by Ken Gibbs
Quetta, a cantonment city in Pakistan close to the border with Afghanistan, perches high above the desert plain so that nomads see the city as their ideal hill station. They trek there with their sheep, camels and other pack animals when the heat has become too much for them around Sibi at the bottom of the Bolan Pass. Colourful caravans with camel trains laden with beautifully decorated camel-bags can be seen moving slowly up and away from the suffocating heat in spring. Through the heavy atmosphere one can often hear the clonk of camel bells.
We moved to Quetta in 1985 to work for the United Nations soon after the annual nomad migration there, and started our stay in the Lourdes Hotel, an older-world corrugated iron roofed building which seems to have been built soon after the devastating earthquake of 1935 – fifty years before our arrival. Given that our arrival coincided with the 50th anniversary of that earthquake, we examined the structure of the hotel with some misgivings. Fortunately, geological processes seem not to be tied into the Gregorian Calendar.
The office I joined was a mix of both national and expatriate staff, and the work was focussed on the well-being of children and women. Of particular concern at that time, was the unnecessarily high mortality rate from diarrhoeal dehydration in infants – something which was seen as entirely normal in the early twentieth century – but which we were trying to change. So, one of the first agenda items was to check that we were providing communities with advice that was clinically accurate and effective, and culturally appropriate.
Quetta lies on a major trading crossroad with goods moving east-west from Iran to China and India and back passing through the city, and carpets and opium moving from Afghanistan south through Karachi for destinations throughout the world. This meant that many different nationalities are seen in the bazaars of Quetta which is reflected in the number of different languages that are spoken in and around the city. The official languages of Pakistan – Urdu and English – are only the home language of a very small minority in Baluchestan, with Baluch, Pashto and Sindhi being more widely spoken by the tribal communities in which we mostly worked.
Any programme which seeks to fit in with the cultural norms of the area requires an intimate knowledge of family life in the setting for which it is designed, which requires that the staff involved must not only speak the relevant languages but also must have some sensitivity about what is acceptable and what is not. Expatriate staff start at a considerable disadvantage in this respect, so that team building must dovetail the technical expertise of the expatriate with the cultural and language expertise of the national staff. Our office was particularly fortunate in the choice of national staff who were exceptional in being able to describe what worked and why; and what was inadvisable, and why.
“Purdah” is a widespread practice in Baluchestan rural areas which sees women kept within the family compound from the age of puberty. The only time many will move is to another family compound when they are given away in marriage, or to be buried when they die. While the practice is considered to be outdated by westerners, it is the main reason why the adult female literacy rate in Baluchestan is so poor – the census data suggested it to be as low as 1%. Which means that 99% of rural mothers are likely to be illiterate, and that getting information to them which they can both understand and use, is quite challenging.
Because Baluchestan was, at that time, a relatively poor area which had been heavily over-burdened by close to a million Afghan refugees, a number of humanitarian organisations had come to help. This brought its own set of problems with it. Medical advice didn’t always follow the Pakistan Government guidelines and each agency was anxious to implement what it felt was the ideal system. When it came to the promotion of oral rehydration therapy within the home (ORT Home Solution), there were at least five different systems being promoted in Baluchestan so that anyone in urgent need of accurate advice was likely to be completely confused and babies would die as a result. Obviously, something needed to be done.
So here we had many infants dying unnecessarily; their mothers, who could change this if they knew what to do, unable to read; and a number of humanitarian agencies anxious to help, all ‘doing their own thing’ which considerably confused everything. What was there to do ?
First things first. We set about unifying the home solution system to be promoted by all agencies in the province which we felt might dent a few egos (by showing up systems which simply didn’t work) but which, in the event, was a salutary lesson in inter-agency cooperation. We eventually agreed that the ‘pinch-and-scoop’ method of mixing salt, sugar and water was the only alternative because of its simplicity and ease of comprehension, and much more importantly, because it always produced a solution which would save the life of a severely dehydrated patient. The next challenge was to produce something that every mother would understand and which she could keep at home to remind her what to do in a diarrhoeal emergency. With almost total illiteracy amongst the women we wished to reach, whatever it was would have to be pictorial.
Thus was the Baluchestan ORT poster born. It had to identify the symptoms of acute dehydration; it had to show the ingredients needed to make the solution and mix it; how to feed it to the patient; and it had to show nutritional advice (like the continuation of breastfeeding and which foods to use to build up strength after a diarrhoeal episode). All good clinical stuff. Except that the picture to promote continuing breastfeeding was particularly challenging given that we were working in an ultra-conservative society.
Ah-ha ! In some societies, one would simply show the mother with the infant suckling, but experience showed that in conservative cultures, problems were faced in the amount of flesh shown; whether or not you could show all or part of the breast and, most importantly, the look on the face of the mother, bonding with her child. So, when it came to drawing and testing the breast-feeding picture to go into the poster, we needed to tread with caution.
Before starting, I asked our in-house female sociologist and our graphic artist to meet with me so we could agree what would (or would not) be shown in the picture. We chatted about the tribal groups that would use the information and how they might react to different ways in which the information could be presented. My own experience inclined me to suggest that the woman’s eyes had to be ‘neutral’, and how this was to be achieved was discussed. I particularly wanted there to be no feeling that the picture was prepared for one rather than all tribal groups, and how the woman was to be dressed – and her jewellery – was considered. Finally, the graphic artist was sent on his way with his instructions.
A few days later, he arrived back and rather shyly placed a covered drawing on my desk and waited for my reaction. “The breast-feeding picture ?” I asked. He nodded and blushed a bit – which is interesting as he is Sindhi and has a reasonably dark complexion anyway – so I looked at the picture. It was disarmingly simple but there was something about the structure that seemed in need of correction. The left breast doesn’t usually spring from the centre of the body, so I acknowledged that it was excellent, but perhaps he might wish to move the breast a little to one side ? He nodded vigorously, grabbed the picture and disappeared.
Two days later, we went through the same procedure with another charming picture but this time with the breast apparently attached to the left upper arm. Well, at least he could move it when asked ! We had a short chat about it and then I had a brainwave – he was married, so I suggested that he ask his wife for advice; after all, she had the equipment. He left with the picture under his arm.
Two days later, we went through the process again, only this time it was superb. Everything was right. The proportions were right. The woman had tribal jewellery which couldn’t be identified as Pashtoon or Baluch. Her eyes were neutral. The child was obviously suckling and conveyed the message. I acknowledged that it was perfect and the artist was so embarrassed that he blushed deep scarlet yet again.
And his wife presented him with their third child exactly nine months later, making me believe that this tale puts a whole new meaning into ‘life drawing’.
We moved to Quetta in 1985 to work for the United Nations soon after the annual nomad migration there, and started our stay in the Lourdes Hotel, an older-world corrugated iron roofed building which seems to have been built soon after the devastating earthquake of 1935 – fifty years before our arrival. Given that our arrival coincided with the 50th anniversary of that earthquake, we examined the structure of the hotel with some misgivings. Fortunately, geological processes seem not to be tied into the Gregorian Calendar.
The office I joined was a mix of both national and expatriate staff, and the work was focussed on the well-being of children and women. Of particular concern at that time, was the unnecessarily high mortality rate from diarrhoeal dehydration in infants – something which was seen as entirely normal in the early twentieth century – but which we were trying to change. So, one of the first agenda items was to check that we were providing communities with advice that was clinically accurate and effective, and culturally appropriate.
Quetta lies on a major trading crossroad with goods moving east-west from Iran to China and India and back passing through the city, and carpets and opium moving from Afghanistan south through Karachi for destinations throughout the world. This meant that many different nationalities are seen in the bazaars of Quetta which is reflected in the number of different languages that are spoken in and around the city. The official languages of Pakistan – Urdu and English – are only the home language of a very small minority in Baluchestan, with Baluch, Pashto and Sindhi being more widely spoken by the tribal communities in which we mostly worked.
Any programme which seeks to fit in with the cultural norms of the area requires an intimate knowledge of family life in the setting for which it is designed, which requires that the staff involved must not only speak the relevant languages but also must have some sensitivity about what is acceptable and what is not. Expatriate staff start at a considerable disadvantage in this respect, so that team building must dovetail the technical expertise of the expatriate with the cultural and language expertise of the national staff. Our office was particularly fortunate in the choice of national staff who were exceptional in being able to describe what worked and why; and what was inadvisable, and why.
“Purdah” is a widespread practice in Baluchestan rural areas which sees women kept within the family compound from the age of puberty. The only time many will move is to another family compound when they are given away in marriage, or to be buried when they die. While the practice is considered to be outdated by westerners, it is the main reason why the adult female literacy rate in Baluchestan is so poor – the census data suggested it to be as low as 1%. Which means that 99% of rural mothers are likely to be illiterate, and that getting information to them which they can both understand and use, is quite challenging.
Because Baluchestan was, at that time, a relatively poor area which had been heavily over-burdened by close to a million Afghan refugees, a number of humanitarian organisations had come to help. This brought its own set of problems with it. Medical advice didn’t always follow the Pakistan Government guidelines and each agency was anxious to implement what it felt was the ideal system. When it came to the promotion of oral rehydration therapy within the home (ORT Home Solution), there were at least five different systems being promoted in Baluchestan so that anyone in urgent need of accurate advice was likely to be completely confused and babies would die as a result. Obviously, something needed to be done.
So here we had many infants dying unnecessarily; their mothers, who could change this if they knew what to do, unable to read; and a number of humanitarian agencies anxious to help, all ‘doing their own thing’ which considerably confused everything. What was there to do ?
First things first. We set about unifying the home solution system to be promoted by all agencies in the province which we felt might dent a few egos (by showing up systems which simply didn’t work) but which, in the event, was a salutary lesson in inter-agency cooperation. We eventually agreed that the ‘pinch-and-scoop’ method of mixing salt, sugar and water was the only alternative because of its simplicity and ease of comprehension, and much more importantly, because it always produced a solution which would save the life of a severely dehydrated patient. The next challenge was to produce something that every mother would understand and which she could keep at home to remind her what to do in a diarrhoeal emergency. With almost total illiteracy amongst the women we wished to reach, whatever it was would have to be pictorial.
Thus was the Baluchestan ORT poster born. It had to identify the symptoms of acute dehydration; it had to show the ingredients needed to make the solution and mix it; how to feed it to the patient; and it had to show nutritional advice (like the continuation of breastfeeding and which foods to use to build up strength after a diarrhoeal episode). All good clinical stuff. Except that the picture to promote continuing breastfeeding was particularly challenging given that we were working in an ultra-conservative society.
Ah-ha ! In some societies, one would simply show the mother with the infant suckling, but experience showed that in conservative cultures, problems were faced in the amount of flesh shown; whether or not you could show all or part of the breast and, most importantly, the look on the face of the mother, bonding with her child. So, when it came to drawing and testing the breast-feeding picture to go into the poster, we needed to tread with caution.
Before starting, I asked our in-house female sociologist and our graphic artist to meet with me so we could agree what would (or would not) be shown in the picture. We chatted about the tribal groups that would use the information and how they might react to different ways in which the information could be presented. My own experience inclined me to suggest that the woman’s eyes had to be ‘neutral’, and how this was to be achieved was discussed. I particularly wanted there to be no feeling that the picture was prepared for one rather than all tribal groups, and how the woman was to be dressed – and her jewellery – was considered. Finally, the graphic artist was sent on his way with his instructions.
A few days later, he arrived back and rather shyly placed a covered drawing on my desk and waited for my reaction. “The breast-feeding picture ?” I asked. He nodded and blushed a bit – which is interesting as he is Sindhi and has a reasonably dark complexion anyway – so I looked at the picture. It was disarmingly simple but there was something about the structure that seemed in need of correction. The left breast doesn’t usually spring from the centre of the body, so I acknowledged that it was excellent, but perhaps he might wish to move the breast a little to one side ? He nodded vigorously, grabbed the picture and disappeared.
Two days later, we went through the same procedure with another charming picture but this time with the breast apparently attached to the left upper arm. Well, at least he could move it when asked ! We had a short chat about it and then I had a brainwave – he was married, so I suggested that he ask his wife for advice; after all, she had the equipment. He left with the picture under his arm.
Two days later, we went through the process again, only this time it was superb. Everything was right. The proportions were right. The woman had tribal jewellery which couldn’t be identified as Pashtoon or Baluch. Her eyes were neutral. The child was obviously suckling and conveyed the message. I acknowledged that it was perfect and the artist was so embarrassed that he blushed deep scarlet yet again.
And his wife presented him with their third child exactly nine months later, making me believe that this tale puts a whole new meaning into ‘life drawing’.
Excellent story and very interesting. Thanks for telling it.
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