March on! Fellow Robots and Cyborgs! Enjoyed the poem, but you do overstate the case against science and technology a little bit. If humans hadn`t been spurred on by circumstances and genius to innovate and transform, we would still be arrested in pre-paleolithic times, using fire to ward off animals and keeping warm, losing more than half the children that were born to us. Isn`t technology the main reason that Malthus was proven wrong?

I don`t think knowledge leads us away from spirituality. In fact, the deeper that one gets into a scientific problem, for example, the workings of a tiny bacteria, the more one is filled with a sense of wonder. How does the damn thing do what it does?

Power has always been concentrated in the hands of the few - we`ve always had a system of the mighty rule, and don`t want to share. However, one could argue that evidence shows that almost every region in the world is better off compared to 100 years ago. Trends in mortality and improved life expectancy worldwide certainly support this view. Also, with rare exceptions, wealth seems to be concentrated in fewer hands than it was a hundred years ago. The middle class is much larger, there is less hunger, less disease, fewer wars.

Having said that, human development does depend on a lot more than just science and technology. Issues of environmental preservation and equity are just as important. And if we continue our present emphasis on economic growth through more and more technology without paying attention to its ecological implications and issues of equity between the developed and the yet to develop, we are surely on a path to self-destruction, may be not a 100 years from now, but certainly a 1000 years from now. If capitalism and consumerism is here to stay (and looks like it is), and Western population growth rates stagnate (which looks like they will), then the only markets to sell to to have continued growth will be outside ones - and if the outside world is not in a position to consume, than capitalism is no longer sustainable. One hopes that the industrialized countries will see that sooner, rather than later.

Ironically, if anything will save us - it will be technological know-how. Safer, higher-yield agricultural practices, more sharing of information, more education, more technology invested in environmentally-friendly manufacturing processes, invested in leading healthier lives, lower birth rates, more empowerment of women (do not underestimate the effect of technology on behavior change).

That is what we should be looking towards, looking forward to, try to achieve - a more just and humane world through the power of technology. To me it seemed you were implying we should be doing it the other way around - looking back towards good times that have already passed us buy- the good old days, when we didn`t have technology, rather than looking towards technology to get us out of this mess.

Anita

Baybay
``On the contrary, there is so much evidence now that economic independence for women results in better health for them and
their children, increased levels of education in their sons and daughters, improved standards of living, increased life expectancy,
and reduced birth rates.``

Syed Ahmed quotes the above para from me and says:

``This is complete hogwash - please cite your sources, - greater education for women and I shall completely agree but economic independence that is sheer bull.``


Syed Sahab,

You obviously have no background to speak of, in this area, and are way out of your depth.

Take it from me - it has convincingly been shown that economic independence for women is an INDEPENDENT factor correlated with all the variables I cited above.

A study by my husband and colleagues in Orangi (Health, attitudes, and beliefs of working women. Social Science and Medicine 1990;31:1029-1033) showed the following (abstract quoted verbatim):

``A cross-sectional case-control study was conducted comparing [married] working women employed by the Women`s Work Centres of the Orangi Pilot Project with nonworking matched controls [matched for age, level of education, ethnic background, ownership of dwelling, presence of electricity in dwelling]. Differences in the knowledge, attitude,and practice of several variables were elicited.

Working women`s families had significantly higher immunization rates (73% versus 55%), and shorter duration of illness (5.9 days versus 8.8 days), compared to controls. More working than non-working women supported contraception (100% versus 74%), desired equal education for sons and daughters (83% versus 75%; p less than 0.005), and had a dominant role in family health decision-making (48% versus 12%). We conclude that these working women in Orangi have a better set of beliefs and practices than nonworking women and this results in better health of their children.``

Similar results have been found in numerous studies in India, Sri Lanka, and Bangladesh i.e better health indices are observed even after matching for level of education among families where women are wage earners. A good summary is Caldwell JC: Routes to low mortality in poor countries: Population and Development Review 12, No 2 (June 1986): 171-220.

John C. Caldwell has done tremendous work in the area of fertility transitions and women`s develoment issues.

If you are in the area and crave an enlightening experience, you could perhaps attend a seminar that he is giving in the near future in the Boston area. It is on Dec 1 at 1 pm at the Center for Population and Development Studies, Harvard Square (9 Bow Street).

Anita

Baybay Re: Syed Ahmed

And while I am on the subject of spousal abuse in Pakistan, let me also give you data on emotional abuse of women (the previous posting just talked about physical abuse).

The study sponsored by the Aga Khan University shows that 90% of married women in Karachi are subjected to ``psychological`` or ``emotional`` abuse. The terms are defined as ``threatening physical violence without follow-through, threatening divorce or separation from children, exerting Islamic ``male previlege`` in demanding sex, not letting wife meet her relatives (isolation from family), and/or ridiculing and demeaning in front of children or others.

Again, the findings were corroborated by an independent random sample of men who reported the same levels of this type of behavior.

As we wake up to gross human rights violations, systematically targeted against women, especially poor women, in Pakistan, I have a simple solution for you.

Just close your eyes, and imagine a fairy land, where the vast majority, if not all women in Pakistan are very happy in their family life, without ever needing to strive for independence; most girls are born with silver spoons in their mouths to be fed with, and taken care of all their lives, by their benevolent and ``mature`` male providers who believe in ``equity``. Divorce in such circumstances of course, would be unthinkable and entirely unnecessary!!

Anita

Anita

Baybay Syed Ahmed Sahab,

I do not think marital relationships should be confrontational - rather that each couple should have the freedom to decide for themselves what it is that they want from their relationship, instead of following some prescribed path. So using priniciples of (as you say) mutual respect and equity MIGHT be interpreted by the couple as sharing the responsibility of child rearing, instead of it always being gender-defined.

Also, what is the evidence that makes you think that increased economic independence of women, leads to WOMEN becoming ``UNREASONABLE``, and therefore leads to divorce, which is to be avoided at any cost?

I wonder what you would say to data that shows 37% of women from low- and lower-middle income groups in Karachi (area where the survey was done) report being physically abused by their husbands, almost a quarter of them severely enough to need medical attention at some point in their life. The most common form of abuse is slapping, followed by pulling hair, pinching, arm-twisting, kicking, and burning by cigarette butts. About 8% of the 37% have been stabbed. The study has been validated by another independent study of unrelated men who report similar levels of spousal abuse in their households. Data from India is also very similar (about a third of all married women are physically abused).

None of the women in Karachi had sought divorce or separation. All of them cited lack of independent economic means to support themselves as the reason they continued to stay. They essentially had no where to go, as their own families couldn`t or wouldn`t support them. Additionally, there was very strong correlation between wife beating and child beating.

One could argue that in these situations, divorce would have been healthier for the wife and children rather than staying in abusive relationships, as you would suggest.

Also, I should refer you to Amartya Sen`s writings which provide very strong indirect evidence of systematic discrimination against women. He refers to this as the ``disappearing women`` problem of South Asia and China (refers to less actual number of women in the population than would be expected, given longer life expectancies of women if one makes a comparison to other countries, even other developing countries), both regions that practice intense discrimination against women from the moment of birth.

Also, it would appear that you hold the view that women should become economically independent only if forced to by circumstances (i.e. husband is poor, disabled, dead). Besides the obvious fact that the vast majority of the world`s women are already in that situation, for those that aren`t, it would mean either of two things - either that they do not acquire the skills to become independent early on (i.e miss out on education and training in their younger years when it would be easiest to learn), or that if they do, they should then waste those skills cogitating at home shackled by multiple children that they shouldn`t have had in the first place. Developing countries can ill-afford this perpetuation of dependency.

On the contrary, there is so much evidence now that economic independence for women results in better health for them and their children, increased levels of education in their sons and daughters, improved standards of living, increased life expectancy, and reduced birth rates.

Syed Sahab, you are still arrested in the pre-industrial era, and unfortunately for us, the women of Pakistan, as well as our future generations, so are the majority of other Pakistani men.

Anita

Miracle Workers at Shifa Umair, I totally agree with you - the potential benefits of information technology and computerization to Medicine are enormous, and are finally being realized. Just within the last year, there’s been so much change in our work environment for the better. The vast majority of communication among colleagues is now via e-mail instead of phone/pagers. I write all my clinical notes on-line - letters to referring physicians and patients are generated automatically from these (patients love having copies of all their notes), our order entries are computerized, billing is computerized, the pharmacy is on-line, laboratory results are on the Web, the medical record is electronic. The availability of MEDLINE on WWW for free (has abstracts of all medical articles published in indexed journals since 1966) puts more than 30 million scientific articles within reach of our fingertips. Many investigators now list their e-mail addresses in the abstract, so there is the ability to e-mail specific experts for their opinion on an unusual or rare condition. At Children’s there are templates for ER notes, discharge notes, clinic notes. Clicking on a few buttons generates the note in most ``standard`` illnesses. For example, if I see a three year old with ear pain, I can click on ``three years``, ``ear pain``, ``physical exam``, and I’ll get one of several algorithms to go down on depending on the history and findings. After choosing the most appropriate one, I have the choice of choosing one of several treatment options with headings like ``Otitis Media -Standard Plan`` and I have a note that has the history, the findings, the treatment (with the right dose of antibiotic calculated etc.), a printed prescription, and a hand-out for the patient with information about ear infections and the treatment given to that specific child, at the click of a few buttons. What I really enjoy is the look of astonishment on the patient’s face. They can’t figure out how I generated such a comprehensive note in the space of a couple of minutes.


Children’s Hospital, Boston has been a leader in Medical Informatics (The Sept 15’ ‘98 Annals of Internal Medicine article is from here). A friend of mine who has his own software firm, but is also a physician (trained as a pediatrician at Children’s) has been doing some amazing stuff to improve the efficiency and productivity of the hospital staff. Situations where there is a lot of room for improvement are enhanced communication with patients to supplement face to face physician-patient encounters. For example, ability of patients to make on-line appointments with physicians for non-urgent problems, the ability to make on-line referrals to other physicians within the system, informing patients of their laboratory results via e-mail, having Web sites that list all patient care services available, including physician credentials and areas of research (Children’s website does this - www.childrenshospital.org), answers to FAQs etc.

Coming to the question of the use of Internet for medical consultations, I can give you our experience and the problems with making it a revenue-generating operation. Presently, our system for offering consultation to patients and other physicians from outside the hospital is very inefficient. Community physicians either access the website, or call the main phone line. Patients call the main phone line, or send unsolicited e-mail via the web site. As a public service, each division dedicates a person who takes responsibility for getting back to the requester and provides consultation free of charge. For Infectious Diseases, I am that person (25% of my job description). The way the system works, is that whoever, and from wherever in the world (we routinely get out of state and international calls) or e-mails and asks for an Infectious Disease consult gets routed to my office. My secretary takes down a detailed history and e-mails me (or pages and e-mails me for urgents). I call them back according to the urgency of the problem, but within 24 hours, and also write an on-line note mailed back to my office (the recording is necessary for liability reasons).

Given the inefficiency of the system, and the volume of calls received, we have explored the possibility of having an Infectious Disease Website through which patients and other physicians seeking advice on a tough case can contact us, instead of the present calling on the phone system. However, there are several concerns. Firstly, since we offer this as a free service, we might be overwhelmed with requests, especially from people from whom we have no way of generating money. Children’s Hospital has been rated the number one hospital in the US (if not the world) for several years, so this concern is quite legitimate. Presently, only 5% of the calls that I handle result in the patient being seen at Children’s (barely enough to cover 25% of my salary - i.e. this service runs at a loss to the hospital). The remaining 95% are either calling from long-distance, or the patient is admitted at another hospital, or the problem can be taken care of by their own physician and a visit to Children’s is unnecessary, or its a patient already known to us, and its a follow-up call.

Secondly, for a patient calling directly who is from out of state, or from another country, it is illegal for me to be giving medical advice b/c I am not licensed in that state/country (its okay to be advising another physician, though), and its only a matter of time before states start cracking down on this (all we are waiting for is a couple of disasters to happen).

Thirdly, if we were to decide to charge for on-line consults, several problems arise: a) who would pay - physicians don’t want to, b/c in the managed care environment with intense competition for patients, they can easily find somebody who’ll do it for free as a matter of goodwill, or they’ll just develop a special relationship with a particular ID doc and bypass the call system (I get called by many community docs who’ve gotten to know me through the years, even when I am not on call - hey just today, a Saturday, a persistent doctor, now in Texas, who needed advice on a patient admitted at a local hospital, finding that he was unable to reach me at home, had me paged through the hospital operator. I was at the park with my daughter, and am not on call. So, I had to come home to find out who had paged me urgently to a number in Texas on Saturday - didn’t think to take my cell).

Insurers, obviously have conveniently refused to pay. So, it would have to be out of pocket expense for the patient. b) if we start charging patients on a credit card, tremendous ill will is created in the community which will backfire on our referral base. Additionally, if dishing out money from their own pocket is necessary, patients at least in the US and other industrialized countries are more likely to just seek medical care at a local expert’s office and have their insurance company foot the bill, or get their physician to call for them.

Fourthly, and most importantly, focusing on patients who contact us on-line, and trying to make money off them necessarily perpetuates, in fact, aggravates the disparity of health care offered to the haves and the have-nots. These represent the most educated elite who already have access to the best care. Most of us in academic medicine did not stay in academics to make more money. But that’s where the best expertise is available. Therefore, I do not see academic medical institutions starting to charge patients for consults given over the phone or via e-mail. These services should and most likely will remain free for anyone who seeks them.

On the other hand, I see a lot of potential for revenue generation in situations where small hospitals contract with academic medical institutions to tap into their expertise, since these are win-win situations for everyone involved. Let’s say a small peripheral hospital (P) contracts with the academic center (A) for neurological services. A patient with stroke presents to P. P has no neurologist of its own but contacts A’s neurologist and sets up a video-link through which the neurologist at A watches P’s doctor perform a history and physical exam, has opportunity to ask questions, and can look at the MRI and advise on further management. The patient wins b/c he/she doesn’t have to be transferred to a hospital far away from home, the peripheral hospital wins b/c they do not lose revenue on this patient, and also get away without having to have a neurologist on staff with his/her salary and benefits. The academic center wins b/c they can influence practice in a larger area, as well as make money on the consult. The insurance company wins b/c they are not saddled with the substantially increased costs of medical care at a tertiary care hospital.

This is I think the business model of Telemedicine that is the most viable, and will increasingly be seen. Of course international video-links are also possible and no licensure rules are violated since all care is directed through the local physician.

From the medical side anyway, there is an active effort underway from the Big Names to capitalize on Telemedicine technology. That is the model that the New England Medical Center is building with its international program. MGH is also actively building a program. Saad has been working on validating the accuracy of the neurological exam over a video-link so that the Neurological Service can expand its patient base to outside Massachusetts. Most academic medical centers that I am aware of now have an Informatics Department with full-time employees working on expanding their services. As you say, Medicine and Information Technology are finally getting married as we speak.

Anita

A Ray of Hope SR, you point to a very important problem with many health-related philanthropic projects in Pakistan. Even with a large endowment and constant fund-raising, not to mention substantial charges from the patient base, the AKU hospital is barely getting by with staying in the red.

Imran Khan is hopefully making every effort to ensure that this wonderful initiative can continue even after he is gone. There is no shortage of magnificent but empty structures remaining behind to gather dust after the benefactor has bit the dust.

Anita

Baybay RE: Tehsin,

Yes, I do think the game of the ``pursuer`` and the ``pursued`` as being gender-defined will change - (with the caveat that we are talking about industrialized countries and the upper and upper middle classes of developing countries).

I was specifically referring to the negative stereotype of older women as not being considered attractive as being a thing of the past. Look at the Vogue-enhanced pictures of Hillary Clinton. Look at Elizabeth Dole, or Patricia Ireland. All women with power in their fifties who look attractive to many.

RE: ferozk

Very well said!

RE: Godot

I share your views to some extent. Shahbaz comes across as being ``mixed-up`` in his attitudes towards women, and what he wants/expects from them. But of his own admission, his ideas are not fully matured - and I do like his candor and lack of inhibition.

Re: Syed Ahmed

You talk about compromise, Sir - so would you then agree that among men and women, both should have equal opportunity and desire for compromise, if they decide to reproduce themselves into a family?

Also, there is such a high correlation of economic independence for women, with developmental progress among the poorest of the poor - the recent examples of all the microcredit programs in South Asia and sub-Saharan Africa targeted especially to women come to mind. Should we get rid of these to satisfy the gender-based roles that you see for men and women?

I think you are guilty of looking at the issue from a very narrow focus. To me, increased economic independence of women is a sure way towards development.

Now, if you deny that development, as seen in the West is not what you want for the rest of us, then we can have a different argument - we might even find some common ground - but I would have to ask you to explain the choice that you made in living here (the evil but developed US), rather than in the beloved homeland.

Re: MAK

You bring up a good point - I touched upon it briefly in one of my earlier replies. The reason that women start looking older (than men), in my mind, has a lot to do with expectations from life. Once the children grow up, and become independent, which happens to most Pakistani women in their late thirties (even 12-15 year olds are pretty independent), all that is left to look forward to in life is the childrens` marriage and grandchildren. Depression sets in, at they feel the lack of utility in their lives. Personal health suffers - and menopause hits as the final nail in the coffin.

In my experience (there is data to support this view in the West, but not in Pakistan - may be Aliya, our Chowk psychiatrist can comment), older Pakistani women who work have much lower rates of depression, and much better physical health, than those who don`t. I compare my 63 year old highly energetic and physically fit working (and widowed for 6 years) mother to those of my friends and relatives mothers - and there is no comparison. She has so much going in her life, so much to occupy herself with, to offer and stimulate other people, both young and old - she`s a constant inspiration to the lives that she touches. As somebody else said, age is all in the mind - its the attitude to life that matters.

Anita

Baybay Re: RanaRansher

I do think that societal conditioning plays a key (although not the only) role in whom we find attractive. Excluding prehistory, positions of power have been occupied almost exclusively by middle-aged or older men. Therefore they look attractive. As we gradually shift to a more egalitarian social system with equal opportunity for women, older women will look attractive too. Traditionally, women have let themselves age excessively - thought that now that the children are grown-up and gone, its time for them to shrivel up and die. Now, there`s a whole life of freedom to look forward to. Additionally, after much neglect older womens` health issues have also gotten attention. Osteoporosis is going to be mainly a disease that our grandmothers and mothers needlessly suffered from (the problem that makes bones lose mineral so that women lose height and bend over), safer versions of estrogen have been developed. There will be no such thing as menopause.

Yes, the world`s a changing. And men who have been used to getting their way have good reason to worry about what the future may bring.

As an aside, I agree with you about the hair removal business - but that`s a whole another debate. Will come back to it at another time.

Re: iconoclast

Girls are bombarded from a very young age to be receptive to the idea of Prince Charming as their hero and saviour. They grow up having this expectation from a marriage. As we actively move away from such gender-based conditioning, these naive expectations will give way to more realistic ones.

Re: SR

Malthus in fact advocated marrying older women, or not marrying at all as a way of decreasing population growth rates. He called this a ``preventitive check`` on the population, as opposed to ``positive`` and less adaptive checks (enhanced mortality through war, famine, disease etc.).

Re: Syed Ahmed

In my view equality in a relationship is a simple concept really. It means that both people in the relationship should have an equal opportunity to pursue their dreams and desires, whatever they may be, and regardless of gender. If you have that, you have equality. That`s what I mean by saying ``harmonious relationships need no longer be based on a male breadwinner, and a female stay-at-home figure.`` A relationship could be whatever the two people in the relationship decide would be good for them as a couple, and as a family.

Also, just for the record - I am not a first generation professional. My mother, the most highly educated among her family of five brothers, studied medicine in the `50`s, and went on to specialize in England. I was born during her residency.

Anita

Baybay Important topic but poorly analyzed.

From an evolutionary standpoint, it would appear that marriage for women at a young age would maximize fertility and thus be advantageous to the propagation of species. However, fertility transitions towards smaller family size related to increasing female age at marriage were evidenced in Europe as early as the late 17th century, so it is indeed surprising that the gender gap in age between men and women at the time of marriage still persists universally, albeit it is shrinking slowly as we hit the 21st century (see data given below).

A multiplicity of factors in addition to biological ones are obviously at play. One of the most important, to my mind is that with access to improved health, life expectancy at birth for girls is on the average 7 years more than that of boys. This adds to the supply/demand problem. There are just many more women around than there are men. With the obsession that society now has with looking youthful and radiant, and with men having the luxury of choosing a mate, one would expect them to choose from among the youngest and most beautiful, even excluding biological considerations.

Economic, cultural, and patriarchal factors all act together to accentuate the disparity in age at marriage. From an economic standpoint, women who do not want to earn independent livelihoods prefer to marry men who are financially solvent, and therefore generally older. Lower rates of higher education for women (positively associated with young age at marriage), at least in India and Pakistan are also big factors in early marriage.

Finally society continues to look upon spinsterhood with stigmatization everywhere in the world (unquestionably more so in our part of the world). One only has to look upon parallel words to indicate never-married status in the English language to realize the depth of this stigma. The world ``bachelor`` connotes eligible status - a temporary personal choice is implied - the understanding is that the gentleman in question is a bachelor by choice and can change that status whenever he so wishes. By contrast , the word ``spinster`` implies a woman that no one has found attractive enough to marry - the woman exists in this pitiable unmarried state through no choice of her own, and would (or should)jump to marry the first guy that comes along - the word says. This stigmatization of course creates unbelievable anxiety in the minds of parents of young girls, so that they indoctrinate in the daughters’ minds the importance of early marriage to the first ``suitable`` rishta, in order to avoid this tragic fate.

The good news is that things are changing, even in India and Pakistan towards greater parity in ages at marriage, as well as rising age at marriage.

India’s data from the ‘92-’93 National Family Health Survey show average age of men at marriage as 25, and women 20. This compares to 21.9 for men, and 15.9 for women in 1961. In urban areas, the gender age gap is about 4 years.

Pakistan just had a massive Health and Demographic Survey done, results from which are still in the press. The last survey from 1991 showed that average age for men at marriage is 26.5, and that of women 21.7. This compares to 23.3 for men, and 16.7 for women in 1961 (census data). Not surprisingly, given longer life expectancy for women, and younger age at marriage, more than half of all Pakistani women are widowed by age 65.

Now of course, it is possible to interpret the rising age at marriage for both men and women as being driven by Malthusian forces - but the positive correlation with education and delayed marriage argues otherwise.

In the final analysis, I continue to hold to the view that women must strive towards economic independence, and that independent women should prefer to remain unmarried rather than compromise on principles of equality in marriage. Additionally, women should get away from the notion that they have to marry someone more ``qualified`` and older than them, thus perpetuating patriarchy, and doing themselves an enormous disservice. Thankfully, harmonious home life need no longer be based on a male breadwinner, and a female stay-at-home figure.

anita

Silent together Re: Zehra

``...even though stories about doctors and dying patients are getting hackneyed..``

That`s just it Zehra. These are not stories. These tragedies happen to thousands of children and parents every day.

You might think that Dr. Chekov`s work, for example is fictional, but in fact, much of it is based in reality and is drawn from his own medical experiences.

If you refer to the television show ER, a lot that is on there is also based on real events, just that the events that may unfold over days are compacted into an hour, so they appear over-dramatized.

Anita

Silent together Aliya, this is something, the awkwardness that one feels when telling parents that their child has a terrible incurable disease, is a feeling that no amount of ``practice`` can cure. It is an utterly terrifying experience - relived over and over again - forever marks on the heart.

I read this and thought of all who have died on my watch - all those who went with a smile, braving it to the end, knowing it all, but still smiling. And the parents left behind.

Anita

Seasonal Swings Very quaint Ms. Farooq. Sirdiyon ka lehaaf mein ghush keh bethna yaad aa gaya.

As for missing the horror of the December shaadi scene - well, isn`t it more than replaced by the daily forced feeding practiced at those ubiquitous iftaar parties - sometimes three to an evening?

Anita

The Boys who will be Men Powerful Shandana, eerily powerful and disturbing. Stays in the mind. Superbly executed.

For people in or near the Boston area, a researcher from the Aga Khan University is presenting her work on domestic violence in Pakistan at the Global Chat Forum at the Harvard School of Public Health on November 18, 12.30-1.30. The title is ``Cycle of Domestic Violence - a Power and Control Trap. Those interested can contact me at Zaidi_a@a1.tch.harvard.edu

Anita

Smitten by Helen RE: AA`s question

``...You a doctor, she a nurse, is this a Mills and Boon doctor-nurse unrequited romance?``

Dear AA,

This of course, is a story from my imagination :). Now it is true, that in real life, I have been known to be, on occasion, aggressively competitive, but 10 years of marriage to Saad (btw he is Sana Shafqat`s brother) has mellowed me a bit.

Here what I wanted to portray was the narrator`s lonely acceptance of her way of life as being the only way she could get her way, careerwise, yet she lacked the courage to pursue an unusual love interest.

The description of the apartment complex is largely based on real life. The names are fictional, and are a play on Homer`s Odyssey and Iliad (Troy, Cilicia, and Lectos are all islands in the Troad, and that`s where `Helen` came from, and that`s why Helen is objectified - from the phrase ``the face that launced a thousand ships``).

RE: slink and sohail,

Interesting - what you two have to say about modern city living. I could indeed see the goings on in the apartment across from my baywindow. And a woman who spent a lot of time doing her hair. But she always did have her clothes on :).

Sohail,

Your praise means a lot to me. Unfortunately, this essay was censored in some parts, which was very disappointing to me. I expected more from Chowk.

Anita

My Terrible Secret Re SR:

The author of this courageous essay probably was not expecting a medical exposition, but since you bring it up, the early age of menarchal onset here is indeed striking.

While it is true that the age of menarche in girls has been slowly decreasing, and is attributed to a host of psychosocial (early sexualization through media exposure affecting endogenous hypothalamic gonadotropin releasing hormone activity etc.)and nutritional factors, the most important determinant is still genetic i.e age of maternal, as well as other female relatives` onset of menarche.

The appearance of secondary sex characterstics (breast budding in girls, testicular enlargement with reddening and thinning of the scrotum in boys) are usually the first signs of puberty. The appearance of secondary sex characterstics before the age of 8 in girls (and therefore menarche before the age of 10, since there is on average a two year lag between start of breast development and periods), and before the age of 9 in boys is definitely considered precocious in any part of the world.

Precocious puberty is much more common in girls, than in boys. Most often, no cause can be found and it is labelled idiopathic. However, there can be well-characterized medical reasons for it that need to be ruled out before it is labelled idiopathic.

Similarily, delayed puberty (beyond the age of 16) can also have a number of causes, the most important factor again being familial. High activity levels such as seen in elite athletes and ballet dancers (I suspect your wife was dancing through her teenage years), and poor caloric intake (e.g anorexia nervosa) are additional important causes today. From a medical standpoint, delayed puberty is generally more concerning than precocious puberty. As the author well illustrates, in Pakistan, it is probably the other way around.

Finally regarding your remark about pediatrician epidemiologists, I suspect you refer to me. Unfortunately, I have only a passing interest in reproductive endocrinology. The love of my life remains infectious disease epidemiology.

Anita

Love in the 90’s Re: Mohammad Faisal

``...There is inherent irony in most modern concerns; the accused becomes the accuser, the oppressed becomes the oppressor etc (REF: Martin Heidegger on action/inaction paradox). ``

Alas, political correctness is the orthodoxy of today.

Politically incorrect views are censored, banned, edited out. Individuals expressing such views are seen to have no right to speak their minds. We are told it is wrong to judge. Only the politically incorrect can be judged by the self-appointed spokesmen and spokeswomen of the politically correct group, who of course, are insulated from criticism of any kind ... since they are so PC.

Anita