Health and road transport in Pakistan

OBJECTIVE

The 1998 Global Burden of Disease Study estimated that road traffic injuries (RTIs) will become the third leading cause of lost disability-adjusted life years, with two-thirds of the deaths occurring in the least developed nations. Moreover, automobile-based transport systems are associated with air pollution (lead toxicity, asthma and greenhouse gas accumulation), noise disturbances, physical inactivity and obesity.

STUDY DESIGN

This study (1) reviewed road transport literature in Pakistan and the impacts on health outcomes; (2) examined health policies to assess their focus on transport-related health problems; and (3) identified policy gaps for future research.

METHODS

A methodological review of the literature on direct and indirect effects of road transportation in Pakistan. This review includes government documents, memos, statements and draft policies as well as relevant articles indexed in MEDLINE.

RESULTS

A systematic review revealed no approved transport policy in Pakistan, despite three national health policy documents. The Health Chapter of the 9th Five Year Plan appreciates the grave threat of unchecked RTI, but fails to offer specific policy interventions. Despite ambitious plans by the Pakistan Environmental Protection Agency, actual projects and their implementation remain scarce, resulting in ever-increasing air pollution. The health impact of lead toxicity, noise pollution and RTIs remain high, while obesity is on the rise.

CONCLUSION

The increasing health impact of road transport on 140 million people calls for immediate policy action. Government agencies must intervene effectively to establish monitoring and decentralised enforcement nationwide, while simultaneously supporting alternative modes of transportation.

Measuring the burden of premature mortality in Pakistan: use of sentinel surveillance systems

INTRODUCTION

In developing countries, finding valid and reliable data is a great challenge. The Federal Bureau of Statistics in Pakistan maintains a surveillance system that records vital events. Results are reported as the Pakistan Demographic Survey (PDS).

METHODS

The adjusted mortality data from PDS-1997 was used to estimate the burden of premature mortality using the healthy life year (HeaLY) methodology.

RESULTS

The burden of premature mortality for Pakistan was 367 HeaLYs lost per 1000 population. More than half of the HeaLYs are being lost due to infection, maternal and perinatal conditions, and malnutrition.

CONCLUSION

In the absence of a system maintaining reliable information regarding vital events, PDS provides a good alternate source of such information that can be used to aid policy making for health care and future research.

Ethical review of health research: a perspective from developing country researchers

BACKGROUND

Increasing collaboration between industrialised and developing countries in human research studies has led to concerns regarding the potential exploitation of resource deprived countries. This study, commissioned by the former National Bioethics Advisory Commission of the United States, surveyed developing country researchers about their concerns and opinions regarding ethical review processes and the performance of developing country and US international review boards (IRBs).

METHODS

Contact lists from four international organisations were used to identify and survey 670 health researchers in developing countries. A questionnaire with 169 questions explored issues of IRB review, informed consent, and recommendations.

RESULTS

The majority of the developing country researchers were middle aged males who were physicians and were employed by educational institutions, carrying out research on part time basis. Forty four percent of the respondents reported that their studies were not reviewed by a developing country IRB or Ministry of Health and one third of these studies were funded by the US. During the review process issues such as the need for local language consent forms and letters for approval, and confidentiality protection of participants were raised by US IRBs in significantly higher proportions than by host country IRBs.

CONCLUSION

This survey indicates the need for the ethical review of collaborative research in both US and host countries. It also reflects a desire for focused capacity development in supporting ethical review of research.

Interventions for control of road traffic injuries: review of effectiveness literature

OBJECTIVE

In 1998, road traffic injuries were estimated to be the 9th leading cause of loss of healthy life globally and are projected to become the 3rd leading cause by 2020. The majority of this burden can be located in the developing world where most of the projected increase will occur. Yet health systems are least prepared to meet this challenge in these countries. At the same time, there are effective interventions for road traffic injuries being implemented in the developed world. An extensive review of the literature reveals more than 16 different interventions in four categories that have been implemented. Renewed testing of these and new interventions will take both time and funds--resources that are scarce in developing countries. As a result, it is imperative to study the effectiveness of those interventions already tested and attempt to evaluate their potential implementation in developing countries.

METHOD

Literature review to identify effective interventions and the magnitude of the effects.

RESULTS

Four broad classes of interventions can be identified from the literature; health education/awareness, legislation, product design and environmental modifications.

CONCLUSION

The issues for the developing countries are affordable, infrastructure and sociocultural in implementation of these strategies. The road traffic injuries are also underreported and hence under represented at the priority setting stage. Road safety should be high on the agenda as it can save a lot of lives and disability. Public health professionals should assess and advocate road safety in developing countries.

Newspaper reports as a source for injury data in developing countries

Injuries are an important public health problem and a leading cause of death among adults and children. In most of the developing world, with rapid changes in lifestyle, rural development, urbanization, an increase in number of vehicles, introduction of mechanized farming and pesticides in agriculture, the effect of injuries on mortality and morbidity is expected to increase. Injuries have been infrequently studied in developing countries; their importance is incompletely understood and they are seriously neglected in health research and policy. The reasons for this situation may be many, but one important reason is the unavailability of data in countries to assess the magnitude of the problem. Hospital and police records are the primary data source for injuries in the majority of the developing world. Newspaper reports may be an alternative source for injury data. This hypothesis was tested in the Rawalpindi Division of Pakistan by collecting data from newspaper reports for both intentional and unintentional injuries for 6 months (January-June 1999). This was compared with police data for the same time period. The results revealed that newspapers report more injury-related events and for some categories, such as suicides, the reporting was far greater by newspapers than the police. We conclude that the current system of police data collection needs to be strengthened. Newspapers may serve as a comparative source of information to evaluate the coverage of police data.

Responses to an emerging threat: HIV/AIDS policy in Pakistan

A decade has passed since the discovery of HIV in PAKISTAN: In the presence of a susceptible population, 'high-risk' behaviours and potential for further spread, the policies and programmes addressing HIV/AIDS need to be further developed. This paper explores the response to HIV/AIDS in Pakistan and describes the contributions of the public and private sectors towards AIDS prevention. A review of contextual and social factors of HIV/AIDS in Pakistan is followed by a structural analysis of the response, an assessment of the impact, and policy recommendations for a more integrated approach to this emerging threat. The conclusion calls for better epidemiological information on HIV/AIDS in the country, development of proactive, evidence-based policies, and socially appropriate implementation of prevention and care measures.

Health ethics in Pakistan: a literature review of its present state

National literature on ethics provides an insight into the nature and development of a dialogue on health issues within a population. This study investigated the health ethics discourse in Pakistan. The purpose was to critically reflect on the nature and level of such discussions with the aim of stimulating an interest in the ethical implications of health and medicine in developing countries. The study evaluated the literature on biomedical and health ethics published in Pakistan during 1988-1999. Overall, there is a dearth of published discourse on healthcare ethics in Pakistan. Values that are considered to stem from religious teachings predominate in discussions relating to medical ethics. A lack of effective policy and legislation concerning the ethical practice of medicine is reported to have negative effects on the profession. Research ethics has not been captured in the published papers in Pakistan. Consideration of ethical issues in health is at an early stage in the country and may reflect the situation in a large part of the developing world.

Equity as a goal for health care: an operational inquiry

Difference in health status, allocation of resources, provision of services and development of basic health infrastructure, both within and between countries raise questions of fairness. The means for assessing this differential, developing strategies to overcome them and documenting changes become crucial. This paper will explore the concepts of equity and justice from an operational perspective, present a number of scenarios in dealing with the health of populations and assess the impact of using equity as a goal for health care in those cases. The objective is to present an analysis of how the same goal in health care may result in different actions with variable results. An evaluation of the potential conflict between equity and utility is presented. Implications for further work on the means of assessing inequities, use of indicators and measuring the result of interventions is discussed.

Geographical display of health information: study of hepatitis C infection in Karachi, Pakistan

The prevalence of hepatitis C and other infections is increasing in urban areas of developing countries. Data on such diseases are often limited to facility-based information. However, even this is not available in a usable form to health care providers, health managers and policy makers. We present a simple technique for visually displaying facility based prevalence information on hepatitis C using basic geographic information system (GIS) techniques. We display the prevalence of hepatitis C for the city of Karachi, Pakistan for the first time. The distribution tends to indicate that there are areas of higher prevalence located in specific districts. There is also a trend of higher prevalence in less affluent urban areas. Such simple applications of mapping technology are useful for rapidly summarizing and displaying information in a contextually and spatially meaningful fashion, and its use should be encouraged for displaying health indicators in developing countries.

Motor vehicle crashes in Pakistan: the emerging epidemic

SETTING

Motor vehicle injuries are increasingly being recognized as a growing public health issue in the developing world. Pakistan is a developing country in South Asia where motor vehicle use has increased since independence in 1947.

OBJECTIVE

This paper explores the magnitude and impact of injuries from motor vehicle crashes in Pakistan.

METHODS

An exhaustive review of published and gray literature, together with a detailed analysis of government data from 1956.

RESULTS

The data indicate a persistent increase in the numbers of motor vehicle crashes, injuries, and fatalities. Changes in the reporting of rates are important to note in evaluating the data. Commercial vehicles contribute disproportionately to these motor vehicle injuries.

CONCLUSIONS

There is a need to further the recognition of injuries as a public health issue in this country. Specific exploration of the epidemiological data; intersectoral collaboration between health, law, police and transport; and the development of appropriate information systems, will contribute to an appropriate response by Pakistan.

Applying burden of disease methods in developing countries: a case study from Pakistan

OBJECTIVES

Disability-adjusted life-year (DALY) and healthy life-year (HeaLY) are composite indicators of disease burden that combine mortality and morbidity into a single measurement. This study examined the application of these methods in a developing country to assess the loss of healthy life from prevalent conditions and their use in resource-poor national contexts.

METHODS

A data set for Pakistan was constructed on the basis of 180 sources for population and disease parameters. The HeaLY approach was used to generate data on loss of healthy life from premature mortality and disability in 1990, categorized by 58 conditions.

RESULTS

Childhood and infectious diseases were responsible for two thirds of the burden of disease in Pakistan. Condition-specific analysis revealed that chronic diseases and injuries were among the top 10 causes of HeaLY loss. Comparison with regional estimates demonstrates consistency of disease trends in both communicable and chronic diseases.

CONCLUSIONS

The burden of disease in countries such as Pakistan can be assessed by using composite indicators. The HeaLY method provides an explicit framework for national health information assessment. Obtaining disease- and population-based data of good quality is the main challenge for any method in the developing world.

Injuries in Pakistan: directions for future health policy

Injuries result in major financial and productivity losses to nations while inflicting tremendous personal burden on the injured and their families. Two-thirds of the global deaths from injuries occur in the developing world, consuming substantial health sector resources. Pakistan is a developing country with a population of 136 million and no reported estimate of the national impact of injuries. This study presents a profile of injuries in Pakistan, estimates the impact on the country and recommends strategies to further delineate this important public health problem. A methodical review of published, unpublished and government literature was undertaken and data collected for all types of injuries principally over the 1982-1994 period. Motor vehicle injuries, homicides, assaults, work-related injuries, poisonings and risk factors have been included. Selected epidemiological estimates have been generated and the WHO motorization index has been used to assess road-side accident risk. The lack of reliable data and under-reporting of work-related injuries is revealing. The rising time trend in all injuries, the significant loss of life from injuries and the age of those injured have a critical impact on the national economy and health system. Data on injuries in Pakistan are primarily recorded by police authorities and used for legal purposes. Pakistan must institute an information system to evaluate the true impact of injuries and develop national safety standards. Implementation of such standards is especially important for road traffic safety and occupational health in industrial units within the country.

Steady state assumptions in DALYs: effect on estimates of HIV impact

OBJECTIVE

The disability adjusted life year (DALY) and the healthy life year (HeaLY) are both composite indicators of disease burden in a population, which combine healthy life lost from mortality and morbidity. The two formulations deal with the onset and course of a disease differently. The purpose of this paper is to compare the DALY and HeaLY formulations as to differences in apparent impact when a disease is not in an epidemiological steady state and to explore the implications of the differing results.

DESIGN

HIV is used as a case study of a major disease that is entering its explosive growth phase in large areas of Asia. Data from the global burden of disease study of the World Bank and World Health Organisation for 1990 has been used to compare burden of disease measures in the two formulations.

SETTING

The data pertain to global and regional estimates of HIV impact.

RESULTS

The DALY attributes life lost from premature mortality to the year of death, while the HeaLY to the year of disease onset. This results in very large differences in estimates of healthy life lost based upon the DALY construct as compared with the HeaLY, for diseases such as HIV or those with a strong secular trend.

CONCLUSION

The demonstration of the dramatic difference between the two indicators of disease burden reflects a limitation of the DALY. This information may directly influence decision making based on such methods and is critical to understand.

Sub-national response in HIV/AIDS: a case study in AIDS prevention and control from Sindh province, Pakistan

HIV/AIDS in Pakistan is slowly gaining recognition as a public health issue of great importance. However, the responses to the disease have been marred by lack of coordination and commitment. We examine, in this paper, the situation in the Sindh province of Pakistan, which is recognized as having the sole fully functioning AIDS prevention and control programme in the country. In discussing the results of the Sindh programme's activities we highlight progress made as well as gaps in data and surveillance. We also recommend strategies for implementation at the provincial and national levels. In addition this example of a sub-national government programme provides a case study for similar programmes in the region.

HIV/AIDS in Pakistan: the context and magnitude of an emerging threat

STUDY OBJECTIVE

The objectives of this review were to: (1) assess the nature and comprehensiveness of information regarding HIV/AIDS in Pakistan; (2) to evaluate the extent of HIV/AIDS in Pakistan by epidemiological estimates; (3) to indicate the implications of the results for health policy in Pakistan and other regions at a similar stage in the epidemic.

DESIGN

A structured review of published, unpublished, and government literature was undertaken to collate all available information and present a descriptive epidemiological profile of HIV/AIDS in the country.

SETTING

Pakistan, a developing country in the South Asian region. National and regional information and analysis are presented in so far as the data allowed. Sample sizes varied from 1.35 million people screened at the national level to smaller studies of fewer than 100 screened.

RESULTS

Data pertaining to HIV/AIDS in Pakistan showed the best national estimates of HIV prevalence as 64 per 100,000 (0.064%). Within patients with sexually transmitted diseases the seroprevalence was as high as 6100 per 100,000 (6.1%); in men with extramarital contacts, 5400 per 100,000 (5.4%) and was as low as zero in some studied populations as well. The average age of onset was reported as 30 years. It is estimated that if all incident cases of AIDS were to die, there would be at least 5000 deaths annually attributable to HIV/AIDS.

CONCLUSION

Coupled with the extremely low awareness of HIV/AIDS in Pakistan, as well as growing number of cases, the AIDS epidemic is poised to take a hold in Pakistan. The presence of additional risk factors such as unscreened blood, and low condom use rates make the situation fertile for AIDS to become a major public health issue. Pakistan's health policy must be proactive in tackling this emerging health threat.

Measuring the burden of disease: healthy life-years

OBJECTIVES

This paper presents the background and rationale for a composite indicator, healthy life-year (HeaLY), that incorporates mortality and morbidity into a single number. HeaLY is compared with the disability-adjusted life-year (DALY) indicator, to demonstrate the relative simplicity and ease of use of the former.

METHODS

Data collected by the Ghana Health Assessment team from census records, death certificates, medical records, and special studies were used to create a spreadsheet. HeaLYs lost as a result of premature mortality and disability from 56 conditions were estimated.

RESULTS

Two thirds of HeaLYs lost in Ghana were from maternal and communicable diseases and were largely preventable. The age weighting in DALYs leads to a higher value placed on deaths at younger ages than in HeaLYs. This spreadsheet can be used as a template for assessing changes in health status attributable to interventions.

CONCLUSIONS

HeaLY can aid in setting health priorities and identifying disadvantaged groups. The disaggregated approach of the HeaLY spreadsheet tool is simpler for decision makers and useful for country application.