Hameed Haroon, CEO and Publisher of Dawn, the largest English-language newspaper in Pakistan, has kindly given 3 Quarks Daily permission to publish this introductory note to a dossier (see Appendices at the end) that he has compiled about recent assaults on freedoms of the press in Pakistan:

Dear Madam / Sir,

I am writing to draw your attention to an important matter that indicates the rapidly worsening environment for the freedom of press in Pakistan.

It has always been difficult for governments to coexist with a free and independent press in Pakistan. Of late, however, the government headed by President Musharraf has become increasingly intolerant towards criticism in the press and towards the publishing of news that reflects poorly on the performance of his government on security matters.

One of the intended casualties of this swelling hostility between government and press in Pakistan is the DAWN Group of Newspapers, the country’s largest independent English language newspaper and magazines publishing house.

Since December 2006, the DAWN Group is facing massive advertising cuts equivalent to two thirds of total government advertising. This has occurred primarily as a consequence of a decision ostensibly taken by Prime Minister Shaukat Aziz’s government, but in reality ordered by General Musharraf and engineered by several of his advisors that constitute the government’s inner cabinet.

It is clear that objections to the propriety of the DAWN Group’s editorial policies emanate mainly from President Musharraf’s office and his stance is heavily influenced by key advisors who have been entrusted with responsibility for implementing crisis management and conflict control in flashpoint areas. Particularly sensitive for the agreement are the escalating developments in Pakistan’s western province of Baluchistan, and in the tribal agencies of North & South Wazirstan on the Afghan border. Also irksome have been the DAWN Group’s related attempts to monitor a recurring tendency toward covert militancy among responsible decision-makers in government.

While preparing this dossier, I have attempted to include details and supporting documentation wherever possible, to facilitate your assessment as a key practitioner in the press rights movement internationally. Recent events in Pakistan indicate that attempts by the government to curtail the autonomy of the judiciary have been on the increase. This may have facilitated a temporary unintended pause in the government’s relentless campaign to muzzle the press. But such pauses presage a return to more coercive methods by government against the press, once the messy business of the executive – judicial conflict is brought to a successful halt.

If you peruse the documents accompanying this letter, you will find a chronology of events that cover the continuing conflict between the DAWN Group and the Government of Pakistan in the critical years 2004 to 2007. (Refer Appendix A 1.0) and that reflects some of the main causes of the present breakdown of communication between the government and the DAWN Group.

In the first phase, approximating with the years 2004 to 2005, the Government of Pakistan essentially worked by attempting to exert pressure on the Dawn Group by proxy – the proxy in this case being the Provincial Government of Sindh. It is in Sindh’southern metropolis of Karachi, that the headquarters of the DAWN Group of Newspapers are located.

This period first witnessed the government’s exerting of harsh pressures on our daily evening newspaper – The STAR – by attempting to intimidate and harass journalists with false cases and concocted charges, and by a failed attempt to implicate the writer of this letter, as CEO of the Group, in a totally fabricated incident of terrorism and illegal weapons possession. (Refer Appendix A 1.1.1, to, 1.1.4 and 2.1.2)

This attempt culminated with a complete ban on advertising on DAWN Group newspapers and magazines by the Government of Sindh. However, in response to a petition filed by DAWN’s lawyers, the Sindh High Court ruled in DAWN’s favour. The Sindh Government sensing an impeding debacle withdrew the advertising ban in advance of the Court’s final verdict.

The second stage involved the direct exerting of pressure by the Federal Government itself. After a series of fumbling measures and half-hearted advertisement bans by the Federal Government with respect to DAWN in 2005, a turning point was reached when one of our influential current affairs magazines, the HERALD, published a series of controversial stories and articles from June 2005 onwards on topics such as the Pakistan Government’s war against Al-Qaeda and the Taliban in North and South Wazirstan; a possible resurgence of covert government support to Kashmiri militants; and also on the mushrooming policy debacle for government with respect to the Bugti insurgency in Baluchistan. (Refer Appendix A 1.2.1, to, 1.2.4 and 2.2.2)

In September 2006 when the government approached DAWN in its attempt to seek a news blackout regarding Baluchistan and the troubled FATA agencies of North and South Wazirstan, the editor of DAWN, Mr. Abbas Nasir, and the Directors of the Board of the DAWN Group, concluded that the government’s ‘request’ was unreasonable and needed to be firmly turned down. (Refer Appendix A 2.2.2 September – December 2006)

As a consequence, the government imposed an almost comprehensive ban on Federal Government advertising. (Refer Appendix A 2.2.2t) with an intent to provoke the financial collapse of the DAWN Group.

The DAWN Group had somewhat anticipated events from the increasingly strident tone of government criticism of its news policies and from the subsequent escalation in unreasonable informational demands from the government. As a precautionary measure aimed at reducing large financial deficits, we were forced to suspend the publication of our newspaper, the STAR, an important, but financial deficit generating newspaper, which has existed for over half a century and had been founded by working journalists of the DAWN Group.

Financial conditions within DAWN now became even more vulnerable to outside pressures as a consequence of our decision to commence work on a new TV channel – DAWN News. The grant of television broadcasting licences by the government towards such end is farmed out to a government organisation – the Pakistan Electronic Media Regulatory Authority (PEMRA) set up courtesy of an Ordinance passed in 2002. The President of Pakistan had on three different occasions in the last three years publicly announced that the controversial cross-media ownership rule (illegally tagged onto the PEMRA Ordinance as a subsequent rule/regulation by the authority) would be withdrawn and the large resource of talent available in the print media would be allowed to participate in the burgeoning electronic media revolution in Pakistan. Public opinion expressed itself in the widely held conviction that with the entry of the mainstream print media in the electronic media profession, discriminatory attitudes and the repressive stance of PEMRA with respect to press freedoms in the electronic media (Refer Appendix B & Appendix C) would be rolled back. However, the government’s current position in the courts with respect to DAWN’s application for a television broadcast licence (Refer Appendix A 2.3.2) has forced a rapid reassessment of public opinion with respect to the bonafides of government intention and clearly demonstrates that President Musharraf’s government is bent on pursuing a policy of blatant cronyism vis a vis the inclusion of selected and preferred print media houses in the electronic media revolution, and the rejection of others considered as hostile or non-compliant to government needs.

The government also appears determined to continue the domination of all news content on TV channels and on FM radio through harsh and repressive regulatory directives from PEMRA, evidenced in the grant of temporary uplink permissions in place of valid broadcasting licenses to selected channels of PEMRA’s preference.

The recent spate of programmes banned on television by PEMRA and a physical attack engineered by government on the offices of a prominent TV news channel-cum-newspaper office, clearly demonstrate the prevalence of government’s excesses in this matter.

In early December 2005 when the Prime Minister of Pakistan, Mr Shaukat Aziz summoned the undersigned to a meeting at Governor House (Sindh) to announce the Sindh Government’s decision to withdraw its advertising ban on the DAWN Group, he clearly informed me that the government was keen that DAWN should go ahead and set up a TV channel for the broadcast of English language news. The President’s constant public declarations regarding the withdrawal of the notoriously exclusionary cross-media ownership clause in the PEMRA rules and regulations and Parliament’s decision to finally withdraw this rule have not resulted in the licenses promised to newspaper publishing houses outside of government favour- this despite the passing of the legislation by both houses of Parliament . Such permissions have only been granted arbitrarily to selected groups by the government. This has led to a situation where we, at DAWN, in anticipation of the government decision to implement the new law have set up an entire organisation in Pakistan, employing over 350 journalists, technicians and managerial personnel and are anxiously awaiting the promised government license, all the while being forced to squander large financial outlays in anticipation of this.

The government’s refusal to give us a license mainly stems from our refusal to submit to its unethical pressures while reporting events in Baluchistan and North & South Waziristan. This refusal has become an acute cause of concern for the future financial viability of our publishing group.

Clearly the government would dearly like to see us lay off our journalists as they are viewed as a potential source of unwelcome criticism of government policies, rather than as compliant sheep to be hurriedly shepherded by PEMRA according to government whim.

Our colleagues in organisations devoted to protecting the freedom of the press throughout the world have always been a source of moral inspiration and help to us in our struggle for press freedoms in Pakistan.

We therefore urge you to extend your help in this matter and would appreciate if you address your concerns to the authorities in Pakistan regarding the following areas:

1. That the advertising ban by the Federal Government on the DAWN Group’s advertising is both unwarranted and unethical and a transparent mechanism to exert pressure on the newspaper group’s policies in contravention of the internationally accepted norms of objective news reporting.
2. That the decision to withhold a television broadcast license to the DAWN Group by the government is in violation of the judgments of the High Court of Sindh and the consent declarations made by PEMRA and the Federal Minister of Information in the Sindh High Court. Such right should be granted to other applying media groups as well on the same terms .
3. That the Government of Pakistan continue to submit its policies in Baluchistan and its agreements with the pro Taliban tribesmen of North & South Waziristan to the rigorous assessment of public and media scrutiny.
4. That the Government of Pakistan desist from abducting and arresting journalists in the judicious performance of their duties, and desist from physically attacking newspaper offices as has occurred last week in Islamabad.

Your concerns in this respect may be addressed to:

• The President of Pakistan, General Pervez Musharraf,
• The Prime Minister of Pakistan, Mr Shaukat Aziz,
• The Acting Chief Justice of the Supreme Court of Pakistan, Justice Rana Bhagwandas,
• The Federal Minister for Information Development, Government of Pakistan, Mr Mohammed Ali Durrani.

In addition your concerns should also be expressed to other key decision makers in the Government of Pakistan, urging all of them to desist from repressive, illegal and unethical practices deployed in their effort to subvert press freedoms.

For your ease of communication, I am including relevant fax contact details:

• General Pervez Musharraf, President of Pakistan +9251-9221388
• Mr Shaukat Aziz, Prime Minister of Pakistan +9251-9212866
• Justice Rana Bhagwandas, Acting Chief Justice of the Supreme Court of Pakistan +9251-9213452
• Mr Mohammed Ali Durrani, Federal Minister for Information Development, Government of Pakistan +9251- 9203740

Thank you in anticipation for your much needed support in this matter.

Appendix A — SUMMARY & CHRONOLOGY: 2004-2007
Appendix B — MEDIA CONTROL THROUGH THE PEMRA ORDINANCE
Appendix C — EXPLANATORY NOTE ON THE PEMRA RULE ON CROSS MEDIA OWNERSHIP
Appendix D — SUPPORTING DOCUMENTATION

The Yamkut

Justin E. H. Smith

We all know the deer: a beast formed of grace and terror. She is graceful because all the visible terror, at being shot, at being torn by claws, is concentrated in the eyes alone; she is terrified, in her eyes and in her soul (which is invisible), because the world is cruel to whatever does not prey.   Throughout the serpentine empire of the river Yam, the deer (or more precisely, capreolus pygargus) is a ubiquitous enough zoological entity to make its presence felt cartographically, in place-names both Russian and native.  The capital and business center of Yamkutka is called by the Russians ‘Olen’sk,’ (‘Deerville,’ if you will).  The Yamkut name for the city, ‘Yum,’ also honors the region’s second-most common large mammal, and first-most among the ungulates. 

In contradistinction to most self-descriptions of indigenous peoples, which are usually very nearly translatable simply as ‘the people,’ Bocharov and Ginzburg report in their groundbreaking 1958 study, Perspektivy na iamkutskoe obshchestvo: primitivnyi kommunizm ili paleoaziatskii men’shevizm? [Perspectives on Yamkut Society: Primitive Communism or Paleo-Asiatic Menshevism?], that the elders of the tribe sometimes offer as a translation of the Yamkut word for ‘Yamkut’ [jam’çïa]: “Those who are not cloven-hoofed, shit not pellets, and are neither graceful nor –though they certainly ought to be– terrified.”  If you are a Yamkut (which you assuredly are not), deer and life are as one. A Yamkut creation myth tells of Mother Deer, a doe whose udder grew and grew until it gushed forth seas and lakes and rivers of fatty and clotted milk, and of how in the dreamtime before the time we know the mighty Yam flowed thick and white.   

In the golden age of Mosfilm and Lenflim, after the Georgians had founded Gruzfilm and the Turkmen had founded Turkmenfilm and even Tadzhikistan had its own studio of some renown, the Yamkut became determined to convince Moscow that they too needed Yamkut-language films created at their very own Yamkut studio. True, they were just an autonomous oblast and not a Soviet Socialist Republic, but, they thought, it was worth a try.  The red tape took no more and no less time to cut through than for any other project under communism, and after a number of years, Yamfilm was born, with technical consultants arriving daily from Moscow and Kiev, workers diligently constructing a movie set on the outskirts of Olen’sk that, for some as yet unknown reason, had slowly begun to resemble the Reichstag.

It would turn out that the elders among the Yamkut had been forced to cut a deal with the bureaucrats in Moscow in order to gain approval for the Yamfilm project. The Yamkut could have their studio, but the first five films, to be completed in the first five years of production, were to depict the Soviet victory in the Great War for the Fatherland, with a particular emphasis on the enemy camp.  Now the Yamkut would much rather have made films depicting their way of life, films about what interested them, what they spent all their time discussing, which is to say, most importantly, the deer-hunt.  In fact, most Yamkut found it difficult even to act, before a camera and under pressure from Mosfilm supervisors, as though they cared about anything other than deer, such as heroism, medals, and the purported difference between Stalin and Hitler. To the Yamkut, it was just two men with moustaches, enormous moustaches, having it out over issues that ought to have had no bearing on the lives of scraggly-whiskered, Mongoloid hunter-gatherers such as themselves. 

But a deal’s a deal, and so the first Yamkut film made it into production.  Some particularly memorable footage I saw on a recent visit to the Yamkutka oblast‘s historical archives shows rejected takes of a scene in a conference room at the Reichstag.  A crucial strategy meeting between all of the highest ranking Nazis was about to begin. Yümat keeps screwing up his lines, slipping out of character, while lead actor Yügd has failed to show altogether.  Here is the translation T. L. Vainshtain provided me of the outtake’s dialogue (I decided to pay her to come along with me from Moscow to work as my interpreter):

Goebbels: Heil Hitler, Herr Speer.  Where’s Goering?

Speer: Heil Hitler, Herr Goebbels. Goering comes. (Goering enters). Oh, Herr Goering, Heil Hitler… Hey, where is Hitler, anyway?

(Tense pause.)

Goering: Hitler out in tundra. Hunting deer. Back at sundown.

Yes, the Yamkut know deer. But it is the Yamkut alone who know the mysterious çüm’t.  The name might roughly be translated out of Yamkut as “That which wreaks pure terror, and perceives not grace, with glowing quills and without a face.”  Bocharov and Ginzburg (ibid.) describe it variously as “a Yeti for the steppe,” “a spectre haunting Siberia,” “the opium of the hunter-gatherers,” “a running-dog for idealism,” and, more to the point, “a big lie.” 

But whatever the çüm’t is, it’s no Yeti, and it’s no lie. Unlike the mythical mountain-bound snow monster, the çüm’t is a river-dweller, or, more precisely, a Yam-dweller, its habitat extending no more than 100 meters from the banks of this great flow. Moreover, the çüm’t is a quadruped, if you can call those things feet.  In all the world, these are the only feet, if you can call them that, that are both webbed and clawed. The webs help the çüm’t propel itself as it wishes, upstream or downstream, through the Yam’s swift currents. The claws help the çüm’t to subdue its prey, though this is seldom necessary, for its prey is the docile deer. Its face, which is to say its mouth, is located somewhere beneath that mass of glowing quills. Some Yamkut elders say the teeth glow as well. Some even say there is no real difference between the quills and the teeth at all, that other than its webbed, glowing-clawed feet the çüm’t is nothing more than an enormous mouth. 

The çüm’t’s existence has not gone entirely unnoted by the scientific community.  In his largely forgotten 1934 field guide to the wildlife of Siberia, Die Tierwelt Siberiens, Macarius Müller mentions the Hystrix candens Mülleri or ‘Müller’s glowing porcupine.’ He notes: “Just as the people of Jamkutka might be said to exhibit in an exaggerated form the physiognomic and behavioral traits of their cousins to the south, the Dravidians of the southern tip of India and the island of Zeylon, with eyes that bespeak an indifference to suffering and defeat: at the hands of the Indo-Aryans, in the case of the black-skinned Hindoos, and of the Slavs, in the case of the Jamkut; with a communal life as much bereft of concern for basic hygiene as of interest in the profounder things; with a single-minded lust for the steaming blood of the graceful deer they claim to love, and perhaps for the blood of a curious traveller such as myself, so too the glowing porcupine is but a fiercer, more savage cousin of the Hystrix indica or Indian porcupine. Whether it has a face –or not, as the Jamkut claim– I have not been able to approach close enough to determine. But that it glows like an ember, that I can see quite clearly from a safe distance.”

Müller, a young, adventurous soul, lusting for a bit of blood himself, rushed back to Europe at the first promise of war and died a few years later in a so-called fox-hole. Within a few years of his book’s publication, “going East” would take on a new meaning, and few after Müller would ever try to track down the glowing porcupine. It was the fate of the Hystrix candens Mülleri to remain but a çüm’t.  And so it has, right up to the present day.

When Tanya and I paid a visit on our way back from Olen’sk to the Kazakhfilm archives at the brand-new national history museum in Astana, we came across a notebook of the legendary Kazakh director Mubarak Zhubaikanov.  Assigned in the early 1960s to make films based on the national epics of each of the Soviet Republics, in alphabetical order, he had scarcely begun production on the Armenia installment when he found himself in prison for promoting (i) idealism (i.e., Italian neo-realism), and (ii) the corruption of Socialist values (i.e., homosexuality).  Say what you will about the Azerbaidjanis (alphabetically first, in Cyrillic terms), the Pravda editorialists reflected, it is simply not like them to lounge about pointlessly on interminable island holidays, gazing at one another’s youthful torsos.  The notebook contained what looked to be a sketch of a movie he hoped to make, someday, about the Yamkut, though for the life of me I can’t imagine how he thought this material could ever be translated into the medium of film. “The çüm’t takes a claw-footed/web-footed hike, or swim, or something in between,” Zhubaikanov writes, “against the current of the mighty Yam, in search of a deer.”  He continues:

“The çüm’t makes its way upstream.  It seems as though the icy water ought to extinguish the glow of its quills, and yet they only seem to glow brighter the more fully they are submerged by the current. Soon enough, the beast spies what it’s looking for, a six-year-old doe with white spots, drinking gently at the side of the river. The doe spots the çüm’t, in turn, and freezes, not out of fear, or at least not out of fear alone, but out of awe at the sight of this waterborne fire. No deer that’s seen it has ever lived.  None has ever had the chance to teach the fawns how to survive this terrible beauty.

“The çüm’t draws nearer, and the remaining awe in the doe’s eyes transforms quickly into terror; the terror concentrates in her eyes alone and, however much she would have it so, cannot be communicated to her sinewy legs. The frozen doe watches the glowing beast draw nearer, and as it draws nearer she sees what no Yamkut has ever seen: she sees the mouth of the çüm’t begin slowly to open.

“Located at the front of the torso, at least if we wish to determine front and back in this case by the direction of motion, the quills part down the center of its body and reveal something of a hole, a hole doing something quite the opposite of glowing. Around its rim, there appears a ridge of tiny, sharp, only lightly glowing quills, which would have to be identified as the teeth if anything were to be. The hole is floating in the middle of the fiery light, more powerful than the hottest flames, the sharpest quills, as if ready to devour the deer whole.

“Presently, the çüm’t opens its mouth as wide as it can be extended and plunges the ridge of teeth into the neck of the motionless doe.  The çüm’t leans with all its weight into the deer’s body. The deer, much to her own surprise, finds herself leaning in as well. The çüm’t pushes toward the deer and sucks, and the deer pushes toward the çüm’t as she feels her blood flow out into her partner’s mouth.  She kneels –the first motion we’ve seen from her since she caught sight of the glowing beast– in part because she feels weak, in part because she longs to be closer to her squat attacker.  Just to be closer, just for now, whatever this may bring.  For they are partners, and they are conspiring.

“The deer says to her partner: ‘I am a deer, and I have no defense. Those who are not cloven-hooved, and shit not pellets, and ought to be terrified, but are not, believe that I am formed out of grace and terror. But as you now know, çüm’t, I am formed out of blood, which fuels the fire in your quills, and I am covered in soft velvety hair, which is of a kind with your quills, however different these may seem.  I am formed out of taut muscles and lightning-fast synapses, and I dart across the tundra away from the bang of the clumsy unterrified ones’ weapons, until I am ready to give myself to them.  I haven’t given myself to you, çüm’t. You have taken me.  My blood feeds the fire in your quills, and I cannot keep it from flowing.  My only weapon is my fecundity, which flows like blood throughout the generations of deer, which flowed into my fawn and will flow from her to other fawns still, into generations without end. My own blood will cease to flow when it has all flown into you, but it does not matter, for my own blood would have flown into nothing had you not come to take it. It is sweet to flow like this, for just a few moments more, my çüm’t, though the life flows out of me and into you, sweeter than the soft flow of the rivulets of the mighty Yam, sweeter than the mighty flow of time, and of the soft rivulet of time that was my soft and sinewy life. This is no longer my life flowing, my çüm’t. This is your life flowing, and you are everything.’

“And the çüm’t replies: ‘I am a çüm’t and I cannot help what I am. Those on two legs, who keep their distance, and who know that I glow like embers, but know not that I have a face, say that I am evil itself.  But they are mistaken.  As you now know, deer, I am appetite itself.  I kill in order to live, and I glow because I live, and I cannot help but live.  Evil has nothing to do with it. Some may think that I am evil, but I am only appetite, and appetite is love, and love is all there is. If I am evil, then, all is evil and it says nothing to point this out. You, deer, are feeding my appetite, for now, for this morning. This afternoon, I will feed on another.  You, my deer, know that I love you as much as one creature has ever loved another, my love grows as you cease to be another creature altogether, as you become me, and we become more.  I am all there is, and through me all is one.’

“The çüm’t plunges onward, upstream, and the deer’s carcass lies still at the side of the Yam, flaccid from bloodlessness, one eye underwater, one eye staring expressionlessly toward the overcast sky. And the maggots and flies will soon come and take what the çüm’t did not want. And a Yamkut may happen along, and consider peeling off the velvety hide, but, with a pang of shame, an evolved aversion to vulturism, decide not to. And off in the forest, the bear will say to the rabbit: let us conspire.  And the leaf will whisper to the humus: shall we conspire?  And the fairy ring will ask the deer pellet: why not conspire?  And the sunbeam will beseech the maggot: let us conspire.  And the mighty Yam will cry out: all things conspire.”

*

For Chingiz Aitmatov.

An extensive archive of Justin Smith’s writing may be found at www.jehsmith.com.

About 98.000 people die every year in the hospitals in the USA due to medical errors. The experts calculated this in 1997, after they studied reported adverse occurrences in hospitals in New York, Utah and Colorado in previous years. The data for the rest of the world is not available. If we assume similar incidence in the world and extrapolate, it turns out, every year over 2.1 million people would die in the world, or over 42 million people may have died in the past 20 years because of medical errors. (This shocking number is not based on any hard statistical evidence. The purist may ignore this extrapolation and the cynic can argue that in many countries people die due to lack of medical care and not because of it.)

Most errors occur due to fault in the “process” of care: switching two similar sounding medications (Hydralazine/ Hydoxyzine), wrong dosage units (mcg/mg), confusing two patients with identical names. Extensive use of information technology (IT) can minimize this tragedy and also provide many other tools to improve the processes of health care in the hospitals, local community and the country. Some such benefits are: avoiding repetitive tests on patients, cost containment, early warning of epidemics, post market drug surveillance, disaster management, health care planning and long distance tele-medicine.

The driving component of the health IT – you could call it the ‘operating system’ of the health care universe — is the electronic health record. (EHR), which is a digitized equivalent of a patient’s chart in the hospital or a doctor’s office. An ideal EHR would record each health care encounter and transaction in the life of an individual, from birth to death. This EHR could reside in doctor’s office, a hospital or a central repository, which can allow secure access to pre authorized persons through the Internet.

Why hasn’t it happened? The use of computers in health care is primitive compared to other industries like banking and airlines. IT entered the hospitals through the back door: financial software, including billing and collections settled in the hospital first without any significant linkage to the clinical work, and within clinical disciplines each department procured software to run only its own functions without any electronic data exchange with other departments. The use of IT in healthcare grew by installation of independently functioning modules in enclosed silos and the unintended result was that the departments could not communicate. Medical fraternity learned the hard way that computers are not amenable to behavior modification and software is like a stern nurse: it may do what you ask but not what you want.

What is true of hospital departments is true of institutions; even neighboring hospitals serving the same population cannot communicate with each other. Since health IT has grown in bits and pieces over the past few years, one will have to first dismantle the current system to install the new interoperable information applications.

Five components are essential for the successful operation of a health information network:

• Common interoperable health IT standards.
• Uniform medical nomenclature.
• Policy and regulations to promote the use of e-health platforms.
• User-friendly interface for clinical workers.
• Early involvement of the end users in development and implementation.

The problem of IT standards and clinical nomenclature is nearing resolution. Over the past few years many voluntary and professional institutions have done remarkable work to delineate IT and clinical standards. For instance, we have Health Level-7 (HL-7) protocols for messaging; Digital Imaging and Communication in Medicine (DICOM) for digital images (x-rays) and many other standards have been accepted and vetted. In clinical semantics, Systematized Nomenclature of Medicine (SNOMED) is gaining popularity as the standard nomenclature, which complements the preexisting nomenclature: International Classification of Diseases (ICD-10) and Current Procedure Terminology (CPT codes). These common standards will go a long way to solve the problem of interoperability.

In the past, clinical user interfaces were friendly only to the friends of the programmer. In recent times, the EHR has considerably improved, but the medical world is still waiting for the ideal interface — one which would save time compared to a paper chart, make data entry and retrieval faster, connect with ancillary services, provide alerts and prompts, enhance the business processes and provide frequent updates about advances in the medical sciences. In short, it should be convincingly more efficient than the paper chart to ensure easier acceptance by the clinical workers. We are getting there, but slowly and adequate regulations should accelerate the pace.

The regulations have to address three issues about the data of patients:

• Ownership of data and its authenticated flow to users.
• Secure and need based access to slices of data.
• Security, privacy and confidentiality of data.

These policies have to be in place for transaction of data. At present, the patient owns her health information and it resides in the hospital or insurance company’s servers. These institutions have no incentive to share this data with other competing organizations and would rather keep the information to themselves for business advantage.

The US government envisioned in1994 that the communication between the health care entities and the federal government would be streamlined by electronic communication by 2014. A recent survey of the ambulatory medical care revealed that 25 % of doctors’ offices have either a simple or an advanced IT system. Another survey of the hospitals revealed that implementation of an upgraded EHR was a high priority to improve clinical outcomes and cut costs. A study done by the Health Care Information and Management Society (HIMSS) has found “About 62% of the healthcare organizations based in the U.S. have already made a decision about their (EHR) vendors and are starting an implementation or already have a part of an EHR in place, at least the foundation of it.” Recently adopted regulations in the US will ensure that health IT systems become more prevalent in next ten years.

Many developed countries, with mature health care systems, are in some stage of implementing interoperable health information grids. Some counties like Sweden and Finland are ahead and others like UK and Australia are in the process. European Union is planning to connect all the members on a health grid.

Installation of health IT system has proven to be expensive and slow in almost all countries. Starting in 1998, the National Health Service (NHS) in UK began to implement an electronic patient record in all NHS institutions. The target date was 2005 but by early 2007 the venture was still incomplete and had cost £12.4 billions. Now, the revised completion date is 2008.

In Canada, a not-for profit organization, “Canada Health Infoways”, is leading the implementation of an interoperable health information system, with the participation of federal and provincial health departments. The federal government has invested 1.2 billion Canadian dollars and they aim to have EHR systems operational for 50% of the population by 2009.

For the developing nations, lack of any legacy IT systems may be a blessing; they can leap frog to the latest standards and technology without the burden of dismantling the old. Connectivity and costs will, however, remain big challenges.

India has recently started with a vision of connecting the entire country in one interoperable health IT grid to manage health care and medical knowledge. The vision is to capture most health care transactions, when the system is operational in a few years. The proposed grid will be a hub-and-spoke network with interconnected data repositories stationed through out the country. The project is still in the preliminary stages and probably will gather steam in coming years. Other Asian countries, including China, are also in various stages of developing health IT networks.

On the technology side, many new applications will enhance the capabilities of an EHR system. Mobile platforms like the PDAs and cell phones will access clinical data; personal devices like pacemakers and heart monitors will communicate with the EHR; administrative paper work will be streamlined. If and when individual genomic structure becomes part of the EHR, one would be able to predict disease trends and possible preventive measures for individuals and families. Genetic data would guide the choice of therapy; predict the outcome and even help in new drug development research.

Future of health IT systems is exciting. Once we have strong regulations, interoperability of data and efficient user interface, the EHR becomes scalable. Health care institutions, communities, and even whole country can transact health care information and related business on a web based health grid. It is feasible that in next 30 years we could have a worldwide interoperable health IT network.

Imagine this future scenario: Ms Sally, a 49 years old executive from London has traveled to New York for an urgent meeting. She experiences chest discomfort and is rushed to the emergency room. The doctor suspects a heart attack and advises emergency cardiac catheterization. She declares that a coronary angiogram had been done recently in London for similar symptoms and she believed “it was not that bad.” She had received no treatment as she was in a rush to travel.

It is nighttime in London and her personal doctor is not available. She gives the New York doctor access to her EHR on the Internet, who downloads the angiogram. It is perfectly normal.

The ER doctor looks for another reason for her chest pain and orders a CT scan of the chest, which reveals a large life threatening blood clot in the lung. She receives urgent treatment to dissolve the clot.

Immediate access to the EHR helps avoid an error. It prevents an unnecessary procedure, and saves time and probably her life.

Edward B. Rackley

By today’s measures of geopolitical relevance, Uganda would seem an insignificant country. Its name may trigger a few neuron firings among those who’ve read Giles Foden’s The Last King of Scotland, or seen its recent film adaptation starring Forest Whitaker as Idi Amin.

Ugandans who’ve seen the film are less than delighted. Amin’s son allegedly complained to reporters, “He [Whitaker] doesn’t even look like my father.” More clueful viewers writing in local newspapers claim the film relies on the tired reference of African dysfunction to tell and sell a story to an international audience. Much agreed—although I appreciated the film’s portrayal of complicity with evil as a creeping, dimly conscious evolution, capable of crippling the purest intentions.

At the crossroads of ‘species being’

In fact Uganda is at the center of three, if not more, grand experiments of genuine significance to species well-being. The first of these concerns the success of regional peacekeeping: “African solutions to African problems,” as South African President Thabo Mbeki once envisioned. If successful, Uganda’s recent troop deployment (1500 men) to protect the beleaguered national government in Somalia could rewrite how regional insecurity is locally managed, thereby diminishing the current dependency on international institutions (UN, aid agencies) for solutions.

The war on HIV/Aids is a second theatre of action with global import, currently playing out in Uganda. Here the weapons of choice are western science, massive publicity aimed at transmission prevention, and major international funding to provide low-cost anti-retroviral drugs to those in need. Numerous internationally-funded research efforts have joined up with Ugandan universities to collaborate on preventive and curative studies. The result is a boon for Ugandan academic institutions, and sets a precedent for curative research in many of the so-called neglected diseases plaguing the continent (malaria, kala azar, drug-resistant tuberculosis, sleeping sickness, etc.).

Doomsday predictions in the late 1980s of national decimation if HIV transmission were not arrested immediately have not transpired, thanks largely to Ugandan cooperation with international strategies and recommendations. Uganda’s success in controlling the AIDS epidemic strikes a powerful counterpoint to the South African experience, led by President Mbeki and his cabinet, a cabal of AIDS denialists (their approach is described in Michael Specter’s recent New Yorker article, “The Denialists”).

In South Africa today, a country of 34 million, a thousand persons are reportedly infected daily while 2000 die of preventable and treatable causes. ‘Preventable and treatable’, yes, provided you ignore the government diktat that HIV is a concoction of western pharmaceutical companies to continue the economic enslavement of poor nations to wealthy ones. (I’ve always applauded Mbeki’s reasoned Afrocentrism, but this particular delusion qualifies as criminal.)

The third trial with global repercussions—in which Uganda is more than a random test case but a veritable laboratory under 24-hour observation—concerns the success of recently developed instruments of international justice: the International Criminal Court and a separate set of UN Security Council resolutions protecting children in armed conflict. Whether or not these distinct legal initiatives can deliver their promise of justice and improved protection for victims is slowly unfolding.

Their outcome will have major implications for how the gulf of impunity is addressed in armed conflicts elsewhere—or whether it is addressed at all. Inconclusiveness or outright backfire may encourage conservative fulminations against the ICC, the United Nations, and the human rights regime in general. So-called ‘rogue states’ like Sudan or the US will continue to operate above international law, and rightfully so, because those instruments will have proven themselves pallid in tooth and claw.

I wrote about the ICC and its impact on the gruesome practices of the Lord’s Resistance Army and its leader, Joseph Kony, in an earlier 3QD piece. I wrote there that ICC indictments have triggered a return to all-out war, when in fact a curious stalemate is currently holding sway. LRA forces have for the most part respected a de facto ceasefire with Uganda by retreating to Sudanese and Congolese territory. Khartoum has supported the LRA in the past, and it has not signed the Rome Statute, the founding document of the ICC, meaning the LRA are safe in Sudan. From their camps in southern Sudan and northeastern DRC they attack local villages and health centers for food and medical supplies while negotiations with the Ugandan government drag on.

Could it be that the threat of ICC prosecution prompted LRA withdrawal to territory outside ICC jurisdiction (Sudan), thus disabling it from terrorizing its target population in Uganda? Is the ICC ultimately responsible for the current cessation of hostilities? Kony will not say, nor is the evidence conclusive. Will the Ugandan government forego ICC indictments and the experiment with international justice, and instead promise amnesty to Kony and his men to bring them back to the negotiating table? Ugandans themselves want peace and security; their primary concern is that ICC prosecution will bring revenge upon them from Kony’s residual support base. The ICC may turn out to be just another flashy gadget in the general diplomatic toolbox, occasionally useful when dealing with screwball sadists like Kony. It is a carrot or stick, or both, depending on the context. I doubt this is what its conceivers envisioned, particularly if amnesty ends up trumping justice.

The ‘era of application’

As I happen to be in Uganda to help implement the Security Council resolutions mentioned above, I’ll comment on their impact so far.

Armed conflicts have a devastating effect on children. From direct observation we know that thousands of children are killed, others take part in combat, schools and health facilities are targeted for attack and essential humanitarian aid is denied to children. The increasingly documented phenomenon of child soldiers is but one facet of the many ways that children are manipulated and exploited by adults as cannon fodder, munitions mules, spies and scouts, camp minders, cooks and porters, and sex slaves.

Peter Singer’s book, Children at War, is one of the best accounts I have seen of how accepted conventions on wartime conduct have deteriorated to the point where children are abducted and re-programmed to kill and be killed, while their adult overlords watch from a safe distance. Absence of economic opportunities in many of today’s conflicts means militias and armed groups need no active recruitment or abduction, as youth are attracted by the only apparent exit from destitution and vulnerability wrought by the war raging around them. Yet the true extent of violations against children remains elusive without a mechanism to monitor and record violations in situ. Evidence-based advocacy is the primary aim of data collection on such violations—but what authority can make violating parties accountable for their crimes?

The United Nations system, to cite another observer of philanthropic foundations, is basically “a large body of money surrounded by people who want some.” Absorbing and allocating resources constitutes the bulk of its activities and is responsible for the overwhelming red tape that constrains it. For all its faults, and there are many, it is the sole such body to have embarked on the uncharted path of setting and enforcing standards of treatment towards children in situations of armed conflict around the world. No single state has proposed a solution—many including the US have rejected proposals, conventions and treaties drafted by the UN.

Over the last ten years, with much prodding and cajoling from NGO coalitions specializing in children’s rights, the Security Council has issued a series of resolutions to enhance the protection of children in situations of conflict. As part of this process, in 2005, the Secretary General issued a list of 54 armed groups in 11 different countries responsible for the systematic violation of the rights of children in conflict. The Ugandan national army was included on this list as were the LRA, whose sadism is legion, as well as government-sponsored paramilitary groups called ‘Local Defence Units’.

Much ‘setting of standards’ has gone on; the point now is to enforce them. The most recent UNSC resolution (#1612), now almost two years old, aims to apply the prohibitions and injunctions of the previous resolutions. While these have not halted the practices they decry, they have influenced and improved much of the relief programming aimed at these target groups. Including children in the disarmament, demobilization and reintegration programs for former combatants is one such shift in policy (before they were simply abandoned with no psycho-social, educational or material assistance).

Here in Uganda we are setting up a system to document and monitor the following violations:

• Killing or maiming of children;
• Recruiting or using child soldiers;
• Attacks against schools or hospitals;
• Rape or other grave sexual violence against children;
• Abduction of children;
• Denial of humanitarian access for children.

A multilateral structure involving UN agencies, NGOs and government human rights bodies has developed a monitoring and reporting process, and has trained over 100 field monitors to document these violations. We cannot report on LRA activities because they are not active here, for the time being, although the war may resume at any time. For now most of the violations are perpetrated by the government army, whose use of child soldiers continues. Soldiers deployed to protect the hundreds of remote camps for displaced persons commit rape and trade sex for food with destitute girls in the camps.

Use the rod and spare the child

Unlike any other African conflict where I have worked, the Ugandan government actually cares about its international reputation, and wants to get off the Security Council’s list of offending countries. This attitude opens doors where, in places like Sudan or Myanmar, there are but walls and denial. For instance, teams here are close to receiving authorization to conduct unannounced visits to army barracks, to observe recruitment processes, and to enter their ‘Child Protection Units’ where they interrogate and sometimes torture children they’ve captured from the LRA. Abducted and forced to serve as child soldiers for the LRA, these former prisoner-soldiers are now ordered to march for days deep into southern Sudan to help the Ugandan army locate LRA rear bases.

Ultimately, however, the fact that Uganda deploys peacekeepers to Somalia but allows the LRA insurgency to fester leaves many here convinced that their government cares more about international opinion than the fate of its own citizens.

The 1612 monitoring system and the accountability of offending armies it envisions is in many ways an act of faith. No Security Council sanctions have issued from previous UN resolutions against child soldiering or sexual violence against children—why should they now? Given the twenty-year marathon of this conflict, these UNSC resolutions come in some ways as an offensive joke. How could anyone possibly have taken so long to notice, to act?

Uganda is a place with over 26 rebel groups in various states of insurgency; some are dormant, some are surely propagandistic fictions of the government, others are quite active. The country also has an enormous law and order problem across its northern borders, irrespective of LRA activity over the years. In one northern province, Karamoja, the national army has been using helicopter gunships to decimate rural settlements suspected of cattle rustling and arms trading. ‘Suspicious activity’ is the army’s excuse; there is no political insurgency afoot. Armed banditry for economic gain (mostly cattle rustling) is what motivates the bandits, yet women and children are often gunned down in the army’s efforts to impose order.

As a result, Karamoja sees a far greater number of egregious violations against women and children than LRA-affected areas, which are now relatively quiet. Yet no 1612 monitoring and reporting is authorized in Karamoja because widespread violent crime is not accorded the same priority as ‘armed conflict’. We are looking at solutions but for the time being the credibility of UN efforts to bring to book the world’s “worst offenders” is in question.