IIT aspirants from the weaker sections of society in Bihar.Kumar, who hails from Patna, is currently working for a multinational company in Chicago, said Jha. The project was started in memory of murdered engineer Satyendra Dubey, who blew the whistle on corruption on the national highways project in Bihar.IIT engineer Dubey, who worked on the Bihar section of the national highways project in Gaya district, was allegedly killed for writing to the Prime Minister's Office on corruption in the project. He was shot dead in Gaya town, about 100 km from Patna, on Nov 27, 2003. (IANS)

Here is another story:

There were two rickshaw-walas vying for our business when we wanted to go to Sankat-Mochan temple in Benaras. I agreed to go with the one who was about 20, seemed like a regular young rickshaw-wala, but I found something interesting about this fellow in his eyes. I was not proved wrong.

He wanted Rs 50, we said Rs 30. We settled for 40.

Here are the highlights of the conversation that ensued while he rode the rickshaw:

"aap kahan se aaye hain"

"Delhi"

"bijness ya kaam karte hain?"

"naukri karte hain"

"kismein"

"internet mein"

"humara bhi kuch wahin kaam lagwa do"

I just chuckled

"main try kar raha hoon engineering padhne kee. achchi naukri lag jaayegi tab"

"achcha?" I asked a little interested

"haan, delhi mein Guru Gobind Singh Indraprashta University mein engineering ke liye apply kara hai. achchi hai woh university"

"haan, achchi hai", I agreed.

"haan, kal hee maine JEE bhi diya"

"JEE matlab, IIT ka?"

"haan, Joint Entrance Examination" he pronounced it perfectly just to make it clear to me what JEE stood for. "mushkil hota hai exam"

"haan, 2 saal toh log padhte hee hain uske liye, asaan nahin hai" I carried on the conversation

"Delhi mein Akaash coaching institute hain na?"

"haan, hai"

"aapne kya padhai kari?"

"main engineer hoon, aur phir mba bhi kiya"

"kahan se engineer?"

"IIT delhi se"

He swung back, surprised, a little delighted, and smiled. "Ok, aapke liye Rs 30"

Swati and I laughed

Swati asked "padhai kab karte they IIT ke liye"

"bas, rickshaw chalaane ke baad raat mein". Then he added "kismein engineering kari aapne?"

"Chemical"

"toh aapki chemistry toh badi strong hogi"

"nahin, aisa nahin hai"

He continued "yeh bataiye....jab Mendeleev ne Periodic Table banaya tha tab kitne elements they usmein?"

Now it was my turn to get surprised. He was quizzing me. I said "shayad 70-80"

"no, 63" he said sharply. "kaunse element kee electronegativity highest hai?"

Swati was laughing, and I didnt try too hard and said "pata nahin"

"Flourine", he said confidently. Without a break he asked,"kaunse element kee electron affinity highest hoti hai?"

Now I was laughing too and said "nahin pata"

"Chlorine. toh aapka kaunsa subject strong tha?" clearly having proven that my chemistry wasnt a strong point

"Physics", I said

"achha, Newton's second law of motion kya hai"

I knew this one I thought, "F=ma" I said

"Physics is not about formula, it is understanding concept!" he reprimanded me in near perfect english. "Tell me in statement"

I was shocked. Swati continued to laugh.

I said "ok, Newtons second law, er....was...."

" 'was' nahin, 'is'!Second law abhi bhi hai!" he snapped at my use of 'was'

Surely, my physics wasnt impressing him either. "yaad nahin, I said"

"Force on an object is directly proportional to the mass of the object and the acceleration of the object", he said it in near perfect english. "aapne mtech nahin kiya?"

"nahin, mba kiya"

"mba waale toh sirf paisa kamana chahte hain, kaam nahin karte"

"nahin, aisa nahin hai, paisa kamaane ke liye kaam karna padta hai"

He said "arrey, rehene do" or some words to that effect. He didnt think too highly of me apparently anymore.

In a minute we reached our destination. We got off and I told him that he must and should definitely study more, and that I think he is sharp as hell. He took only Rs 30, smiled and began to leave. I got my camera out and said "Raju, ek photo leta hoon tumhari". He waved me off, dismissed the idea and rode off before I could say anything more....leaving me feeling high and dry like a spurned lover.

Damn, what a ride that was! India is changing, and changing fast.