Introduction

Background

At this crux of a critical juncture in human settlement, we close on a decade defined by armed conflicts, global political uncertainty, natural disasters, and affirmation of the permanence of climate change and its consequences [1]. We enter the new decade with the COVID-19 pandemic and uncertainty and fear with a rapid increase in migration from rural to urban settlement hubs for employment and education [1,2]. In Pakistan, that city is Karachi, which is now the fifth-most populous city in the world [3]. Karachi’s population and the number of communities she houses within herself has seismically increased over time while the rate of urban development has severely dampened as the population size increased [2].

The pandemic has significantly worsened the quality of life of people in Karachi, specifically women and young people [4,5]. Therefore, the study will explore the impact and current living state of four different types of communities in Karachi i.e., a community residing in an urban locality of Karachi, a community residing in a peri-urban/rural locality of Karachi, a locality housing a religious or social minority community, and a low-income locality. Considering the impact of the pandemic on geographic and financial accessibility of communities to key resources, the study will explore the communities’ “living state” by assessing respective communities’ perceptions of and access to fundamental healthcare, social, legal, and educational resources.

Materials and Methods

PEER Research

The study used a Participatory Ethnographic Evaluation Research (PEER) approach, which trains members of the target population (‘PEER researchers’) to conduct interviews with trusted peers in their social network [1,6,7]. The PEER approach holds the potential to generate insightful narrative data into the daily lived realities as experienced by men by eliciting ‘rich description’ through story telling. PEER method has proved to be useful for research into sexual and reproductive health, particularly for issues that may be socially sensitive or stigmatized [6]. The PEER process uses third-person narratives (asking ‘what do other people think about’ a behaviour or issue being researched) and, as such, does not require the personal disclosure of behaviour. The method also allows respondents to explore predominant social norms and how individuals may question or re-assert these in their daily decision making, which is particularly useful for formative research and programme development [6,8]. A key part of the PEER process is that data are used for critical and joint analysis between the research team leaders and PEER researchers, which allows further exploration of research themes, including usergenerated recommendations for programme intervention.

The PEER methodology was used for data collection from identified communities. The methodology was operationalized by training members of CSOs as ‘PEER Researchers’ to conduct conversational interviews with trusted members of their social network. Two sets of workshops were conducted by a Research Implementation Consultant with PEER Researchers recruited for data collection purposes.

1. The first workshop was the “Briefing Workshop” whereby the recruited and consenting CSO members were briefed on the study, research ethics, research confidentiality, and interviewing techniques. The interview guide for conducting the conversational interviews was developed collaboratively with the PEER Researchers (PRs). After the workshop, PRs were given a period of five days to conduct three or more conversational interviews with individuals in their social networks. Four briefing workshops were conducted across the four community types. A total of 28 PEER Researchers were recruited who subsequently conducted more than 50 interviews.
2. Participants were then called for a “Debriefing Workshop” whereby the PRs debriefed the Consultant on the stories they collected from their interviews. Four debriefing workshops were conducted, and the debriefing sessions were audiorecorded with consent from participants, and with CSO members for understanding their operational context, their programmatic and field efforts specifically with regards to, and assessed the communities with regards to their accessibility to educational, health, legal, and social resources.

Data Collection and Management

The Consultant collected data through 08 sessions (04 briefing and 04 debriefing sessions with each of the four communities), and the audio-recording of the sessions were later transcribed verbatim by an associate under the supervision of the Consultant. Furthermore, the consultant was responsible for the entire data management of this study, under the supervision of the study investigator. Data were stored electronically in password-protected encrypted computers of the investigator and the consultant.

Data Analysis

Initial qualitative data analysis was guided by thematic content analysis as already defined in the conceptual framework [9,10]. In-depth reflexive memos were read several times to develop themes and new codes based on the actual words of the researchers. The identified codes, themes, and patterns were reviewed alternately by each researcher to minimize bias and to ensure reliability.

Ethical Consideration

The study ensured that the rights, safety and well-being of the participants were prioritized throughout the research process. Informed consent was obtained from all the PRs participating in the study. The research participation was completely voluntary with the study participants verbally informed about their right to either withdraw from the study at any point and/or to refuse to respond to question(s) in either of the workshops.

Results

Sociodemographic Characteristics of PEER Researchers

Mean age of the PEER Researchers was 34 indicating that most of the participants were young adults, and were predominantly men (71.43%) as men were more active as CSO members in the respective communities (Table 1). 64 percent of the PEER Researchers were married or had ever been married with 72 percent having any children; the mean number of children amongst these PRs was 2. Most of the PEER Researchers had attained formal education with 64% having an undergraduate or a graduate degree, and only 11% of the PRs had no or only primary education. 25 percent PEER Researchers were employed as health or medical workers, 18 percent participants were teachers, and the remaining had social, office, government, service, pastoral, fishing, government, and educational occupations. Furthermore, 32 percent participants belonged to peri-urban/rural and minority localities, respectively, with the peri-urban/rural locality populated by a Sindhi ethnic community and the minority locality was populated by a Christian community with a Punjabi ethnicity. Moreover, 18 percent of the participants belonged to urban and economically-marginalized localities, respectively, with the urban locality populated by an Urdu-speaking ethnic community and the latter populated by a Pashtun ethnic community.

Summary of Framework Analysis

The workshop transcripts were coded, and the codes were organized into categories. Aligned with the study objective, four core themes emerged from the categories i.e., perceived healthcare state and resource accessibility, perceived educational state and resource accessibility, perceived social state and resource accessibility, and perceived governance state and resource accessibility. Gender-relevant themes i.e., SRHR, GBV, and CEFMU did not emerge as core themes or categories. PRs attempted to elicit perceptions around the issues and despite there being narratives around it, the issues were not substantive enough to emerge as significant in the analysis. Moreover, the findings and conclusions within each theme are described in the sections to follow.

Theme 1: Perceived  Healthcare State and Resource Accessibility

With regards to the urban community, healthcare facilities and access to healthcare was quite stricken with there being a few private hospitals that offer either poor care or are too expensive. This poor access is further exacerbated by the absence of a nearby public hospital or dispenser, with people reliant on Polio vaccination camps to access a doctor. Lack of clean drinking water coupled with an inadequate sewerage system crossing lines with the drinking water was responsible for causing several water-borne and nephrological diseases. This was one of the primary health concerns in the community. The peri-urban/rural community in the study was a fishing village, and had a similar issue connected to the inadequacy of the sewerage system which drained in the sea hence polluting the fishing waters that serve as the source for the staple food, fish, and drinking water, obtained after traditional purification of seawater.

“There’s sewerage lines disposing the waste into the sea. Fish is our livelihood, and also what we eat. This waste that now goes into the sea is consumed by the fish. We from the fishing community eat these fish which really effects our health”.

    Participant from Fishing Community

Furthermore, there was very low awareness around healthcare in the community with just drug dispensers and no doctors or ambulance accessible to the community residents. This was further exacerbated by the absence of a maternity home or a source of contraceptives for women. This absence of demand and access for reproductive and maternal health care results in a high number of maternal deaths in the community with very few women able to access the “city” for contraceptive or maternal care. A similar story was also presented by the PRs reporting from the Christian community with limited usage of contraceptive and antenatal care coupled by high malnutrition resulting in a high number of births per woman. Large number of children were reported to be physically deficient at birth due to malnourished mothers and very limited access to healthcare, with the nearby private clinics unaffordable for most families. The economicallymarginalized, low-income community, shared a similar narrative highlighting the absence of accessible doctors, with the doctors charging high rates and providing selective care to people with greater financial means. The community members have very little awareness around formal healthcare and modern medicine, and in certain cases, violence at healthcare facilities or against medical professionals is observed as well as a response to this biased care. Furthermore, PRs highlighted Hepatitis C, malnutrition, waterborne illnesses, typhoid, self-medication, and drug overdoses as the primary causes of morbidity and mortality, Hepatitis C to be extremely prevalent in the community.

Theme 2: Perceived Educational State and Resource Accessibility

Across the communities, accessibility to quality and higher education was a very severe problem. PRs from the urban community reported that quality education is not accessible with there being several local and government schools albeit with poor system and infrastructure, and an underpaid and underqualified faculty. PRs from the Sindhi-speaking fishing community highlighted that Sindhi is the lingua franca in the community, with very few people speaking fluent Urdu, the lingua franca of Karachi. This restricted people severely from accessing educational opportunities with there being no secondary schools or colleges, and the primary schools didn’t fulfil the children’s need of Sindhi coursebooks with a fluent Sindhi-speaking teacher. Girls were particularly hampered as there was only one school for girls which was located at the outskirts of the locality, however, it wasn’t considered safe for girls and women, in general.

“Here everyone speaks and only understands Sindhi, but teaching is done in Urdu which causes difficulties for school going children”.

    Participant from Rural Community

PRs from the Christian community reported a similar narrative regarding the schools and the teachers with there being government schools close to the area, but they were neither accessible nor operational. Moreover, the PRs from the lowincome community echoed the same concerns highlighting the lack of quality schools and professional teachers with parents prioritizing madrassah for children’s education in the absence of an adequate schooling system. Furthermore, due to the economicallymarginalized state of the community, children often quit primary schools, by choice or by circumstance, for menial jobs in factories and shops.

“When people don’t have money education isn’t priority, income is, which is why kids as young as 12 years old are working in shops and never seek education”.

    Participant from Low-income Community

Theme 3: Perceived Social State and Resource Accessibility

As discussed earlier under Theme 1, the infrastructure for water and sewerage was reported to be abysmal across communities responsible for a whole host of social, economic, and health problems. According to the PRs, the communities highlighted this as the principal problem that has worsened over time with no intervention from the government or CSO to alleviate the issue.

“Unavailability of clean drinking water is a major issue. People here use water that comes from boring which is already unhealthy. And then the line water gets mixed with sewerage water…all this effects the overall health of the community”.

Participant from Urban Community

Expanding upon the social issues with respect to each community, the urban Urdu-speaking community also referred to as Muhajirs (migrants) highlighted the discrimination and barrier they face as “ethnic migrants” [1,2]. This was specific to obtaining government jobs with this pseudo-identity often used to discriminate against them with regards to employment and academic opportunities. The locality, being urban, is quite densely populated, but do not possess the lease of the residential area which causes strife with the government. The prospect of land contestation and ownership is further complicated by the fact that the community migrated in a large number roughly thirty years ago, and several families reside in one house.

“We have been living here for 30 to 35 years and now the government suddenly remembers that it’s their land and has labelled us as illegal settlers”.

    Participant from Urban Community

Ceding to this, the PRs also linked this lack of resolution over these issues with the “middle-class mentality” of the community whereby self-respect and social status is often prioritized over rights and living status [2]. This results in people making very little effort to understand and alleviate the problems despite being cognizant of the various problems as they consider making an effort to be beneath them. On the other hand, the fishing community lives under a very different social and economic system with fishing being the primary occupation of families living there. The cut-off nature of the community makes it challenging for them to access the city, for employment or education, with private transport being very expensive. Moreover, due to limited opportunities for technical education and employment within the locality, there are only a handful of alternate sources for basic income-generation available to the people there with there being less alternate employment opportunities available for boys and girls able to obtain domestic service jobs e.g., maid jobs. Owing to the aforementioned issue of sewerage affecting fishing, the community’s primary occupation, there has been increasing unemployment, morbidity, and poverty within the community leading to chronic mental distress, increased substance use, and accidents due to absence of safety equipment for fishing.

“The system here is different. There will be too many people on a small boat. Safety equipment is next to nothing which results in many accidents”.

    Participant from Fishing Community

The PRs from the low-income community reported similarities in limited employment opportunities available to the community members and earnings of less than the minimum wage as well as similarities in issues perpetuated by unemployment with increased intra-community violence. PRs from the Christian community emphasized upon the religious bias their community has to face across all walks of life in Pakistan, as a consequence of being a religious minority in Pakistan. They exemplified this by highlighting that a large proportion of their community members are restricted to certain blue-collar jobs and roles such as sewerage workers, janitors, nurses, teachers, and vendors. This ubiquitous social bias prevents community children and adults from attaining benefits from private or welfare entities, and very limited is offered to them by the government with the community not even aware of the quota government has for their community with respect to academic and employment opportunities.

“The benefits given by government or welfares are rarely given to the children from Christian community and instead are only granted to Muslim children”.

Participant from Christian Community

Community members are often underpaid as well, and paid below the minimum wage which is insufficient for household expenses, as even access to drinkable water has a high cost as well. Furthermore, the community resides here with a constant fear of the blasphemy charge; the community members are very mindful of it and ensure that they do not say or act in a manner that can be considered “blasphemous” by the Muslim majority, but the broad nature of the charge makes the community act timid in the society with Muslims [1].

“If anyone has a disagreement with us, they accuse us of blasphemy and we end up in jail.”

Participant from Christian Community

Impact of the Lockdown

The lockdown as a response to the pandemic has resulted in catastrophic loss of life and income for these fragile communities with people losing jobs and their sources of income with increased expenditure, specifically for healthcare, driving communities to extreme actions [4].

“Many have become unemployed, which has led to many of these people resorting to petty crimes resulting in an increase in mugging”.

    Participant from Urban Community

The shop-owners and vendors in the communities encountered severe harassment and violence from the police for opening their businesses, out of necessity. The PRs highlighted that neither the government nor the upper social classes have showcased any empathy for their plights and their helplessness in not following the lockdown regulations. Moreover, in certain communities, out of sheer helplessness and starvation, some people have resorted to mugging and robbing to gain income which has resulted in increased intra- and intercommunity violence.

Cross-community Gender-based Inequities

Reported household norms were not dissimilar to the patriarchal norm found elsewhere in Pakistan [11]. Household decision-making, as a function, was performed largely by men thereby restricting women’s autonomy over individual and household finances. Even income earned by women themselves was handed over to and was managed by the husband. Moreover, if women are involved in decision-making, it is largely for routine household management. Experiences of greater female autonomy was only reported for households in exceptional circumstances whereby the husband was medically incapacitated or a substance user. This imbalance in autonomy and decision-making causes women to compromise over their health and their children’s future, in some cases, as well.

Gender norms reported by participants were reflective of the gender norms in the society at large [12]. Women’s social functioning was largely restricted to the household, the field, and tending to children. However, these restrictions tend to lessen with age with younger women facing a much more restrictive environment than older women. This aligns with unequal gender norms elsewhere in the society as well, whereby social restrictions are used by families as a ploy to stifle women’s sexuality especially in adolescence and the “pre-marital” age [13]. In conservative societies, with progression of age, parity, and social status through marriage and motherhood, women gain greater social independence [14]. Participants identified and recognized the value of education and vocational skills in gaining financial autonomy, however, they were also cognizant of the challenges that women face in attaining them as well. Men were perceived as the ones who are prioritized for receiving education, responsible for getting a job and managing the household, and responsible for performing physical labor. Men are generally not involved in the routine affairs of the household. However, men’s attitude towards women getting jobs has become more favorable in recent years due to progressively increasing inflation and economic hardship, specifically faced by poor and rural households. This aligns with the results of another study that was conducted with rural men in Pakistan [6]. Moreover, within the fishing community, the practice of watta satta (exchange marriage) is still observed with girls married immediately upon reaching “maturity” [14,15]. Matches are often made at birth within the families with girls forced to marry against their will even if the man is a drug user or is involved in socially-violent behaviour.

“In our Rehri Goth, the wrongful culture of watta satta (exchange marriage), an old practice, is still prevalent. It causes rifts between families. Two homes are ruined. This is an emotional torture that wrecks relationships amongst families”.

    Participant from Rural Community

Consequently, emotional violence faced by the girls is generally followed by domestic violence as well as violence within the community due to family feuds if the girl refuses to marry. This highly-frowned upon practice was unique to this community, within the CEFMU ambit; PRs from the other communities did not report the issue to be common within their communities.

“After all, what will the girl say? She doesn’t object so as not to displease an older family member or relative. Poor girl just suffers in silence. This too is a form of abuse”.

    Participant from Rural Community

Furthermore, linking with the healthcare landscape described above, there weren’t facilities offering contraceptive or SRHR services, hence, the demand for these services can be considered latent, and explains the low number of narratives shared around it.

Theme 4: Perceived Legal Issues and Resource Accessibility

PRs across communities highlighted the well-documented issues of bribing and discrimination that community members face in their interactions with branches of government and law enforcement. There is low awareness of what the law is and how it is used with people often not aware of the law that the government or law enforcement is using against them in various walks of life. Expanding upon the bias faced by the Christian community, they refer to their community pastor for any issues within the community instead of the police. Moreover, PRs specifically highlighted the difficulties community members face in obtaining basic legal documentation such as the Domicile and the National Identity Cards. This general attitude of the officials of the state branches deters the community from approaching them, and have to learn to live in the city handicapped without access to these basic identity documents [1].

“People from all states of the country migrate to Karachi, but they only find issues in updating a Christian’s address. If it’s a Muslim, then it’s promptly done but that is not the case for a minority”.

    Participant from Christian Community

PRs from the fishing village explained the alternate governance structure within their community while highlighting minimal awareness of the state law amongst the community members and an absence of state regulation bodies and interference in community matters. There isn’t a court present either in the community as the “wadera” (feudal lord) of the community is considered to be the judge and governor for the community [16]. The waderas do not permit the community members to go to the law, in any situation, and considering that the community is dependent upon the land for their staple and household, community members are scared to go against the will of the wadera.

“Whoever seeks out the Wadera first, with their issue with someone, gains their favour which tips the scales on their side.”

     Participant from Rural Community

Discussion

This study aimed to assess quality of life and resource accessibility of different community types living in Karachi, and learned that the diverse geographic and ethnic communities has resulted in Karachi becoming the city of everyone and noone putting communities in active and passive states of struggle for fundamental human rights conflicts and fulfilling their base physiological and security needs. Minimal state regulation has allowed and in certain cases, catalyzed these issues to fester and result into catastrophic states that deprive community members from accessing society, education, healthcare, and the law.

CEFMU practices and GBV in the community were discussed, but were presented and relayed as part of the communal norm, and were not expanded upon due to low sensitization around these issues with women not having the agency in the community to discuss these. Similarly, there was latent demand for services within the SRHR ambit, but owing to the challenges faced by the communities in accessing fundamental physiological resources for survival vis-à-vis basic medical facilities, specific issues around access to these services were not discussed in-depth. Conclusively, minimal awareness and sensitization of issues, and accessibility to relevant services, related to CEFMU, GBV, and SRHR were the primary reasons for there being only a handful of narratives around these issues. However, from a macro perspective, coupled with impoverishment and lack of infrastructure, the latent need for these absent services alongside the low attention paid to these issues significantly explain the poor quality of life in these communities [1,17].

Conclusion

While the findings break new ground in understanding the experiences of communities in Karachi, it is recommended that further in-depth research is required to understand the nuances of the various developmental issues affecting each community, and expand upon the identified relationships between violence and unemployment, exploitative unregulated labor markets, and institutional ostracization of communities. Finally, the findings of the study can be utilized to develop, propose, and implement a combination of macro- and micro-level interventions for community reform to improve the communities’ quality of life and accessibility to base resources that form fundamental human rights.

Tables

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