National Action Plan Ncds Pakistan
National Action Plan Ncds Pakistan
National Action Plan Ncds Pakistan
National Action Plan for Prevention and Control of Non-Communicable Diseases and Health Promotion in Pakistan
A Public-Private Partnership in Health
The cover design, in addition to highlighting the public-private partnership dimension of this work, depicts an eccentrically placed watermark symbolizing movement as manifested by the circular brush strokes. This logo delineates the circle of health surrounding the human body.
National Action Plan for Prevention and Control of Non-Communicable Diseases and Health Promotion in Pakistan With accompanying CD-ROM
A joint publication of the Ministry of Health, Government of Pakistan; the World Health Organization, Pakistan office, and Heartfile
Produced as part of a formal collaborative arrangement (http://heartfile.org/napmou.htm) Further information or free copies of this publication can be obtained by sending an e-mail to info@heartfile.org; calling 0092 51 2243580; faxing a request at 0092 51 2240773 or by writing to the Heartfile central office, 1- Park Road, Chak Shahzad, Islamabad, Pakistan. Suggested citation: National Action Plan for Prevention and Control of Non-Communicable Diseases and Health Promotion in Pakistan. Islamabad, Pakistan: tripartite collaboration of the Ministry of Health, Government of Pakistan; WHO, Pakistan office, and Heartfile; 2004. This report was produced under the overall direction of Dr. Sania Nishtar, who also contributed her time as the principal author. The report received inputs from panels of experts constituting the National NCD Forum and the International Advisory Board. Members have played a participatory role through representation in working groups, attending meetings, contributing to discussions and providing inputs to the consultative process; details have been appended. The consensus building effort was led by Dr. Khalif Bile Mohamud (WHO Representative in Pakistan) on behalf of the World Health Organization; Dr. Ashfaq Ahmed (Deputy Director General, Health) on behalf of the Ministry of Health and Dr. Sania Nishtar on behalf of Heartfile. Mohammad Nasir Khan (Federal Minister for Health); Mr. Hamid Yar Hiraj (State Minister for Health); Mr. Tariq Farook (Secretary Health) Mr. Ejaz Rahim (Former Secretary Health) and Maj. Gen. (R) Mohammad Aslam H.I. (M) (Director General Health) provided support for this initiative. Heartfile took a lead role in the development of the Action Plan and contributed resources and technical expertise; WHO provided resources for the consultative process whereas the Ministry of Health provided policy and logistic support for the development of the Action Plan. Layout: Yasir A. Mirza, Heartfile Cover: Ideas Workshop inspired by a Shazad Nawaz design Tripartite collaboration on NCDs in Pakistan 2004. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, for any purpose, without the written permission of Heartfile. The copyright notice applies to the printed text, graphics and other illustrations of this document monograph. The CD ROM accompanying this document is covered by its own copyright notice. Heartfile is a non-profit NGO registered under the Societies Registration Act of 1860 in Pakistan. (http://heartfile.org)
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Contents
Pages Prcis Section1: Prelude and Finale 1.1 1.1.1 1.1.2 1.1.3 1.1.4 1.1.5 1.1.6 1.1.7 1.2 1.2.1 1.2.2 1.2.3 1.2.4 1.2.5 1.3 Strengths of the Action Plan Public-private partnership dimension Integrated approach to NCDs An evidence-based approach Maximizing on strengths of partnerships Linkage with national health policies Relationship with development agenda Unrealized ancillary benefits Action Plan-specific descriptions and clarifications Definition of NCDs Focus of the Action Plan What constitutes evidence? Relationship with health systems structure in Pakistan Priority setting Challenges, risks and mitigates 1 5 6 6 7 8 8 9 10 11 11 11 11 12 12 13 14 17 17 18 18 19 22 25 25 26 26 26 27 28 29 30 31 31 35 36 37 39 40 41 42 43 43 43 45 46 48
Section 2: Common Action Areas 2.1 2.2 2.2.1 2.2.2 2.2.3 3.1 3.2 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 3.2.6 3.3 3.3.1 3.3.2 3.3.3 3.3.4 3.4 3.4.1 3.4.2 3.5 Context: paradigm of NCD prevention, control and health promotion Common action areas in the IFA Behavioural change communication strategy Reorientation of health services Research Context Data on cardiovascular diseases in Pakistan Data on coronary artery disease Data on stroke Data on biological risk factors of coronary heart disease and stroke Data on lifestyle-related risk factors common to major NCDs Gender and rural-urban differences in risk factors Risk factor causal associations Preventive strategies: atherosclerotic and hypertensive heart disease Mitigating modifiable lifestyle-related risks Approaches to address risks in populations existing models in Pakistan Screening, risk assessment and management in primary prevention settings Secondary prevention of cardiovascular diseases Preventive strategies: rheumatic fever and rheumatic heart disease Background to RF/RHD prevention and control efforts in Pakistan Approaches to prevention and control of RF/RHD Action Agenda Cardiovascular Diseases
Section 4: Diabetes 4.1 4.2 4.3 4.3.1 4.3.2 Context Data on diabetes in Pakistan Prevention and control of diabetes Approaches to diabetes prevention Diabetes prevention and control-related efforts in Pakistan
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4.4
Section 5: Tobacco Use 5.1 5.2 5.3 5.4 5.4.1 5.4.2 5.4.3 5.4.4 5.4.5 5.4.6 5.4.7 5.4.8 5.4.9 5.4.10 5.4.11 5.5 Context Data on tobacco use in Pakistan Tobacco production in Pakistan Tobacco control strategies Restricting youths access to tobacco Clean air policies Tobacco cultivation Public and professional education Advertising promotion and sponsorship Warnings Price, excise and taxation Dependence and cessation Illicit trade Liability and compensation Research and surveillance Action Agenda Tobacco
Section 6: Chronic Respiratory Diseases 6.1 6.2 6.3 6.4 7.1 7.2 7.2.1 7.2.2 7.2.3 7.2.4 7.3 7.4 7.4.1 7.4.2 7.4.3 7.4.4 7.5 Context Data on chronic respiratory diseases in Pakistan Risks for chest diseases and their prevention Action Agenda Chronic Respiratory Diseases Context Data on cancers in Pakistan Data on adults Paediatric data Regional data on specific cancers Trends in cancer pattern Cancer registration in Pakistan Cancer prevention and control Risks for cancers Lifestyle-related risks for cancer Occupational and environmental risks for cancer Early detection programmes Action Agenda Cancer
Section 7: Cancer
Section 8: Injuries 8.1 8.2 8.3 8.3.1 8.3.2 8.3.3 8.3.4 8.3.5 8.3.6 8.4 8.4.1 8.5 8.6 8.7 8.8 8.8 Context Data on injuries in Pakistan Road traffic crashes Burden of road traffic crashes in Pakistan Road user Roads Vehicle Legislative measures Enforcement of rules and standards policing Occupational injuries Social Security Department Falls Violence Burns Other injuries Action Agenda Injuries
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Section 9: Mental Illnesses 9.1 9.2 9.2.1 9.2.2 9.2.3 9.3 9.4 9.4.1 9.4.2 9.4.3 9.4.4 9.4.5 9.4.6 9.5 Context Data on mental illnesses in Pakistan Population-based data on major and minor mental illnesses Facility-based data Data on substance abuse Framework for prevention of mental illnesses and promotion of mental health Action areas within the framework National policies, programmes and legislation Community care, information dissemination and reduction in stigma and discrimination Provision of treatment as part of primary care Human resource and infrastructure development Availability of psychotropic drugs Linking with other sectors Action Agenda Mental Illnesses
107 107 108 108 110 110 110 111 111 113 115 116 118 118 120 121 135
References Integrated Framework for Action Appendices Acronyms Glossary National NCD Forum International Advisory Board
Tables Table 3.1 Table 4.1 Table 7.1 Table 7.2 Table 7.3 Table 8.1 Table 9.1 Prevalence of CAD and common risk factors for NCDs in Pakistan Diabetes and impaired glucose tolerance in Pakistan: regional prevalence data from DAP-WHO Surveys (1994-1998) Strategies for the eight most common cancers in Karachi females Strategies for the eight most common cancers in Karachi males Factors epidemiologically associated with cancers Distribution of injuries by causes Prevalence of mental disorders in Pakistan 29 44 77 77 78 90 109
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Prcis
NCDs are being addressed within a combined strategic framework
By convention, the term non-communicable diseases (NCDs) refers to major chronic diseases inclusive of cardiovascular diseases, diabetes, cancer and chronic respiratory diseases and their risk factors. As part of this initiative, however, the chronic conditions of mental illnesses and injuries have also been grouped alongside as country requirements necessitated that these be addressed through synchronized public health measures within a combined strategic framework. Collectively, these conditions accounted for an estimated 33.4 million deaths worldwide in the year 2002; of these, 72% occurred in the developing countries.1 NCDs and injuries are amongst the top ten causes of mortality and morbidity in Pakistan;2 estimates indicate that they account for approximately 25% of the total deaths within the country.3 NCDs contribute significantly to adult mortality and morbidity and impose a heavy economic burden on individuals, societies and health systems.4 In most cases, it is the economically productive workforce, which bears the brunt of these diseases. Existing population-based morbidity data on NCDs in Pakistan show that one in three adults over the age of 45 years suffers from high blood pressure.5 The prevalence of diabetes is reported at 10% whereas 40% men and 12.5% women use tobacco in one form or the other.6,7 Karachi reports one of the highest incidences of breast cancer for any Asian population.8 In addition, estimates indicate that there are one million severely mentally ill and over 10 million individuals with neurotic mental illnesses within the country.9 Furthermore, 1.4 million road traffic crashes were reported in the country in the year 1999. Of these, 7000 resulted in fatalities.10 Against this backdrop, the present exercise is the first opportunity to develop and implement a National Plan of Action aimed at preventing and controlling these diseases. Addressing NCDs in a developing country such as Pakistan is a multidimensional challenge with implications at different levels. Lobbying for appropriate investments and policies to facilitate the inclusion of the prevention of NCDs as part of the global development and health agenda is a critical aspect of the issue. 11 However, on the other hand, the implementation of policies for the prevention of NCDs is a challenge in its own right because of the diverse nature of strategies that need to be instituted in tandem. These include institutional, community and public policy level changes set within a long-term and life-course perspective. These considerations lent impetus to the formulation of a tripartite alliance between the Ministry of Health, Government of Pakistan, the World Health Organization, Pakistan office, and the NGO Heartfile. 12 This public-private partnership aims at the development and implementation of a long-term national strategy for prevention and risk factor control of NCDs and health promotion in Pakistan.
The National Action Plan for Prevention and Control of Non-Communicable Diseases and Health Promotion in Pakistan (Action Plan) has been developed with inputs generated through an extensive process within the different domains of NCDs and is reflective of broad-based consensus.13 This initiative attempts to incorporate core public health principles into country health programme planning through an approach that seeks evidence before planning interventions and utilizes intervention-monitoring to generate further evidence. It has a comprehensive configuration with evidence-based policy and action-oriented dimensions calling for a change at the institutional, community and public policy levels. The strategy has been designed to overcome the tendency to rely on a disjointed set of small scale projects, factoring integration at four levels: grouping NCDs so that these can be targeted through a set of actions, harmonizing actions, integrating actions with existing public health systems and incorporating contemporary evidence-based concepts into this approach. The Action Plan delivers an Integrated Framework for Action (IFA). The IFA has been developed as a concerted approach to addressing the multidisciplinary range of issues within a prevention, control and health promotion framework across the broad range of NCDs. It is modelled to impact a set of indicators through the combination of a range of actions in tandem with rigorous formative research. The IFA emanates from the concept highlighted in Fig. 1 (Page 17). The at-risk population represented in the pyramid can be targeted by dovetailing high-risk and population approaches. These need to be evidence-based and set within a supportive policy and regulatory environment. The IFA encompasses two sets of strategies within this framework those which are common to NCDs and have, therefore, been combined and others which are specific to NCDs. Behavioural change communication, reorientation of health services and monitoring and surveillance fall in the first set of strategies while the second covers legislative and regulatory matters. The approach adopted as part of the Action Plan obviates the need for vertical interventions that have the potential to fragment the healthcare system. Instead, it horizontally integrates the prevention and control of NCDs with the existing primary healthcare and social welfare infrastructure, thus contributing to strengthening of the pubic health configuration; it also influences primary healthcare towards a more preventive orientation by establishing interdisciplinary primary care teams. The Action Plan packages several contemporary as well as novel approaches. The population approach includes a behavioural research and social marketing-guided communication strategy and an active role for local opinion leaders and educational institutions. The Action Plan attempts to horizontally reorient health services to a more preventative orientation around NCDs through the scaling up of professional capacity and basic infrastructure and by ensuring availability and access to certain drugs at all levels of healthcare. In addition, the IFA includes a common population surveillance mechanism for all NCDs (with the exception of cancer). The model includes population surveillance of main risk factors that predict many NCDs and combines a module on population surveillance of injuries, mental illnesses and stroke. It also combines knowledge and practice-related modules and
programme-specific components. This enables tracking of implementation processes using appropriate indicators, facilitating an assessment of how interventions work and which components contribute most to success. The Action Plan maximizes on the strengths of partnerships and outlines a scope of interventions that are built on shared responsibility, allowing agencies to participate according to their own missions and mandates. If implemented in its true spirit, the Action Plan has the potential to improve outcomes across the range of NCDs in Pakistan. This initiative is one of the few initial partnership-based, concerted national responses to the global challenge of NCDs from within the developing countries. The active role of WHO as an international public health agency with the global mandate of promoting best practices through its linkages with governments in respective countries, broadens the scope of this initiative. Lessons learnt from this experience may prove useful for designing analogous strategies in similar settings. Though the ingredients of this strategy are sound, it needs to be supported by a clear, strong and sustained political and policy commitment backed by a legislative framework that is supportive of multi-stakeholder models. Implementation of the Action Plan will lead to generation of new information relevant for improving the performance of the health system by fostering public-private partnerships within evidence-based models. It will also provide the empirical basis for health sector reforms in the area of pubic-private collaboration. The experience will not only permit an analysis of health system models built on shared responsibility for achieving sustainable health outcomes but will also provide an understanding of how to plan, manage and finance such activities in the future.
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Prelude and Finale
High-cost curative care is inaccessible to the vast majority of Pakistans population
Disease prevention and health promotion are the most effective interventions for solving Pakistans healthcare crises. Based on this premise, it is pertinent that this approach be applied to the domain of NCDs. Such sector investments are valid in view of evidence that highlights the existing potential to prevent these diseases and upholds the principles of equity in health, in view of the understanding that technology-intensive, high-cost curative care is inaccessible to the vast majority of the countrys underprivileged population. The global health challenge posed by the escalating burden of NCDs in the developing countries has been well documented in various reports and publications.14 An estimated 33.4 million deaths were caused by NCDs and injuries in the year 2002. Of these, 72% occurred in the developing countries.1 The situation as it relates to individual NCDs in Pakistan has been highlighted within the respective disease domains in the following sections. NCDs have grave economic implications as they incur huge costs in care and lost productivity. It is, therefore, fortunate that they are preventable to a large extent. Against this backdrop, lessons learnt from the experiences of developed countries draw attention to a public health opportunity involving population-level interventions to mitigate risks and to reduce the incidence of these diseases.15 Whilst a preventive population-based approach is known to be the most cost-effective, paradoxically most developing countries have adopted a high-technology approach to the management of NCDs. It is, therefore, important to promote a shift away from individuals at the extreme ends and towards population-wide risk levels. Addressing NCDs in the developing countries is a multidimensional challenge with implications at different levels. Lobbying for appropriate investments and policies to facilitate the inclusion of prevention of NCDs as part of the global development and health agenda is a critical aspect of the issue. This calls for stepping up advocacy efforts to target governments and donor, development and health agencies. However, on the other hand, implementation of such policies in the setting of developing countries is a challenge in its own right because of the diverse and multidisciplinary nature of strategies that need to be instituted to address this issue. Models established in the developed countries offer limited guidance owing to resource and infrastructure incompatibilities. The Action Plan is a locally suited, concerted and integrated approach - one that incorporates both policies and actions. Accomplished through a novel public-private partnership arrangement, the formulation of the Action Plan was a truly national and broad-based exercise involving a wide range of
The Action Plan provides the empirical basis for health sector reform in the area of publicprivate collaboration
stakeholders. This initiative expresses the governments commitment to accord priority to the health challenges posed by NCDs. The Action Plan has been modelled on an integrated approach to the prevention and control of NCDs and health promotion. It delivers an Integrated Framework for Action (IFA), which narrows down the broad agenda for the prevention of NCDs, focusing on a set of indicators that need to be impacted through processes set in tandem.
Injuries and mental health have been included in the framework of NCDs
public health, primary healthcare and social welfare infrastructure. Integration of the prevention of NCDs with the National Programme for Family Planning and Primary Health Care and the WHOs Basic Development Needs Programme (BDN) are examples of this approach. This approach is also valid in the context of the limitations that Pakistans burdened health agenda faces in accommodating vertical programmes; such programmes are heavy on resources, take time to institute and often have the risk of fragmenting the healthcare system. Integration, on the other hand, will build on the strengths of the existing health system. This will help to strengthen the pubic health configuration and will influence primary healthcare systems towards a more preventive orientation. 1.1.2.d Integration of concepts: the Action Plan introduces several contemporary and novel approaches in public health. These include a behavioural research and social marketing-guided communication strategy, an active role for local opinion leaders and educational institutions, reorientation of health services to a more preventative orientation and a common population surveillance mechanism for all NCDs (with the exception of cancer).
upon in this Action Plan: integration with the existing health system, intersectoral and intra-health-sector collaborations, linkages with national health policies and partnerships with the private sector. The Action Plan recognizes the scope of partnerships in public health activities and outlines a scope of interventions that are built on shared responsibility, allowing for agencies to participate according to their own missions, mandates, interests and resources. The Action Plan fosters partnerships and interface arrangements between the public and private sectors so that the federal government is not solely responsible for getting these programmes out to the communities, but can rely on groups and national organizations that have complementary mandates. The programme also fosters collaboration both within and outside of the health sector and calls for inter-sectoral action. Depending on the specific domain of NCDs, a range of preventive efforts need to be initiated as part of the IFA, with active involvement of and in partnership with the ministries of Health, Planning, Agriculture, Education, Finance, Housing, Communication, Environment, and Labour, both at the federal and provincial levels. For this purpose, inter-sectoral collaborating committees need to be established at the federal, provincial and district levels. Furthermore, the Action Plan also outlines a course of action for fostering partnerships with international agencies. Future efforts as part of this Action Plan must also be focused on building a coalition or network of organizations at the national, provincial and local levels, facilitated by federal and provincial health services to add momentum to the prevention and control NCDs as part of a comprehensive prevention effort.
including key NGOs, educational institutions and leadership foci throughout the country. The Action Plan also links in with relevant national health policies. Examples of critical reviews of current legislative measures and the recommendations that evolve within that context for upgrading them to meet public health objectives, particularly in the area of tobacco use, injuries, food and physical activity-related legislation, help to highlight this approach.
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promotion is about improving health and wellbeing. Both approaches are overlapping and complimentary; they can be present in the same programme with similar activities and hold different meanings for two groups of targeted populations with different results. The public health approach to NCDs offers one of the best opportunities to combine prevention and health promotion to improve multiple positive outcomes.
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legislative measures taken at the federal level are binding in the provinces, which is why these federally-developed instruments are envisaged as being appropriate for the desired trickle down effect in the provinces. However, a part of the Action Plan, which relates to reorientation of health services, will be implemented through horizontal integration with existing primary healthcare programmes within the provincial and district domains and with their active collaboration. The implementation modalities allow for the incorporation of appropriate guidance from the provinces; this is viewed as being critical to the success of these interventions. One of the strengths of this programme is its capacity to impact health indicators in the remotest village located in a far-flung district by way of interventions structured at the central level, harnessing the support of the private sector and straddling existing programmes. The first phase of the Action Plan,22 focuses on areas which can be administered at the federal level without delay; however, subsequent actions need to be more closely integrated with provincial mandates.
Priority setting is imperative for the rational utilization of resources for public health programmes in a country
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invest in capacitybuilding
data sources has also been regarded as a priority. Priority areas have been flagged in the Action Agenda at the end of Sections 3-9; similarly, they have also been marked on the IFA. The Integrated Framework for Action helps to narrow down the focus of the Action Plan and outlines priority areas. Within this framework, the first phase of implementation of the Action Plan is already is in the pipeline. Under a formally approved PC 1,22 allocations have already been made to support a population-based NCD surveillance system, a behavioural change communication strategy and a communication campaign at the grass roots level utilizing LHWs of the National Programme for Family Planning and Primary Health Care. However, at the same time, there is a need to identify further concrete steps on an ongoing basis and to align priorities amongst other selected activities with potential for immediate implementation. The tripartite collaboration must foster an active process to ensure this with sustained commitment.
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leverages on the technical strength of the private sector partner and utilizes a horizontal approach to integrating the prevention of NCD with currently operational systems. The execution of these projects from a central level through integration with existing programmes is an attempt to obviate issues that could arise with jurisdictional responsibilities as the provincial and local governments play different roles within the same areas. However, infrastructure and capacity issues will have to be addressed to ensure longterm sustainability. Thirdly, bureaucracies experience difficulties in executing the time-bound synchronized and coordinated actions, which are part of the Action Plan as outlined in the IFA. It is here that the autonomous private sector brings flexibility in implementing actions. Although this partnership emanates from within the overall development policy framework, it does have its own challenges. The partnership has been developed in the absence of a clear-cut legislative and procedural framework. This could, on the one hand, result in issues of power relationships with implications for long-term sustainability of the initiative. However, on the other hand, this situation is also being viewed as an opportunity for providing the empirical basis for health sector reforms in the area of pubic-private collaboration. The experience is expected to provide new information to policy makers about the issues inherent to such partnership arrangements. This example presents a clear imperative for developing a legislative and regulatory framework for public-private partnerships in Pakistan. Such frameworks legitimize relationships, assist with fostering an enabling environment and provide a mandate for the development of ethical guidelines. Moreover, the experience also highlights the need for the development of global norms and standards to guide such actions within countries. The constituents of the partnership arrangement present an opportunity for international actors to deliberate further on this subject. The role of WHO in this regard is viewed as being critical. The Action Plan is both a policy and an implementation document. Spinning a document that serves both as a guideline for the policy maker and bureaucrat, and is of scientific interest to the public health community, has been a challenge. This dual intent is also reflected in the writing style, where an attempt has been made to strike a balance between the technical, scientific and administrative jargons. This has also necessitated an explanation of specific technical terms as part of the glossary. Given the diversity and cross-cutting implications of this attempt, for which a relevant precedent does not exist, several gaps can potentially be identified in this effort. Criticism relating to the strength of the epidemiological data, evidence used and definitional issues may, therefore, be valid. There will be plenty of opportunities for further refining this strategy. However, in the face of the urgency to address the escalating challenge of NCDs, a beginning has got to me made!
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Common Action Areas
Draw support from the network of healthcare providers at the grassroots level
2.1 Context: paradigm of NCDs prevention and control and health promotion
Knowledge of the multidisciplinary characteristics of the prevention-related response to NCDs is one of the guiding principles of the Action Plan one that allows for a comprehensive and integrated set of evidence-based actions based on valid scientific approaches. The Action Plan calls for a favourable policy and regulatory environment and stresses on the need to build capacity and a functioning public health infrastructure. The pyramid illustrated in Fig. 1 highlights the prevention tiers in NCDs; these relate, in particular, to cardiovascular diseases, chronic lung diseases, cancer and diabetes. Those at the base represent healthy risk-free populations that need to be targeted as part of the primordial prevention approach to prevent the development of risks and to promote healthy disease-free societies. The tier above represents populations that need to be targeted through primary prevention approaches to modify risk. Those at the top fall in the secondary prevention category, where efforts need to be directed to those that have suffered events, to reduce morbidity and mortality and to prevent the occurrence of recurrent events. Distinct opportunities exist to prevent diseases within the primordial, primary and secondary prevention frameworks through the high-risk and population approaches. Classically, the population approach needs to be set within the framework of community interventions in target sites such as schools, worksites, through the media and by direct community interventions. The high-risk approach to NCDs largely warrants a reorientation of health services in Pakistan to a preventive orientation. It is evident, however, that there is a great degree of overlap. This is particularly important in Pakistans healthcare and cultural contexts, where community health interventions should logically be structured to draw support from the extensive network of healthcare providers at the grassroots level.
Conducive policy framework, legislative and regulatory support, existence of public health infrastructure; professional capacity and stewardship
Rehabilitation
Population Approach
Secondary Prevention
Primary Prevention
Evidence
High-risk Approach
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Notable among these are LHWs and traditional healthcare providers. On the other hand, high-risk approaches, which are primarily offered by healthcare providers, also need to be locally supported within communities. It is, therefore, imperative for both these approaches to dovetail for mutual benefits. The pyramid also helps to highlight the structure of the approaches as they target prevention tiers; community interventions tailing from below above in a manner in which they are key to the primordial and primary prevention approaches. The high-risk approach, on the other hand, is key to secondary prevention but needs to be interlinked with primary prevention. To poise public health interventions in this framework, the Action Plan incorporates several valid approaches that centre on mitigating risks in the primary and secondary prevention settings and stepping up health promotion efforts and screening programmes within target groups and intervention sites. The illustration further highlights the importance of evidence as being the guiding principle for this approach, as is evidenced by the base of the pyramid on which the entire public health framework rests. This public health course of action needs to be set within a broader policy framework. Streamlined public health systems with adequate infrastructure and capacity are also a key requirement. This makes a strong case for capacity and infrastructure development.
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the grassroots level; these need to be structured to reach out to different segments of the Pakistani population with diverse origins, cultures and levels of education. The tightly-knit community structure in Pakistan can be conducive to disseminating messages. In this context, active involvement of local opinion leaders, clergy, religious leaders and community activists in changing social norms has been recognized as being important. Mosques and places of communal meetings can be regarded as natural sites for advocating behaviour change. By western standards, our public health systems are illequipped and under-funded to implement comprehensive policies for the prevention and control of NCDs. However, there are channels such as those created through primary healthcare and social welfare activities, which have outreach at the grassroots level and integrate public and private sector health services with the community. These channels must be utilized for costeffective outreach. Strong recommendations have been made to utilize educational institutions for advancing prevention-related goals. These are recognized as natural sites, innate for such efforts for two distinct reasons; firstly, because of the availability of infrastructure and secondly, because of the potential that exists to modify behaviour at a younger age. The Action Plan calls for a less categorical approach to school health and recommends integration of the prevention agenda with the academic curriculum, allowing room for local adaptations. In addition, several common risk factors over a variety of outcomes have warranted that preventive messages be packaged not just around NCDs but for a range of preventive measures. The Action Plan has taken into account, validated demonstration projects in Pakistan that have tested intervention approaches, albeit on a limited scale. These experiences are important for generating the required knowledge for expanding the base of such initiatives and replicating them elsewhere. Such experiences have also been recognized, as part of this Action Plan, as an opportunity for building the skills necessary for the prevention of NCDs.
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role of healthcare providers. However, in some cases such as in case of breast self-examination and oral examination for cancers, screening can be performed by individuals themselves. Even in such cases, healthcare providers play an important role by verifying and following-up on the course of management. Early detection or screening approaches for biological risk states and diseases need to make a distinction between population screening and screening of high-risk groups. There are several considerations that help to make this distinction. These include prevalence of the risk state in the general population, potential of impact on mortality and morbidity through early detection, costs involved in the screening procedure, capacity of healthcare providers to perform the screening test, availability of the necessary screening infrastructure and feasibility of mitigating risks through cost-effective therapeutic interventions once diagnosed. Scaling up of population and high-risk screening demands an active role of healthcare providers. Since healthcare delivery in Pakistan is characterized by a variety of roles played by different categories of healthcare providers, it is imperative to draw all into the loop in order to upscale early detection and screening practices. The bulk of healthcare delivery in Pakistan is carried out through formally and informally trained and traditional non-physician healthcare providers; the Action Plan outlines that they must be drawn into the loop to maximize the impact of activities for the prevention of NCDs. Integration of the prevention of NCDs into the work-plan of all categories of healthcare providers is, therefore, one of the cornerstones of this initiative. Capacity-building and training programmes should have a three-pronged focus: firstly, they should provide guidance to healthcare providers on counselling, information dissemination and patient education. Secondly, they should sensitize them to the need for stepping up screening practices in population and high-risk groups and thirdly, they should incorporate simplified risk assessment and management protocols. Trainings should be in congruity with community interventions to impact the same set of indicators. This has been highlighted in the IFA. The Action Plan recommends the development and introduction of structured training programmes focused on the prevention of NCDs for medical students and all categories of healthcare providers. These need to incorporate scientifically valid, culturally appropriate and resource-sensitive training packages, which must be delivered through transparent mechanisms. Ideally, such training activities should be set within a sustainable and comprehensive continuing medical education (CME) programme structured around broadbased prevention-related goals and objectives. Establishing appropriate linkages with provincial health departments, the Pakistan Medical and Dental Council, College of Physicians and Surgeons in Pakistan, university departments, medical schools and medical and professional associations is the first step in towards the achievement of this objective. Physician and non-physician healthcare providers in the public sector [(male paramedics and Lady Health Visitors (LHVs)] are offered regular trainings by the District Health Department-owned District Health Development Centres (DHDC). This offers an opportunity for the introduction of
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practically relevant training packages into their work-plans in liaison with the District Health Departments. It is also feasible to introduce such modules into the work-plans of LHWs of the National Programme for Family Planning and Primary Health Care. This has already been initialized as part of the first stage of the first phase of implementation of the Action Plan.22 Structuring CME programmes on an ongoing basis for physicians, particularly those in the private sector, on the other hand, is a more complex situation as no formal and sustainable training mechanisms exist with which to integrate such efforts. The Action Plan recommends the structuring of a comprehensive CME programme to ensure ongoing capacity-building of private and pubic sector physicians. Such a programme will ensure training of in-service doctors as a permanent function of the healthcare system in Pakistan. However, pending such a structural and sustainable change, the existing models of healthcare provider training need to be evaluated for effectiveness and sustainability and adapted to the prevention of NCDs. The prevention of NCDs can also be developed as a form of specialization for non-physician healthcare providers. The feasibility of this approach needs to be further explored. 2.2.2.b Infrastructure at healthcare settings: assessed from the perspective of the prevention and control of NCDs, infrastructure requirements of healthcare facilities are modest. An assessment of basic health facilities was recently conducted in the outskirts of Islamabad in collaboration with the Geneva-based CVD Unit of WHO.25 This revealed that blood pressure measurement devices and weighing scales are universally available in all healthcare facilities; however, only around 50% of them were found to be in working order; there was also no system for calibrating and maintaining equipment. Ensuring the availability of a calibrated blood pressure measurement apparatus should be made universal as this is a prerequisite for stepping up screening for high blood pressure. Simple risk assessment tools such as tape measures and apparatus to measure urine sugar are affordable; efforts should be made to make these available at all levels of healthcare facilities. 2.2.2.c Drugs at the basic healthcare level: the availability of and accessibility to several drugs is important in the context of the prevention of NCDs. These include beta blockers, ACE inhibitors, aspirin, penicillin, phenobarbitone, chlorpromazine, imipramine, procyclidine, diazepam, sulphonylureas and insulin; however, this list is in the process of being updated. In addition, nicotine replacement should be made available wherever feasible. A review of the Essential Drug List (EDL) in Pakistan reveals that most of these drugs are listed on the EDL. The Drugs Act 1976 makes it necessary for these medicines to be available throughout the country.26 However, an on-ground assessment has revealed that there are several gaps in the availability of these medicines in healthcare facilities. A facility capacity assessment conducted in collaboration with the WHO CVD Unit has revealed that many of the essential drugs necessary for primary and secondary prevention of NCDs were not available at all times in healthcare facilities even though they were affordable and widely available in the market.25 It is, therefore, essential that necessary steps be taken to ensure that
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these drugs are made available and accessible at all levels of the healthcare system.
2.2.3 Research
This Action Plan attempts to bridge the gap between academic researchers and policy makers and administrators engaged in planning evidence-based strategies for bringing about an improvement in health outcomes. Several research dimensions have been flagged as priority areas as part of this Action Plan. These research areas underlie the need to move away from the sole focus on risk factor and etiological research towards surveillance and intervention research to facilitate an assessment of the effectiveness of current policies, disease trends and future health needs. A necessary prerequisite for effective planning, implementation and evaluation of NCD prevention programmes is access to reliable and timely information on mortality, morbidity, risk factors and their socio-economic determinants. This approach has been validated in several settings: WHO STEPwise approach to Surveillance (STEPS),27 the Behavioural Risk Factor Surveillance System (BRFSS),28 of the Centers for Disease Control (CDC) in USA, and the use of various database sources such as the WHO Global NCD InfoBase and those used as part of the CINDI and CARMEN regional programmes of WHO. The need to bring together and display existing data is a useful starting point for assessing its quality and availability from the perspective of its ability to give meaningful data over time; it can act as an entry point for activities related to the prevention of NCDs. Standardised epidemiological information greatly facilitates comparative analysis and ongoing modification of interventions. In Pakistan, lack of comprehensive databases for NCDs presents an obstacle to effective priority setting, targeting of programmes to various population groups, evaluation of processrelated activities and long-term evaluation of preventive interventions. The adoption of practical and economical systems to meet these needs have, therefore, been recognized as part of the Action Plan. There is some potential for strengthening and upgrading conventional data sources such as those that presently exist within administrative systems, public health and primary healthcare structures, individual files, death records and hospital data within the healthcare system in Pakistan. These data sources, however, suffer several limitations. These include lack of systematic data collection systems and population-based data on NCDs; lack of data for population subgroups with heterogeneous health characteristics; relatively small sample sizes in cross-sectional surveys; lack of longitudinal studies; and self-selection bias in sampling methods. By and large, existing data sources in Pakistan do not serve the purpose of monitoring population parameters, which this Action Plan aims to impact. For this reason, a more comprehensive, integrated, systematic and sustainable population-based data collection infrastructure needs to be established, maintained and expanded over time. This can then be supplemented by facility-based data collection systems and stand-alone data sources wherever applicable. Appropriate linkages with institutions such as the Pakistan Medical Research Council (PMRC), which can provide sustainable support for surveillance activities, should be an integral part of this approach.
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NCD surveillance and costeffectiveness studies are priority research areas in the Action Plan
With the exception of cancer and stroke, disease surveillance is not appropriate for Pakistan as deaths are not registered. This notwithstanding, the feasibility of establishing a mortality sentinel site must be assessed; such data sources can provide adequate information to generate reasonable estimates of mortality in large populations. However, in view of the limited resources that may be available for surveillance monitoring, the IFA has developed a common population surveillance mechanism for all NCDs (with the exception of cancer). The model includes population surveillance of main risk factors that predict many NCDs and combines modules on population surveillance of injuries, mental health and stroke. Guidance has been sought from the WHO STEPWise approach; this offers standardized methods and materials for country-specific information on adult populations. Optional STEPS modules on mental health, injury and stroke have also been included in the surveillance model. The model has also incorporated components from the BRFSS module. In addition, it has been adapted for programme evaluation; this will enable it to track implementation processes using appropriate indicators, facilitating an assessment of how interventions work and which components contribute most to success. This will enable the surveillance model to measure outcomes and evaluate processes both qualitatively and quantitatively. Efforts will be made to build on similar data that have already been collected in Pakistan.29 Cost-effectiveness studies have been identified as another priority area for research as part of this Action Plan. While data on the subject exist, there are not enough studies that are applicable and relevant to our setting. Since the results of such studies can better inform decision making for policy purposes, these must be actively disseminated to policy makers, professional practitioners and the community. Cost-effectiveness of preventive strategies can significantly contribute to gaining support from healthcare authorities for such programmes. The third priority area for research focuses on identifying causal associations for risk factors that have implications for setting targets for preventive interventions. This has been referred to in detail in the relevant sections.
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3
Cardiovascular Diseases
3.1 Context
Nearly 85% of the global mortality and disease burden from CVDs is borne by low- and middleincome countries
The Cardiovascular Disease (CVD) epidemic in the developing countries has been well highlighted in reports of WHO,30 and the World Bank, 31 and the Victoria,32 Catalonia,33 Singapore, 34 and Osaka Declarations.35 At a global level, occurrence of 17 million annual cardiovascular deaths, 32 million annually reported heart attacks and strokes and existence of hundreds of millions of those suffering from CVD risk states, help to draw attention to the scale of this epidemic. 36 Nearly 85% of the global mortality and disease burden from CVDs is borne by low- and middle-income countries. This trend has grave implications for economically disadvantaged populations in south Asia, who inherently have a higher coronary risk but limited opportunities to access high-cost tertiary cardiovascular care. 37 Pakistans health sector investment in the area of CVDs has, in the past, been predominantly focused on tertiary care; two of the six federal government centres of excellence in specialized fields of medicine have been dedicated to CVDs.i There are many others that fall under the jurisdiction of the provincial governments. As a contrast, the public health approach has not featured prominently on the health agenda despite repeated calls to action highlighted in technical writings drawing attention to the escalating burden of CVDs in the Pakistani population.38-42 38,39,40,41,42 There is, therefore, the need to prioritize the disease prevention, risk factor control and health promotion approach to CVDs in Pakistan. This is all the more urgent with evidence showing that appropriate investments in prevention can reduce the incidence of CVDs.43 Cardiovascular diseases include diseases of the heart and the blood vessels. In the prevention-related terminology, preventable CVDs refer to two groups of diseases those that are a result of the atherosclerotic process such as coronary artery disease (CAD), stroke and peripheral vascular disease and their associated risk factors on the one hand, and hypertension and its sequels, on the other. There is considerable overlap between these two groups as hypertension is also a major risk factor in the former category. Moreover, common preventive strategies are applicable across the range of preventable CVDs. In the Pakistani setting, rheumatic heart disease (RHD) is another form of preventable CVD and needs to be addressed in the prevention and control
i
Armed Forces Institute of Cardiology (AFIC), Rawalpindi, and the National Institute of Cardiovascular Diseases (NICVD), Karachi.
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framework. This has been separately discussed, later in this Section as the dynamics of the public health response to the issue differ from those applicable to hypertensive and atherosclerotic heart disease. Rheumatic heart disease is a cardiovascular consequence of an infectious illness, which is characteristic of the early stages of the epidemiological transition in the high mortality developing countries with high infectious burden. The persistence of the RHD burden, in parallel with high atherosclerotic disease burden, is evidence of the double burden of diseases in Pakistan.
26
deaths worldwide, equivalent to 9.6 % of all deaths. Two-thirds of these deaths occurred among people living in the developing countries and 40% of the subjects were aged less than 70 years.30 Against this backdrop, there are no population-based data on stroke in Pakistan. Collecting mortality and morbidity data on stroke in populations necessitates the setting up of population-based stroke registries; this is fraught with logistic and methodological issues, making it an impractical approach in Pakistan over the short term. The population-based NCD surveillance system as part of this Action Plan, uses risk factor burden as a proxy for stroke burden in Pakistan (raised blood pressure in particular). A module for estimating stroke prevalence has been incorporated in the NCD population-based surveillance system. However, it is recognized that stroke related population measures do not fit well in population surveys. Several studies have examined the risk profiles of patients presenting with stroke in Pakistan. Raised blood pressure, iii has been observed in 23-64% of the patients suffering from stroke; 31-42% were shown to be suffering from diabetes; 33-53% of stroke patients were current smokers whereas 11-17% were found to be overweight. Studies have also shown that a majority suffered from cardiac disease (46%) and hyperlipidaemia (30%) whereas carotid artery stenosis was observed in 8%.53-58 53,54,55,56,57,58 Methodological issues with data collection in the reported studies and issues with comparability of data notwithstanding, the reported data show a high prevalence of well established risk factors among stroke patients. In the absence of the identification of precise risk factor causal associations for stroke in the Pakistani setting, traditional risk factors will be used as targets for preventive interventions. An epidemiological review of risk factors for CAD and stroke and preventive strategies applicable to both are discussed hereunder.
An estimated 5.5 million men in Pakistan suffer from high blood pressure
3.2.3 Data on biological risk factors of coronary heart disease and stroke
3.2.3.a Raised blood pressure: iv according to the National Health Survey of Pakistan (NHSP) 1990-94, there were an estimated 5.5 million men and 5.3 million women with hypertension in the years 1990-94. The prevalence of hypertension over the age of 15 years was reported at 17.9%, with a higher prevalence observed in urban areas (21.5% vs. 16.2%). Over the age of 45 years, prevalence was reported at 33%, implying that one in every three Pakistanis over the age of 45 years suffers from high blood pressure. Recent reports have suggested that this difference can be accounted for by body mass and waist circumference. 59 A similar prevalence of 15% over the age of 18 years and 36% over the age of 60 years has been reported in another survey conducted in the Northern Areas of Pakistan.60 Another population survey also reported similar trends, with prevalence estimates of 31.5% (above 140/90 mm hg); 11.9% of the individuals above the age of 40 were reported to have blood pressure levels above 160/100 mm hg.61 The National Health
iii
iv
Defined as a blood pressure level of = 140 mm Hg systolic Defined as a blood pressure = 140 mm Hg systolic and or 90 mm hg diastolic and/or taking antihypertensive medication
27
Survey of Pakistan further reported a hypertension control rate of 3%, which is among one of the lowest control rates in the world. 3.2.3.c Obesity and overweight: although a substantial segment of the population suffers from problems related to under-nutrition, obesity is emerging in Pakistan as a public health problem. During the NHSP, measurements were taken to determine the Body Mass Index (BMI) distribution of the population. Overweight in adults was defined as BMI = 25 as recommended by WHO. From the NHSP data, the proportion of adults classified as overweight generally increased with advancing age. It was higher in women compared with men and higher in urban versus rural areas. In the age group of 25-44 years, 9% of the rural men were overweight compared with 22% of the urban men; for women, prevalence of overweight in rural areas was 14% versus 37% in urban areas. When stratified by age, sex and residence, prevalence of overweight was highest (40%) in urban females aged 45-64 years. While the cut-off points of BMI = 25 to define overweight, and BMI = 30 to define obesity is generally accepted, the WHO Regional Office for the Western Pacific, and the International Task Force for Obesity published provisional recommendations in 2000 for adults of the Asia-Pacific region: overweight at BMI = 23, and obesity at BMI = 25. The recommended lower cut-off points for BMI for the Asia-Pacific region compared to western countries is based on studies demonstrating increased risk of co-morbidities at lower BMIs in Asians, who tend to accumulate abdominal fat at lower BMIs. Use of lower cut-off points would reclassify a greater proportion of the Pakistani population as overweight; furthermore, the figures quoted above for the NHSP data would specify prevalence of obesity in Pakistani adults. This would imply that the health burden from overweight and obesity in Pakistan is currently underestimated. 62,63 3.2.3.b Dyslipidaemia: the National Health Survey of Pakistan reported that 12.6% of the total population over 15 years of age or over 7.3 million people have high blood cholesterol levels. In addition, data from the Four Cities Study of Pakistan reports that 31% of the adults have raised blood cholesterol levels; both surveys used a cut-off point of 200 mg/dl. A study carried out on children in Karachi has revealed that more than 62% girls and 54% boys have cholesterol values greater than, or equal to 4.4 mmol/l (170 mg/dl) a level at which dietary intervention is recommended for children.64 Reported data have implications for preventive interventions both for children and adults. For data on diabetes, refer to Section 4.
An estimated 5.3 million women in Pakistan suffer from high blood pressure
28
Table 3.1 Prevalence of CAD and common risk factors for NCDs in Pakistan
Rural % Coronary Artery Disease? Men Women Hypertension? 5 Men Women Overweight? 5 Men Women Diabetes? ? Men Women Smoking 7 Men Women Oral smokeless tobacco 5 Dyslipidaemia? 5 .. .. 16.2* 18** - 25*** 15** - 28*** 9** 14** 6.39-13.5* 10.3* 4.8* 39.13* 12.5* 10* 12.6* Urban % 26.9* 30* 21.5* 28** - 37*** 25** - 43*** 22** 37** 10.8-16.5* 11.1* 10.6* 30.51*
National data Regional data *Age 15 years and above **Age range: 35-44 years ***Age range: 45-64 years ? Using electrocardiographic criteria ? Defined as a blood pressure level = 140 mm Hg systolic and/or 90 mm Hg diastolic and/or taking antihypertensive medication ? Defined as a BMI of = 25 ? Defined as a random blood sugar level of = 140 mg/dl ? Defined as a total cholesterol level = 200 mg/dl ? Refer to table 4.1 for references
29
The section above focuses on prevalence of risk factors. However, describing prevalence of CVD risk factors from a prevention point of view is restrictive as the largest proportion of CVD events in any community arise from persons who have moderate elevations of many risk factors than from individuals with marked elevation of a single risk factor. This spells out the need to address the risk factor distribution in a population rather than merely dealing with those at the extreme high end. This makes the case for population-based interventions even stronger.
30
preventive measures with long-term economic benefits gained through reduction in morbidity and mortality.
31
Policy decisions influencing dietary consumption patterns are known to reduce premature deaths
Action Plan. Evidence shows that women who consume a diet low in transfatty acids and glycaemic load and high in cereal fibre have a risk of diabetes approximately half that of women who do not.79 There is convincing evidence that saturated fats, fatty acids found in meat and dairy products80 and the intake of trans-fatty acids increases the risk of CAD through an adverse effect on the blood lipid levels.81,82 Replacing 2% of the energy from saturated fats or trans-fatty acids with polyunsaturated fats has been reported to lower the risk of coronary heart disease by 42 and 53%, respectively. 83 Trans-fatty acids are known to be more harmful compared with saturated fat; they are created through hydrogenation a process used to convert oil into banaspati ghee and margarine. Given the widespread use of hydrogenated fats in the form of banaspati ghee in Pakistan, this is of particular concern. There is, therefore, the need to examine the pattern of ghee manufacturing, marketing and consumption; such assessments will enable the development of policies and strategies to limit the production of, and access to, ghee as a medium for cooking. This will have to be paralleled with a strong behavioural change communication strategy to change perceptions about fats used for cooking. There is strong evidence to suggest that consumption of fruits and vegetables, non-starch polysaccharides (fibre), fish and fish oil, as well as foods such as nuts that are high in linoleic acid are associated with reduced risk of CAD. 84,85 Diet is also known to impact high blood pressure. The causal association of high salt intake and excessive alcohol consumption is well established. Inadequate intake of potassium has been shown to have a particularly important role in some population sub-groups such as the African American community. Its role in the Pakistani community needs to be studied. 86-92 86,87,88,89,90,91,92 Diet is believed to be second only to tobacco as a preventable cause of cancer.93 In developing countries, around 60% cancers of the oral cavity are linked to micronutrient deficiencies due to a restricted diet that is low in fruits and vegetables and animal products.94 On the other hand, a diet high in fats is known to increase the risk of cancers of the colon,95 breast,96 and ovaries.97 Likewise, populations that are known to have lower rates of chronic diseases are also known to have less adverse dietary patterns.98 Data from Finland have indicated that 50% of the dramatic declines in CAD mortality as a result of community intervention measures could be attributable to changes in the diet of the population; this was generated by community action and the pressure of consumer demand on the food market.99 Dietary interventions particularly those that involve policy decisions influencing consumption patterns are known to result in significant reduction in premature deaths.100 This highlights the need for initiation of major public health action to promote a healthier diet in Pakistan. Most of the evidence in this context to-date has originated from the economically developed countries and therefore, strategies that are referred to have their origins in the western context. The feasibility of their application needs to be tested in the Pakistani setting. Several economic and socio-cultural dynamics are currently contributing to making food unhealthy in the western world. Higher incomes and falling food prices are boosting the consumption of meat, milk and fatty and sugary items.
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The supermarket era, reliance on packaged food and a boom in the distribution technology has increased the use of salt as a preservative. The need to make retail food cheap has necessitated the substitution of butter with hydrogenated oil and the concept of convenience products in food and saving cost of labour in mass preparation of foods is driving people to buy more fast food. Moreover, larger portion sizes offered at restaurants in an attempt to add value to the deal make people eat more. This classical western dietary model offers several opportunities for regulatory public health actions that are aimed at targeting the manufacturer and retailer with implications for production, labelling and shelf choice. However, these dynamics are quite different from what is relevant in the Pakistani setting. Pakistan has a large population; its inherent culture, diversity of the urban-rural divide and heterogeneity in dietary patterns makes it stand distinctly as a population where dietary considerations are unique and where the strategies necessary to promote a healthier diet need to be carved out in a local context. Several issues need to be flagged, from this perspective. The rise in the burden of NCDs in countries like Pakistan has been paralleled with changes in dietary patterns a feature of the complex interplay of industrialization, urbanization, economic development and market globalization. Theoretically, this has a huge impact on the health and nutritional status of populations. Against this backdrop, Pakistans health policy around diet and nutrition remains focused on under-nutrition. There are scant data on dietary patterns relevant to NCDs and the disease burden attributable to an unhealthy diet in the native Pakistani setting. Any effort along these lines will be complicated by the lack of validated tools of assessment and diversity of dietary patterns that exist across the geographic and cultural confines. It is, therefore, important to develop locally relevant and validated tools of assessment and to include assessment of dietary patterns as part of the NCD population-based surveillance system. Identification of associations of particular dietary intakes with NCDs will enable the identification of factors, which can then be subject for relevant research. Improved understanding of dietary patterns will guide behavioural change communication strategies to be structured accordingly. There is also a need to make an assessment of the kind of policy measures from a public health perspective that stand to gain a better chance of making diet healthier in Pakistan. This should also include an assessment of potential agricultural and fiscal policies and policies relating to the structure of production, transportation, storage and marketing of food items that have implications for increasing the demand for and access to healthy food. Within this context, it is important to develop a nutritional policy along the lines of the WHO Global Strategy on Diet and Physical Activity such a policy must be endorsed at the Cabinet level; sustained multi-sectoral action must be initiated for its implementation. 3.2.1.c Physical activity: lack of physical activity contributes significantly to loss of precious human resource. Physical inactivity accounts for 1.9 million deaths globally; additionally, it accounts for 10-16% of cases each of breast, colon and rectal cancers and diabetes mellitus and 22% of coronary heart disease. Physical activity is both a strong means of preventing diseases
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and a means of several social, physical and mental health benefits for individuals of all ages and sexes and a cost-effective method to improve public health across populations.100 Physical activity has been discussed in the section on CVDs but it needs to be recognized that its beneficial effects extend much beyond CVD prevention. Regular physical activity reduces the risk of dying prematurely and protects against CVD, several cancers and osteoporosis and has a favourable effect on many risk states. In addition, it also has several psychological gains and helps an individual feel and look better and work well. Physical inactivity is an independent risk factor for CAD; it operates through its detrimental effects on blood pressure; cholesterol, insulin and glucose metabolism and obesity. Against this backdrop, it is known that most adults do not engage in sufficient levels of physical activity beneficial to their health. There are scant data on physical inactivity in the Pakistani population. Moreover, the tools for assessing physical activity have not been validated in the Pakistani setting; it is important for future epidemiological surveys that such tools be developed, standardized and validated. Physical activity offers additional advantages for risk reduction in the Pakistani population since the highly prevalent risk factors amongst this population such as low HDL, central obesity and insulin resistance respond better to exercise. Stepping up physical activity in a population necessitates bringing about a cultural change. This has two-fold implications; the first involving modification of lifestyles and the second necessitating the creation of a physical and social environment conducive to physical activity. This calls for aggressive promotion of physical activity as part of the behavioural change communication strategy physical activity needs to be inculcated as a cultural and behavioural norm. Presently however, physical activity is culturally unacceptable to the vast majority of the female population in Pakistan and should be encouraged in this group in an environment and form that respects religious proscriptions.69 The Action Plan stresses on the need to generate support from religious leaders, which is seen as being crucial in endorsing the need for full participation of women in Muslim cultures. Urban planning needs to be responsive to the needs of the population in this regard. An enabling environment not only helps to promote physical activity in populations but also creates a greater demand. Setting up of the sidewalk on Margalla Road in Islamabad highlights this example. Though municipalities have stepped up efforts in major metropolitan cities to construct parks, they are far from being adequate. Moreover, they are centred on uptown areas within large cities which make them inaccessible to the poor and marginalized groups and those dwelling in the rural areas. There is also the concern that, in places, these are focused more on the aesthetic aspect. Making environments conducive for physical activity is generally perceived as a challenge in disadvantaged settings. The situation is more complex in the context of Pakistan, where more than 60% of the population resides in the rural areas. Legislation on urban planning in Pakistan stipulates standards and makes it mandatory to have open spaces and sidewalks; however, there are issues with its implementation as the law is not applicable to existing built up structures and the rural areas.
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In view of these constraints, other opportunities of local relevance need to be identified. The feasibility of utilizing open spaces and playgrounds in schools, for public use, needs to be explored. The role of private sector actors needs to be fully realized and explored in this regard. Appropriate and ethical linkages can help to maximize such efforts. The prevention and control of tobacco use has been addressed in Section 5.
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indigenous Pakistani setting. The implementation of this preventive strategy has been designed on an experimental model, with pre-evaluation assessing risk factor burden, knowledge, attitudes and practices in the areas of intervention. The primary goal of the intervention was to study the hypothesis that educational efforts among intervention families would increase knowledge and awareness of CAD and its determinants and improve knowledge about effective efforts to prevent CAD compared with control families. Additional goals for intervention households were to reduce salt in cooking by 25%, replace ghee in cooking by polyunsaturated and monounsaturated vegetable oil entirely and reduce fat in cooking by 33%. This experience has provided useful lessons for future interventions of the kind. Baseline assessments highlighted the need for a body of well-trained staff for educating community leaders and stressed on the need for establishing effective contact in the community. 105,106 Mid-term evaluation of the project has revealed that such interventions are useful in impacting household practices. The intervention is reported to have been successful in influencing household practices in reducing salt, ghee and fat consumption to significant levels.107 These results provide useful insight into populationbased risk factor modification strategies that could be adopted at the household level. 3.3.2.c The Karachi Study: the Department of Clinical Epidemiology at the Aga Khan University Hospital (AKUH) has recently secured funding for a community-based CVD intervention study in Pakistan. This study aims to study population-based strategies for effective control of high blood pressure in Pakistan. The three-year factorial design project, which uses cluster randomization methodology, will assess the impact of different strategies on blood pressure levels and other cardiovascular risk factors. These include population approach of home health education by community health workers and cost-effective management of blood pressure administered by intensively trained local general practitioners. Lessons learnt from these three community demonstration models will prove helpful in designing similar strategies at the national level.
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recommending the population screening approach for high blood pressure as it fulfils all the criteria stipulated in Section 2. Blood pressure screening is perceived by the public as well as the providers as meeting a recognized clinical need. The programme is unlikely to encounter powerful resistance of organized vested interests as, for example, a tobacco control programme would; since risk reduction at every level of elevated blood pressure (above 115 mm hg SBP) envisages comprehensive CVD risk reduction as the goal, reductions in the mean population level of blood pressure would also be a vehicle for dietary control, tobacco control, diabetes control and obesity control. Thus, it would open the door for effective multi-pronged community intervention for CVD control.108 All categories of healthcare providers can play a part in population screening for high blood pressure. Lady Health Workers who are not formally trained to measure blood pressure can advocate for blood pressure checks; nonphysician healthcare providers trained to check blood pressure can play a part in screening, recommending lifestyle modifications and referring for further management while physicians play the central role in screening, risk assessment and management. In order to upscale population screening for high blood pressure in the country, awareness needs to be created among various categories of healthcare providers regarding the need and effectiveness of screening. Scientific principles of blood pressure measurement also need to be promoted. As screening is closely linked to risk assessment and management, a comprehensive training package needs to be introduced. Such a package needs to be scientifically valid, and introduced as part of an inherently sustainable CME programme. In addition, it needs to be resource-sensitive, practically feasible and rewarding for healthcare providers. A recent demonstration project set up by Heartfile in the districts of Jhelum and Chakwal focuses on blood pressure screening as an entry point to addressing risks factors at a population level. In the Heartfile JC Project,109 attention has been given to all elements critical to the development of training modules referred to above. These modules incorporate locally adapted versions of WHO CVD-Risk Management Package for low- and mediumresource settings,110 which have been developed by the WHO CVD Unit. These use opportunistic screening for high blood pressure as an entry point to comprehensive CVD risk reduction. Risk assessment and management algorithms in this package have been validated in the native Pakistani setting, which makes them suited for inclusion as part of this programme. Algorithms in this package are meant to be implemented in a range of healthcare facilities in medium- and low-resource settings. For this reason, they have been designed for three scenarios that reflect the commonly encountered resource availability strata in such settings. The feasibility of up-scaling this model at a national level needs to be assessed.
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Secondary prevention is also known to be cost-effective. To scale up secondary prevention practices, it is essential that appropriate investments be made in professional education, developing infrastructure for secondary prevention and creating awareness among those that have suffered an event. Secondary prevention of CVDs has received considerable attention in Pakistan owing to the efforts of several professional groups. These strategies have targeted affluent practices within busy cosmopolitan cities drawing on the support of physicians in tertiary and secondary care settings. However, such efforts have not been part of an inherently sustainable training programme. Moreover, they have largely been supported through commercial sources. There is, therefore, a need to build a concerted and sustainable secondary prevention programme based on an assessment of the currently prevailing trends in relation to secondary prevention. Such efforts must be evidence-based, resource-sensitive and scientifically valid. A significant step in this direction was the inclusion of Pakistan in the Prevention of REcurrences of Myocardial Infarction and StrokE (PREMISE) Study116 a WHO-coordinated international multi-centre collaborative study conducted by the CVD Unit, Geneva. This study aimed to assess prevailing patterns related to secondary prevention of coronary heart and cerebrovascular diseases in tertiary, secondary and primary healthcare settings in the developing countries. Preliminary results of the PREMISE Study show that patients access to appropriate and cost-effective drugs is limited in Pakistan. Over 50% of the patients with CAD were not on aspirin, 40% were not on beta-blockers and over 80% were not receiving statin prescriptions. Over 60% beta-blockers, 70% ACE-I and 80% statins were obtained through out-of-pocket expenses; this was perceived as a barrier to ensuring compliance. Majority of the patients experienced difficulty in following risk-modifying advice, in particular dietary advice, because of cost considerations. Results also reveal that up to 20% of the patients continued to smoke despite their current condition. Moreover, up to 50% had not had their blood sugar or cholesterol levels checked in the past year. Results of the PREMISE Study have several important implications for scaling up secondary prevention efforts in the country. These include improving skills essential for rational prescription of drugs and relaying risk modifying information to patients. Assessment of secondary prevention practices at the primary healthcare level also yielded important results, revealing that a majority of the patients who could access care and recognized the need for doing so visited tertiary health facilities when they had their first CAD or CVD event. The PREMISE Study has identified the need for updating clinical practices for improving the quality of secondary prevention programmes within all healthcare and particularly primary care sites. A considerable amount of resources is channelled towards secondary prevention through commercial sources in Pakistan. There is a need to channel these resources in a structured manner to promote evidence-based sustainable training programmes that are scientifically valid. The role of the Ministry of Health in structuring this and bringing it within the framework of an inherently sustainable CME
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programme in collaboration with professional societies is critical. Results also stress the need to improve access to appropriate cost-effective drugs. This has implications for ensuring sustained availability of drugs at all levels of healthcare. As a follow-up to the PREMISE baseline survey, an intervention component entitled PREMISE 2 is in the pipeline for initiation. This aims to pilot test resource level-relevant training packages for different categories of healthcare providers with the overall objective of scaling up secondary prevention-related capacity in primary, secondary and tertiary care settings. The active role of all stakeholders such as the Ministry of Health, Heartfile and professional societies such as the Pakistan Cardiac Society and others, in this initiative will help to ensure its application beyond the pilot stage. Every effort should be made to link in with this initiative with a view to assessing the long-term feasibility of its application. The PREMISE data reflect secondary prevention practices of healthcare providers within tertiary, secondary and primary healthcare settings; this represents the tip of the iceberg; there is no account of those with events who do not access healthcare facilities. The opportunity that exists to impact CVD mortality and morbidity by identifying this group and ensuring their access to healthcare needs to be emphasized.
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established, long-term antibiotic therapy is indicated as part of secondary prevention measures to prevent the occurrence of RHD, which can cause serious valvular damage to the heart and other tissues. Total coverage for primary prevention requiring treatment of every streptococcal sore throat is almost impossible even in affluent societies and in countries with manageable populations. However, intense secondary prophylaxis and primary prevention, wherever feasible, has proven to be reliable and cost-effective in developing countries.122 In Pakistan, a considerable amount of work has been done in relation to RF and RHD prevention in the last two decades. A review of this is critical since new initiatives must be built on previous efforts.
Primary prevention, wherever feasible, and secondary prophylaxis of RF has proven to be reliable and cost-effective
Pilot study in 1985 and prevalence survey in 1986-89. Three-day training workshops held in 1988 and 1989.
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mandates. Finally, in 1996, the RF/RHD prevention initiative was integrated with the Prime Ministers Programme for Primary Health Care. vii This provided an unprecedented opportunity to plug in RF/RHD with the workplans of 50,000 LHWs and would have enabled access at the grassroots level. Initial efforts in this direction were positive; workshops were arranged at the provincial level and training materials were developed. In tandem, efforts were also made to ensure availability of oral and injectable penicillin at all levels of healthcare. Additionally, RF/RHD Registers were opened at cardiology departments of 18 medical colleges/teaching hospitals and several trainings were conducted in facility-based settings. However, for a public health strategy to succeed, it must first be modelled in a demonstration area and incorporate an evaluation protocol so that important elements may be refined and lessons learnt applied to a wider setting.
Currently known as the National Programme for Family Planning and Primary Health Care.
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at CVD prevention, control and health promotion in Pakistan. The Action Agenda items as part of this strategy have been listed below. However, as part of the Integrated Framework for Action, CVD has been grouped alongside other NCDs in an integrated model which combines a range of interventions and actions across other NCD domains. 3.5 Cardiovascular Diseases - Action Agenda
?
? ? ? ? ? ? ? ? ? ?
? ? ? ? ? ?
Integrate surveillance of cardiovascular risk factors with a population-based NCD surveillance system; develop and validate tools of assessment for the Pakistani population. Integrate public health programme monitoring and evaluation with NCD surveillance. Promote physical activity and a healthy diet as a cultural norm as part of the NCD behavioural change communication strategy. Create awareness about the risks of CVD and its mitigates, prevention of RF and RHD and screening approaches. Promote strategies for mitigation of cardiovascular risks through population-level approaches. Revisit health policy on diet and nutrition to expand its current focus on under-nutrition. Develop a nutrition and physical activity policy seeking guidance from the WHO Global Strategy on Diet and Physical Activity. Develop policies and strategies to limit the production of, and access to, ghee as a medium for cooking. Develop agricultural and fiscal policies that increase the demand for, and make healthy food more accessible. Create an enabling physical and social environment for physical activity. Generate support from religious leaders to endorse the need for participation of women in physical activity. Enforce effective legislation to stipulate standards for urban planning. Utilize available open spaces for physical activity where feasible and appropriate. Integrate concerted primary and secondary prevention programmes into health services as part of a comprehensive and sustainable, scientifically valid, culturally appropriate and resource-sensitive CME programme for all categories of healthcare providers. Promote screening for raised blood pressure at the population level. Promote high-risk screening for dyslipidaemia and diabetes in high-risk groups only. Focus attention on improving the quality of prevention programmes within primary and basic health sites. Ensure availability of aspirin, beta blockers, thiazides, ACE inhibitors, statins and penicillin at all levels of healthcare. Conduct clinical end-point trials in the native Pakistani setting to define cost-effective therapeutic strategies for primary and secondary prevention of CVDs. Build capacity of health systems in support of CVD prevention and control. Build a coalition or network of organizations at the national, provincial and local levels facilitated by federal and provincial health services to add momentum to CVD prevention and control as part of a
comprehensive NCD prevention effort.
Priority Action Areas Priorities within other Action Areas will be determined subsequently
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4
Diabetes
4.1 Context
Diabetes is a growing global health concern. The worldwide prevalence of diabetes in the adult population over 20 years of age, reported at 4% in 1995 with an estimated 135 million people affected, is expected to rise to 300 million by the year 2025; 75% of these people will hail from the developing countries.127 Pakistanis are an ethnic group having an inherent predilection to develop diabetes; 128 increase in life expectancy and major changes in diet and lifestyles that are a part of urbanization and social development further contribute to the existing trend.129 Undiagnosed, untreated and poorly controlled diabetes is known to exhort a considerable toll on individuals, communities and the healthcare system. It significantly adds to the burden of preventable diseases and leads to economic losses that stem from high cost of care and lost productivity. On the other hand, scientific evidence highlights the potential to prevent diabetes and its complications through cost-effective , measures at the population and high-risk levels of intervention. 130 131
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Punjab. The overall prevalence of IGT in these surveys ranged from 5.39% to 11.2%.6,134-135 (CRsindh) ,133,134,135 A higher prevalence of obesity and IGT was observed among women compared with men in all surveys, indicating that diabetes has not yet manifested to its full extent in women, who can thus be seen as a potential target group for primary prevention. Moreover, it is a matter of grave concern that both diabetes and IGT are manifesting at a much younger age group (3544 years) in our population compared with western populations. Nearly onethird to one-half of the subjects in these surveys had undiagnosed diabetes. In all these studies, data revealed associations between diabetes prevalence and age, obesity, central obesity and a positive family history of diabetes. The association of central obesity was greater for women compared with men. These results were among the first in Pakistan to document that diabetes and glucose intolerance could no longer be regarded as a problem confined to migrant communities; published data from these surveys played an important part in creating awareness about the magnitude of the issue. However, it should be recognized that the available prevalence data is based on the old WHO diagnostic criteria and that the prevalence of diabetes would actually be higher if the new criteria are adopted.
Table 4.1 Diabetes and impaired glucose tolerance in Pakistan: regional prevalence data from DAP-WHO Surveys (19941998)**6,134-135
Province Sindh (Rural) Sindh (Urban) Balochistan (Rural) Balochistan (Urban) NWFP (Rural) Punjab (Rural) Punjab (Urban) Overall prevalence Diabetes (%)? 13.9 16.5 7.5 10.8 12.0 6.39 13.23 11.47 IGT (%)? 11.2 10.4 7.4 10.4 9.4 5.39 11.54 9.39
** Age 25 years and above ? Defined as a fasting glucose of = 140 mg/dl or 2 hour post 75 g glucose load = 200 mg/dl ? Defined as a 2 hour post 75 g glucose load = 140 mg/dl and = 199 mg/dl
Against the backdrop of the high prevalence of diabetes and IGT in Pakistan, the NHSP reported a very high unawareness rate for diabetes, with 36.3% of the diabetics being unaware of their condition. The survey also reported one of the lowest control rates for diabetes in the world; less than 3% of the diabetics had their condition in control.viii Recently conducted surveys have revealed that knowledge relating to diabetes and its prevention is significantly low even in the urban metropolitan areas; only 40% of the known diabetics treated at tertiary healthcare facilities in Karachi had correct knowledge relating to diabetes and its complications.136 In urban Quetta, only 33% of the diabetics were aware of essential information relating to diabetes and its
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Control was defined as having a random blood sugar of = 140 mg/dl among those taking medication for diabetes
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complications.137 With these trends, it can be assumed that both the control and awareness rates would be much lower in the underprivileged rural areas. Data from the aforementioned surveys serve two purposes; firstly, they serve as an entry point and a valid baseline to build the diabetes component of the NCD surveillance system. Secondly, they provide valid scientific evidence relating to the burden of diabetes in Pakistan. Since the data are representative of the general population, they provide sufficient information to initiate public health action for the prevention and control of diabetes. However, it is important to gather information on diabetes on an ongoing basis and in that context, essential to include diabetes in the population-based NCD surveillance system. Inclusion of diabetes in the surveillance process entails adding information obtained from blood samples. This approach in Pakistans context may not be feasible in the short term because of resource constraints. As an alternative, the physical measurement of waist circumference can be used as a proxy for the risk of diabetes. In a recently conducted case-control study on patients with angiographically defined CAD versus controls with no evidence of disease, waist circumference was strongly associated with the risk of developing CAD and diabetes.69 However, future efforts in upgrading the surveillance system should be structured to allow a more comprehensive assessment, expanding this approach to include laboratory assessments. From a diabetes-related epidemiological standpoint, future research efforts should also be aimed at identifying novel causal associations which could be potential targets for preventative interventions.
Diabetes has one of the strongest causal associations with CAD in the Pakistani population
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risks, both at the primary and secondary prevention levels. Any attempt aimed at reducing diabetes-related morbidity and mortality should ideally encompass prevention and treatment of diabetes and its complications and rehabilitation. The Action Plan focuses on primary and secondary prevention; however, issues that relate to treatment and rehabilitation are outside the scope of this initiative. Future efforts that further build on this initiative must take this into account.
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Nonphysician healthcare providers can be taught to screen those at high risk of developing diabetes
impaired glucose tolerance/impaired fasting glucose are predisposed to subsequent development of diabetes and suffer the highest risk in this respect. Although there are no data from diabetes intervention trials in the native Pakistani setting, a number of studies conducted on western populations have shown that with lifestyle interventions, it is possible to delay or prevent diabetes in the high-risk population. Diet and/or exercise are known to have led to a significant decrease in the incidence of diabetes amongst those with IGT and delay the progression from IGT to diabetes.142,143 Data from more recently conducted randomized clinical trials, also including those at increased risk of developing diabetes by virtue of being overweight and having a family history, show that lifestyle interventions could reduce the risk of diabetes by 58% in the high-risk group.131 Moreover, this study showed that lifestyle changes were more effective compared with drug treatment. The ongoing Indian Diabetes Prevention Programme is currently involved in evaluating the efficacy of lifestyle modifications and drugs as a means of primary prevention in a population with similar environmental conditions and genetic propensity as the Pakistani population. 144 Results of the study are likely to yield useful lessons for the Pakistani setting. Intensified case finding in high-risk groups must involve the recognition of those at high risk and the settings in which they can be identified. Awareness must be created as part of community intervention strategies about the need for high-risk groups to be tested for diabetes. However, the major focus should be on healthcare providers who play a major role in risk factor counselling, intensified case finding and risk assessment and management. A recent survey assessing knowledge, practices and attitudes of family physicians has shown that there are several gaps in their understanding and consequently their practices with regard to screening and management of diabetes. 145 Prevention of diabetes should, therefore, be an integral component of the structured NCD training programme discussed in Section 2. This should be aimed at stepping up the knowledge level, skills and capacity to screen and assess those at the risk of developing diabetes, and managing those at highrisk and with established diabetes. Appropriate interventions must be developed for all categories of healthcare providers. Lady Health Workers, non-physician healthcare providers and physicians are all important in this loop. The non-physician category of healthcare providers can be taught to identify and screen those at high risk of developing diabetes and refer them for further workup and management. Physicians can be trained to include risk assessment and management of diabetes as part of their routine work-plan in a simplified manner. This implies that guidance on intensified case finding in high-risk groups and simplified customized algorithms on management of diabetes should be included in NCD training packages for all categories of healthcare providers, as appropriate. This concept has previously been highlighted as a common Action Area in Section 2. Healthcare providers in the reproductive health systems must also be part of the loop so as to facilitate screening of high-risk women. Guidance on prevention of diabetes as part of NCD training packages needs to be locally relevant to the Pakistani population. Evidence points to the need
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Evidence highlights the need to have populationspecific targets for prevention in the Pakistani setting
to have population-specific targets for prevention in the Pakistani setting. There are many indications that in south Asians, the risk of diabetes starts to increase rapidly at levels of BMI or waist circumference well in the acceptable range for Europeans, implying that cut-off points as recommended for European White populations have little value in identifying Asian individuals at high risk. 146 Emerging data from the INTERHEART study also show that in south Asians, increases in BMI from 22 to a range of 23 to 25 are associated with a 30% increase in CVD.147 Based on these considerations, lower BMI cut-off points need to be recommended. Similarly, cut-off values for waist circumference also need to be lowered. The World Health Organization recommends a limit for waist circumference of 102 cm and 88 cm in men and women, respectively; however more appropriate waist circumference action levels are now being sought to specify risk levels relating to diabetes in Asian countries. This is being done to alert those with lower BMIs to their increased risk. A recent study from India attempted to find out the normal cut-off values for BMI and upper-body adiposity by computing their risk associations with diabetes. The study has defined a BMI of 23 kg/m2 as normal for both men and women; cut-off values for waist circumference were 85 cm for men and 80 cm for women; for waist-hip-ratio they were 0.89 for men and 0.81 for women. 148 China has adopted its own standards defining abdominal obesity by a waist circumference of 85 cm in men and 80 cm in women and recommendations have also been made to lower cut-off points for Pakistanis. Based on these, the upper limit has been defined as 91.5 cm in men and 84 cm in women.37 However, this needs to be validated by longitudinal data sources. Based on this information, it will be possible to develop region-specific risk scores for the Pakistani setting. Patient education is one of the critical elements of the high-risk approach to diabetes. This needs to be part of the NCD training packages for all categories of healthcare providers. There is also a need for concerted efforts to involve the patient and the family in the process as this will enhance the chances of success.
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present context while developing the diabetes component of the NCD training packages. The Diabetes Plan also made strong recommendations for the Ministry of Health to identify an effective mechanism to ensure that it assumes its role as initiator and coordinator of diabetes prevention-related activities with active inputs of private sector stakeholders and spelt out the need for appointment of a focal point for NCDs in this connection. The second Diabetes Plan updated objectives and strategies, reviewed progress in terms of activities and proposed further initiatives for the period 1999-2001.150 The revision was prepared on the basis of discussions held in Karachi in March 1999. In addition to further strengthening the recommendations of the first Diabetes Plan, the second version made specific recommendations to adopt the WHO standards of care. The Diabetes Plans were successful in developing clinical guidelines for the management of diabetes and in securing a changeover to a unified strength of insulin. However, for a Plan of Action to succeed, it must first be modelled in a demonstration area and incorporate an evaluation protocol so that important elements may be refined and lessons learnt applied to a wider setting. The Diabetes Plans packaged morbidity-related outcome measures projected over a long term without a clear definition of short- to medium-term processes and outputs level measures. As part of this Action Plan, an attempt has been made to bridge these gaps. Moreover, diabetes prevention has been integrated with other NCDs; the Integrated Framework for Action highlights this approach. The Action Agenda specific to diabetes is summarized below. 4.4 Diabetes - Action Agenda
? Integrate surveillance of diabetes with a comprehensive population-based NCD surveillance system.
? ? ?
? ? ?
Use waist circumference as a proxy indicator for the risk of diabetes in the short term. However, as part of future efforts, upgrade surveillance to allow a more comprehensive assessment incorporating biochemical assessments. Build on previous data collection efforts. Integrate public health programme monitoring and evaluation with NCD surveillance. Integrate prevention of diabetes as part of the comprehensive behavioural change communication strategy (refer to Action Agenda in cardiovascular diseases and tobacco sections). Build capacity of health systems in support of prevention and control of diabetes. Integrate prevention of diabetes and intensified case finding in high-risk groups into health services as part of a comprehensive and sustainable, scientifically valid, culturally appropriate and resourcesensitive CME programme for all categories of healthcare providers. Ensure availability of anti-diabetics (insulin, sulphonylureas, metformin) at all levels of healthcare. Seek guidance from and build on previous scientifically valid efforts in Pakistan related to prevention and control of diabetes. Build a coalition or network of organizations at the national, provincial and local levels facilitated by federal and provincial health services to add momentum to diabetes prevention and control as part of a comprehensive NCD prevention effort.
Priority Action Areas Priorities within other Action Areas will be determined subsequently
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5
Tobacco
5.1 Context
The annual death toll attributable to tobacco is expected to rise from its current estimates of 5 million per year to 10 million by the year 2025. Parallel to this trend, there are also projections for a shift in the disease burden from its current split between the developed and the developing countries to a scenario where 70% of these deaths will occur in the developing countries by the year 2025.151 However, the devastation caused by tobacco goes much beyond this picture with implications for individuals, societies and health systems.
Clearly, tobacco is an enormous public health challenge. Its use appears to be a matter of a simple individual choice; however, the dynamics influencing this choice are linked to economic factors and are embedded in a complex interplay of several policy and environment parameters with implications for growers, transporters, traders, advertisers, public authorities, the health sector and the tobacco industry. Consequently, the control of tobacco use has to be a combination of measures that integrate public health interventions to alter individual behaviours with the objective of reducing demand on the one hand. On the other hand, such measures should focus on interventions to alter the legal, social, fiscal, economic and physical environment. The tobacco industry puts forward the argument that it runs a legitimate business; markets and sells a legal product and has the constitutional right to communicate with their consumers. This highlights the need for generating a dialogue on fundamental issues at the global level. The development of an international strategy on the future of product modification should be part of this approach. Reliance on revenue generated from tobacco is one of the fundamental barriers to effective tobacco control in Pakistan. This will continue to remain a hurdle, undermining any strategy that aims to address tobacco control in a comprehensive manner. The government relies heavily on revenue generated from tobacco. In the year 2000, tax revenues from cigarettes totalled Pak Rs. 19.8 billion (including Pak Rs. 18.5 billion in excise and sales tax); this represented approximately 25% of all excise revenue and more than 6% of all taxes collected in the country for that year.152,153 Against this backdrop, there are no data available on the social costs of tobacco compared with revenues earned. Clearly, this highlights a public health challenge of a significant magnitude and places the onus of responsibility on the government to institute measures to seek alternative means of revenue generation.
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More than 40% men and 12.5% women use tobacco in one form or the other
The tobacco issue has a larger international context; liberalization of international trade makes the developing countries a natural market for tobacco. Within this context, it became increasingly clear that the absence of a global set of binding rules would jeopardize regulatory efforts within countries. The World Health Organization responded to this challenge by taking a lead in developing the Framework Convention on Tobacco Control (FCTC) by exercising its constitutional right (Article 21) to negotiate a set of globally-binding rules.154 The FCTC is aimed at building an international regulatory framework, which will assist and support countries in national regulatory policies within the framework of tobacco control. Unanimously adopted by all the 192 member states of WHO, including Pakistan, at the 56th session of the World Health Assembly in May 2003, the FCTC needs to be officially adopted and ratified by 40 countries that wish to integrate the protocols stipulated in this treaty into their tobacco control legislative frameworks, before it comes into force globally. The Framework Convention on Tobacco Control (FCTC) marks a watershed in global tobacco control. The FCTC includes the most effective measures known to reduce the incidence of tobacco use including higher taxes, smokefree areas and bans on advertising. But turning the promise of the FCTC into concrete legislative and regulatory gains will require that policymakers and advocates understand and take a holistic approach to the issue. The Action Plan revolves around the different provisions of the FCTC and can form a baseline for the process of ratification of FCTC in Pakistan. Some of the issues earmarked in the Action Plan such as those requiring further research and understanding can be achieved in collaboration with the global community. This cooperation is ensured under FCTC and countries that ratify FCTC can look forward to benefiting from and sharing of research and knowledge in this respect. One of the major areas where Pakistan can benefit from FCTC ratification is the issue of tobacco growing, especially in small land holdings which were dedicated to growing food previously. Being a tobacco growing country, Pakistan would require sharing of experiences from other countries for the diversification of crops and finding suitable alternatives for tobacco growers. FCTC encourages governments to promote, as appropriate, economically viable alternatives for tobacco growers in cooperation with each other, and with competent international and regional intergovernmental organizations. Other cross-border issues related to tobacco control like illicit trade, advertising through internet and opening of trade barriers to cheaper foreign brands which form a part of global cooperation for tobacco control, are all tackled under FCTC.
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years and above. According to this survey, smoking was commoner in rural compared with urban areas and among the illiterate as opposed to the literate population.5 A recently conducted survey reported a higher prevalence among the illiterate (41.2%);7 however, lack of comparability between this and earlier surveys obviates the possibility of comparing results. A recent cross-sectional survey on a random sample of 632 urban schoolgoing children in Islamabad carried out by The Network for Consumer Protection has revealed that 28% of the urban adolescents between the ages of 15-18 years currently smoke. Of these, 75% are regular smokers and 58% have been smoking for the last two years; 92% of those who smoke were aware of the hazards of smoking and 78% had even tried to give up. Peer pressure was reported as the predominant cause for initiating smoking, with 76% of the smokers in this survey referring to it. In the remainder, portrayal of style through advertising was outlined as the initiating factor.155 A recent surveillance effort introduced in Pakistan is the Global Youth Tobacco Survey (GYTS). Focusing on adolescents aged 13-15 years, this school-based survey provides an insight into students' knowledge, attitudes, and behaviours as these relate to tobacco, inclusive of issues pertaining to access and availability, exposure to passive smoke, tobacco use cessation, media advertising, and school curricula. Results of the survey demonstrate that cigarettes are used far less often than other tobacco products. For example, in Islamabad, while only 1.7% of the students (2.5% boys and 0.5% girls) reported use of cigarettes in the last month, 10.3% of the students (11% boys and 8% girls) reported use of other tobacco products. These results also demonstrate relatively high exposure to passive smoke; in Islamabad, almost three in 10 students live in homes where others smoke in their presence, and almost four in 10 are exposed in places outside their home. More than nine in 10 students thought that smoking should be banned in public places. Just over half the students (57.3% in Islamabad and 55.8% in Lahore) reported being taught in school in the past year about the dangers of smoking. One encouraging finding was that although eight in 10 students reported seeing cigarette advertisements in the previous month, about eight in 10 also reported seeing anti-smoking media messages. Finally, a significant proportion of students reported being offered free cigarettes by tobacco company representatives (22.8% in Lahore and 18.5% in Islamabad). These results can be used to guide the development of programmes and policy, and to monitor the implementation of such policies along provisions of the FCTC.156 The need to establish surveillance mechanisms that track NCD risk factors over time has been clearly laid out in Section 2; such systems will make it possible to track changes over time in smoking trends. Surveillance of tobacco use must, therefore, be integrated with a population-based NCD surveillance system. Tobacco use is known to have a strong causal association with a number of diseases in western populations;157 association of tobacco use with diseases has also been demonstrated in the native Pakistani setting. Association of current, past and passive smoking has been documented with
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angiographically defined CAD in a recently reported case-control study from Pakistan. 69 Associations have also been demonstrated between tobacco use and cancer in Pakistan. A case-control study of biopsy proven carcinoma of the oral cavity and oro-pharynx and age and sex matched controls has revealed that the risk of developing cancer when pan was used was 4.2 and 3.2 times higher in males and females respectively, compared with controls; when both pan and tobacco was chewed, the risk increased six times for females and nine times for females whereas the combination of pan, chewing tobacco and smoking caused the risk to increase 23 times for males and 35.9 times for females.158 The demonstration of significant causal associations in the native Pakistani setting makes a very strong case for addressing tobacco as a risk factor at all levels of prevention within the country. Furthermore, a strong causal association has also been demonstrated between tobacco use and tuberculosis in India.159,160 This may well be the case in Pakistan and needs to be further explored in our setting.
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The trend of child labour in Pakistan has forced many children into becoming vendors
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organizations and other elements in the adolescents social environment.170 These have been discussed elsewhere in this chapter.
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commitment are also perceived as barriers. There is, therefore, the need to periodically assess the quality and degree of implementation of tobacco control measures as stipulated in the Ordinance. The effective enforcement of the Ordinance also requires active support of the professional community and scientific forums; endorsement of professional societies must be actively sought and their potential harnessed in this initiative. Public support and commitment needs to be generated in order to support its enforcement within a variety of environments. Clean indoor air policies also need to be actively supported in the working environment. A smoking cessation programme, combined with a clearly publicised smoking policy and heath education campaign that discourages tobacco use, is one of the most cost-effective strategies for tobacco control in worksites.171 Worksites are also excellent mediums for such efforts because of the availability of a captive audience. Every support should be provided to worksites in order to enable them to adopt and implement this strategy.
Worksites are excellent sites for tobacco control efforts because of the availability of a captive audience
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market; however, there are at times, disagreements between the grower and the buyer over the terms that underlie financial transaction involving issues that stem from grading and rating of the crop.173 Developing alternatives to tobacco cultivation and crop substitution are recognized as being a part of comprehensive tobacco control efforts. However, as long as a market exists for the crop, measures aimed at regulating its plantation may not be comprehensively effective. There are, nevertheless, several strategies that are known to discourage tobacco cultivation; these include provision of guidance to farmers, crop substitution and mixed cropping and ensuring better marketing of alternative crops. These efforts must be initiated alongside other tobacco control efforts albeit with a clear understanding that they have a limited role in tobacco control.174
The tobaccorelated health education budget of the Ministry of Health amounted to Rs. 2 million in the year 2002
There are several views with regard to developing alternatives to tobacco cultivation. A group of farmers from NWFP deny the possibility; however, such views are not reflective of a long-term vision as part of which crop substitution can clearly be addressed. Majority of the growers in Pakistan agrees that if they are ensured alternative income, they would switch over to other crops and businesses and feel, in particular, that alternative crops such as orchards have an equivalent yield by value. xi However, the time lag that elapses between experimental plantation and sustainable fiscal yield and the uncertainty with marketing the crop compared with the situation that exists with tobacco is a strong disincentive for them to diversify their businesses. The government can take several measures to discourage tobacco cultivation and assist with diversification. Firstly, all indirect subsidies must be withdrawn; secondly, technical assistance for the cultivation of equally remunerative crops should be provided; this should be guided by studies to determine what is feasible and economically viable. Alternative crops, promoted as part of such arrangements, can be given insurance protection. Thirdly, the government should assist with providing income support for tobacco farmers until the process of diversification is complete and sustainable. All these suggested measures have implications for operational research, and for building a working relationship with the growers and ties in the role of the ministries of Agriculture, Commerce and Finance; farmers associations and local NGOs. Such an effort must begin with mapping and registration of growers as such data are presently unavailable.
xi
The investment per acre for tobacco cultivation roughly amounts to Rs. 125,000 in Pakistan; the net return on the crop per acre is around Rs. 25,000-30,000 under favourable conditions. xii Total health education budgets for that year amounted to Rs. 255 million.
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The advertising budgets of companies with 98% of the market share totalled Rs. 61 million for the same year
There is a general impression that consumers are more aware of the harmful effects of tobacco today than they were decades ago. This can be attributed to investments made in anti-tobacco health education interventions over the years; however, due to the lack of a system to monitor this intervention, an assessment of its impact cannot be made. It is, therefore, imperative that future interventions should encompass sound evaluation strategies and process evaluation measures. Tobacco should be featured prominently as part of the comprehensive behavioural change communication strategy for NCDs; the principles of this approach have been outlined in Section 2. Anti-tobacco health education interventions should also provide information on the magnitude of the damage tobacco can cause and should be able to provide critical information related to the role of tobacco advertisements in the initiation of smoking. In addition, information on quitting must be provided. High-risk groups such as young women and adolescents deserve special attention. Women in Pakistan are more vulnerable to tobacco use because the socio-cultural norms that previously prevented them from smoking are weakening. This, coupled with a rise in womens spending power and the impact of advertising images of freedom, emancipation, glamour and wealth, are enticing more and more women in urban settings to smoke. In addition, huqqa and naswar use is socially acceptable in rural areas. There is a clear need to create culturally-relevant awareness among women both in the urban and rural areas through appropriate channels. Such efforts should strongly integrate messages that highlight the ill-effects of tobacco on the foetus during pregnancy, the health hazards of passive smoking and the potential illeffect on young children in the house. There is also a potential in using the religious argument for anti-tobacco campaigns. The recently published monograph by EMRO summarizes Islamic rulings on tobacco.175 This monograph encourages the use of Islamic fatwas for tobacco control and highlights the magnitude of influence that the clergy can exercise in promoting tobacco cessation. This potential needs to be harnessed. Tobacco was non-existent in the times of the Holy Prophet Mohammad (Peace Be Upon Him) and, therefore, there is no guidance on this matter or else that pronouncement would have been binding. However, by analogy, tobacco has been declared makroh (undesirable) by the Council of Islamic Ideology, which supports a complete ban on advertising. Involvement of the media is critical to the public awareness approach. In addition to drawing on their support to disseminate information relevant for health education; it is important to draw their attention to the ways in which tobacco companies have worked hard to thwart policy change over the last several years.176 Media activities around dedicated days such as the World No Tobacco Day provide a platform for accelerating such efforts. Professional organizations and groups have a responsibility to sensitize their members to the importance of serving as non-smoking models. This is particularly important as cigarette smoking rates are known to be high among health professionals and students.177 Help from professional societies and organizations is essential to achieve this objective. Moreover, engaging health professionals to lobby for anti-tobacco activities at the community level is critical. Healthcare providers play an important role in influencing
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lifestyles of their patients. It is necessary to involve all levels of healthcare providers in this loop through an approach that has been discussed in Section 2.
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impact is the greatest. Any form of advertising from a public health perspective is, therefore, opposed to this principle. There is a general impression that tobacco sponsorship for sports is indispensable. However, that may not be the case. The Pakistan Cricket Board (PCB) disassociated itself from PTCs sponsorship in 1997-98; yet both cricket and PCB have continued to flourish. Another similar success story can be quoted from international experiences with FIFA declaring World Cup 2002 as smoke-free. 180 The Framework Convention on Tobacco Control (FCTC) recommends gradual phasing out of all types of tobacco promotion and advertising by 2005. It recommends this for countries with constitutional constraints, otherwise a comprehensive ban is recommended. Statutory restrictions on tobacco advertising in Pakistan were non-existent prior to the promulgation of the Prohibition of Smoking Ordinance 2002; earlier laws dealt with the issue of sales to minors and inscription of health warnings. In 1997, the Lahore High Court Bench banned all kinds of cigarettes advertisements on the electronic media on a petition filed by the Pakistan Chest Foundation. However, a larger bench repealed that order citing technical reasons. Subsequently, the federal government came up with Prevention of Smoking Ordinance 2002. The recently promulgated 2002 Ordinance imposes restrictions on tobacco advertising in Pakistan. However, there are issues with this Ordinance as it imposes a partial ban on advertising. This creates ambiguities, making its implementation vague and exploitable. Evidence suggests that while comprehensive bans on all forms of tobacco promotion can be effective in reducing tobacco use, partial restrictions have limited or no effect.181,182 These gaps notwithstanding, the promulgation of this Ordinance is a step in the positive direction and in line with international trends which call for gradual phasing out of all kinds of tobacco advertising, sponsorship and promotion by 2005. The Ordinance and its preamble provide the scope around which rules of business can be drafted.
Active lobbying efforts are required by all stakeholders to push for further amendments in the Ordinance aiming for a comprehensive ban on tobacco promotion, advertising and sponsorship; groups such as the Tobacco-Free Initiative, Pakistan (TFI-Pakistan) will hopefully play an active part in this endeavour. These efforts come at a critical time when the Ministry of Health acknowledges and has indicated that it is possible to aim for a total and comprehensive ban on tobacco advertising. Nothing less than that is acceptable or effective.
5.4.6 Warnings
The Cigarettes (Printing of Warning) Ordinance 1979 made it binding for manufacturers to print on all cigarette packs, both in English and Urdu, the following warning Warning: Smoking is Injurious for Health; 183 a subsequent amendment of this Ordinance in 1980 exempted cigarettes meant for exports from carrying this health warning. 184 Subsequently, the 1979 Ordinance was amended in 2002,185 making it necessary for warnings to occupy 30% of the front and back of cigarette packs. In addition, it is now
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mandatory for all electronic media advertisements to devote 20% of the air time to warnings. The larger and more conspicuous warnings come to the consumer at no additional cost to the government; however, they may only be marginally better than the previous pattern of warnings in altering health behaviours of smokers. It is, therefore, necessary to bring about innovations in warning styles based on feedback received from pilot studies conducted in local settings. Successful examples exist of how such innovations have been effective in bringing about behavioural changes. Studies conducted in Canada, where pictorial warnings cover 50% of the pack surface, have also suggested that such approaches are effective. 186,xiv In light of this evidence, conscious and culturally-relevant efforts need to be initiated to make warnings more effective. 187,188 Given the high illiteracy rate in Pakistan, this may also require pictorial representation of the warning. The overall design of the cigarette pack also plays an important role in how warnings are internalized the same way as it plays a part in coining brand image. Many countries are advocating plain packaging. Some also propose the banning of words such as Mild or Light, as they may convey the impression that these cigarettes are less harmful or contain fewer harmful constituents. Every effort should be made to integrate these lessons to further strengthen warnings.
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the Revenue Department in relation to the possible negative impact that smuggling can have on revenue generation. However, in a public health context, price increase is known to be effective and should be actively pursued. The World Bank and the IMF both agree on the effectiveness of price increase on tobacco consumption. The latter supports the idea of a specific tax on tobacco in order to reduce consumption. 190 With rising poverty and lower incomes in Pakistan, consumption is likely to be more sensitive to price changes, regardless of the inelasticity of demand. Tobacco is a significant source of revenue in Pakistan.xv191 Dependence on revenue generated from tobacco is an impediment for tobacco control. Policy thinking needs to be diverted from the focus on gains in the form of revenue to the health costs of tobacco use. It needs to be fully realized that tobacco control is highly cost-effective as part of a basic public health package in low- and middle-income countries and it compares well with other interventions like child immunization.
One of the two most important measures that have the potential of impacting tobacco mortality trends is the widespread use of effective means of treating tobacco dependence, especially if cessation rate is dramatically increased.192,193 Majority of the smokers realize the need to give up smoking but finds it difficult to do so in the absence of any organized effort on smoking cessation. Against this background, there are no smoking cessation clinics in Pakistan even in tertiary care settings; smoking cessation advice is given on an ad hoc basis in clinics. In addition, there is no formal training of healthcare providers on smoking cessation and no printed information is available to them through a structured and sustainable mechanism. Moreover, Nicotine Replacement Therapy (NRT), which is an affordable and effective deterrent against smoking, is not registered in Pakistan. There is, therefore, the need to integrate smoking cessation with healthcare delivery at all levels and to address it as part of professional education. Investment in smoking cessation clinics with equitable outreach is also overdue. These can be developed in the setting of major public sector hospitals; in addition, it should be made mandatory for private sector hospitals to offer such services and guidance. Healthcare providers in BHUs and THQs should be provided with simple tools enabling them to assist patients with smoking cessation. In the context of tobacco use cessation, it is also important to make NRT available in Pakistan through the process of formal registration.
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holding 10% of the market share in 2001 to 20% in 2002.162 This results in yearly revenue losses approximating to Rs. 1.2 billion. Counterfeit cigarettes have 2.4% of the market share in Pakistan. 152 The tobacco industry tends not to acknowledge the magnitude of this issue publicly, as this would have implications for consumer confidence and brand image. Counterfeiting has public health implications as it makes cigarettes more accessible by increasing availability and reducing cost. In case of counterfeiting, manufacturing details, retail mechanisms and trade routes are well established; however, being a sustainable activity, it is hard to break. The government can address this issue by enhancing market intelligence and fixing a minimum price. Cigarettes are the worlds most widely smuggled legal consumer product. According to estimates, 4-6% of world cigarettes are smuggled. 194 Cigarettes are not imported into Pakistan; any cigarette packing which does not have a warning in Urdu is a smuggled item. Ninety percent of the tobacco smuggling in Pakistan is due to trade arrangements with Afghanistan. This practice is becoming rampant in the absence of effective monitoring and surveillance of this trend both at the entry and sale points. The response to this issue involves effective implementation of laws that exist on smuggled contrabands and raising the economic cost of smuggling, thus narrowing the margin between the price of the legitimate and the smuggled product in the market.195 The use of difficult-to-forge tax-paid markings, excise stickers and printing of unique serial numbers is known to be effective since any tobacco product not carrying such stickers offered for sale can be seized and destroyed even after it enters the country. This is one area where cooperation with the tobacco industry can prove helpful since they have a vested interest in reducing the scope for untaxed tobacco products. Addressing this issue in a comprehensive manner brings in the role of Customs, the ministries of Finance, Commerce and Industries and the local governments.
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Many products with health benefits are often effectively banned from the marketplace due to burdensome regulatory standards. Against this backdrop, it is ironic that tobacco products are excluded from consumer protection laws, such as food and drug legislation. It is, therefore, necessary to lobby for legislation as part of which tobacco should be subjected to stringent regulations governing pharmaceutical products.
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? ? ? ? ? ?
? ? ?
Integrate surveillance of tobacco use with a population-based NCD surveillance system. Monitor trends in tobacco use and its determinants. Feature tobacco prominently as part of the comprehensive NCD behavioural change communication strategy; provide wide-ranging information relevant to all aspects of tobacco prevention and control and smoking cessation. Institute means to reduce dependence on revenues generated from tobacco and seek alternative means of revenue generation. Aim for gradual phasing out of all types of advertising and complete ban on advertising. Develop and enforce legislation to subject tobacco to stringent regulations governing pharmaceutical products. Allocate resources for policy and operational research around tobacco. Build capacity of health systems in support of tobacco control. Integrate public health programme monitoring and evaluation with NCD surveillance. Build a coalition or network of organizations at the national, provincial and local levels facilitated by federal and provincial health services to add momentum and legitimacy to tobacco control as part of a comprehensive effort for the prevention of NCDs. Integrate guidance on tobacco cessation into health services as part of a comprehensive and sustainable, scientifically valid, culturally appropriate and resource-sensitive CME programme for all categories of healthcare providers. Adopt measures to discourage tobacco cultivation and assist with crop diversification. Ensure availability and access to Nicotine Replacement Therapy. Implement effective legislation on smuggling contrabands and counterfeiting.
Priority Action Areas Priorities within other Action Areas will be determined subsequently
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6
Chronic Respiratory Diseases
6.1 Context
Four of the top ten leading causes of death in the world are respiratory in origin these include lower respiratory tract infections, chronic obstructive pulmonary disease (COPD), tuberculosis and lung cancer.4 However, in the wake of the disease pattern shifts that are part of the global epidemiological transition, the burden of chronic respiratory diseases (CRD) inclusive of COPD, lung cancer and asthma is consistently on the rise whereas the burden of communicable respiratory conditions is likely to lessen.
Females in the rural areas have the highest prevalence of chronic bronchitis
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Prevention of CRDs needs to be integrated with a comprehensive NCD prevention and control framework. There is valid scientific justification for this approach, given the commonality of risk factors and preventive approaches. Prevention of CRD necessitates reduction or avoidance of personal exposure to risk factors; these include direct and indirect exposure to tobacco smoke, exposure to air pollution derived from indoor and outdoor sources, occupational exposure to toxic agents, exposure to common allergens, malnutrition, low birth weight and multiple early lung infections. Of these, tobacco has been discussed in Section 5 whereas occupational exposure to toxins has been addressed in Section 7 as part of cancer prevention and control. Malnutrition and infections are outside the scope of the present discussion. This Section focuses on environmental pollution. Exposure to environmental pollution is a major risk factor for COPD in the developing world, where poverty, lack of investment in modern technology and weak environmental legislation combine to cause high pollution levels.199 The associations between pollution and disease are complex and poorly characterized for a number of reasons; these include diversity of exposure pathways and processes, uncertainty about levels of exposure, long latency time and effects of cumulative exposure. Despite these issues, particulate matter pollution has an established causal association with COPD.200 This includes both indoor and outdoor air pollution. Indoor air pollution takes many forms; these include smoke and solid fuel combustion and organic compounds in modern buildings. Indoor air pollution from combustion of biomass/traditional fuels and coal is known to be an important risk for COPD in Pakistan. In the NHSP, more females compared with males were shown to suffer from chronic bronchitis in the rural areas. It is important to examine these trends and their determinants so that appropriate public health interventions can be developed to address this issue. Outdoor air pollution is also a major issue in Pakistan, particularly in the crowded metropolitan areas. In many cities, air pollution levels are known to have crossed safe limits whereas in others, they have reached threshold limits.201 Particulate matter in large cities is largely derived from vehicular and industrial emissions, burning of solid waste, brick kilns and natural dusts. A recently conducted ambient air quality study examined pollution levels in traffic congested areas in Islamabad, Karachi and Rawalpindi; the study revealed that the average suspended particulate matter in our cities is 6.4 times higher than WHO guidelines and 3.8 times higher than Japanese guidelines. This raises serious concerns relating to the risks that such pollution levels pose to the health status of populations. A number of factors can be held accountable for this, foremost among them being increased traffic load, bad road conditions, unpaved roadsides and other natural and mobile sources. The number of vehicles in Pakistan has increased from 0.8 million to about 4.0 million within 20 years, showing an overall increase of 388% with an annual compound growth per annum of 12%. Over the last two decades, maximum growth has been seen in two-stroke vehicles, which are known to be the major source of particulate matter because of the use of inferior quality
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Public health strategies must be instituted to reduce outdoor and indoor air pollution levels
lubricants.198 Diesel vehicles emit excessive graphitic carbon (visible smoke) due to several factors. High content of lead in gasoline further contributes to this. Moreover, industries such as cement factories, fertiliser plants, stone crushers and primitive brick kilns that are not sensitive to anti-pollution technology are further contributing to this trend. Several public health strategies can be instituted to reduce outdoor and indoor air pollution levels. These include reducing emissions from industrial and other sites with potential to pollute the environment, conversion of vehicles to Compressed Natural Gas (CNG), avoidance of vehicle overloading, use of better quality lubricating oils, and other measures to care for the environment. Recently, as part of a pilot activity, rickshaws have been converted to CNG this programme has implications for reducing the emissions of particulate matter. The public health potential of other such interventions needs to be determined. In particular, research must be conducted to quantify the magnitude and determinants of diseases attributable to indoor air pollution in the rural areas. Appropriate public health strategies should be designed to reduce risks in such settings. The broader contextual framework of environmental protection relating to this has been discussed in Section 7. Since asthma has a low fatality rate, it draws less attention than other respiratory conditions even though it affects about 150 million people worldwide. Studies undertaken in Pakistan over the last decades provide growing evidence of an increase in atopic diseases and sensitization to common allergens. For asthma, primary prevention implies prevention of sensitization to factors that might subsequently induce disease; this has been discussed in the section on pollution. In case of occupational asthma, early detection is essential to prevent further progression and to ensure costeffective management.
6.4 Chronic Respiratory Conditions - Action Agenda ? Partner with global efforts to assist with the development of globally acceptable criteria for the diagnosis of CRDs and inexpensive methodologies to monitor CRDs, suitable for use in the developing countries. Integrate surveillance of CRDs, with a population-based NCD surveillance system when feasible. ? Integrate prevention of CRDs with a comprehensive NCD prevention and control framework. ? Examine trends in outdoor air pollution levels and examine their determinants in order to develop appropriate public health interventions. ? Conduct research to quantify the magnitude and determinants of chronic lung diseases attributable to indoor air pollution both in the rural and urban areas. Appropriate public health strategies should be designed to reduce risks in such settings. ? Integrate guidance CRD prevention and control into health services as part of a comprehensive and sustainable, scientifically valid, culturally appropriate and resource-sensitive CME programme for all categories of healthcare providers. ? Refer to Action Agenda in Sections 3, 5, 7.
Priority Action Areas Priorities within other Action Areas will be determined subsequently
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7
Cancer
7.1 Context
Commonest cancer sites amongst males in Pakistan: lungs, oral cavity and larynx
Cancer is a significant contributor to the global disease burden. This burden is estimated to increase from the currently reported 10 million new cases each year to 15 million by the year 2020; more than 60% of the new cancer cases will occur in the less developed parts of the world. Presently, cancer is known to be the second most common cause of death in the developed countries, and evidence points to the emergence of a similar trend in the developing countries.202 Pre-empting cancer is a major challenge. Experts drawn from all over Pakistan convened at Karachi in 1990, with support from the WHO headquarter, to develop recommendations addressing a range of dimensions relating to cancer prevention and control in Pakistan.203 However, as cancer prevention did not feature as a priority area within the health sector, the recommendations could not be followed through. Scientific evidence shows that at least one-third of the annually occurring cancers can be prevented and another one-third diagnosed early or downstaged at diagnosis. This can lead to significant reductions in cancer-related mortality.202 It is, therefore, imperative to invest in public health approaches that focus on minimizing exposure to the risks of cancer and step up early detection. Both these approaches are a critical component of a cancer prevention and control programme and are addressed as part of this Action Plan. Other dimensions encompassing pain relief, palliative care and treatment also known to be cost-effective should also be included in a cancer control programme; however, these are outside the scope of this initiative. There are several gaps in evidence relating to valid and locally applicable strategies for preventing common cancers in the Pakistani setting; there is a need to bridge these gaps by structuring appropriate studies; however, this is likely to have time implications. In view of this, the Action Plan acknowledges that adequate treatment facilities and access thereto are urgently needed to cope with the growing number of cancer patients. The Action Plan also recognizes that pain relief and palliative care are costeffective and need to be prioritized alongside prevention and control efforts. This is particularly important as stimulating early detection in a previously unscreened population will uncover many cases of advanced cancer.
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Commonest cancer sites amongst females in Pakistan: breast, oral cavity and gall bladder
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Institutional studies carried out at the Pakistan Institute of Medical Sciences (PIMS) reported similar results.207 The relative frequency of leukaemia was the highest, followed by central nervous system tumours (CNS) and lymphomas. A pathology-based study carried out at AKUH showed that within solid tumours, lymphoma was the commonest, followed by CNS tumours and osteosarcoma.208 Studies have also reported retinoblastoma as the commonest tumour followed by lymphoma and leukaemia.209,210
It is conventional to set up cancer registries for continuous monitoring of cancers or cancer surveillance. The next section deals with the situation as it relates to cancer registration and surveillance in Pakistan, the strengths and gaps of what exists on ground and the suggested course of action to bridge these gaps. This section also deals with a variety of generic issues that relate to cancer registration and their implications in the native Pakistani setting.
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as the major barrier to such efforts in Pakistan. The overall relevance of the concept of registries in the contextual framework of being necessary for evidence generation is often ignored. Additionally, duplication of effort, lack of consolidation and the absence of a central mechanism to utilize evidence generated for policy building are other barriers. For Pakistan, it is advisable to have cancer registries that centre on specific populations representative of different cultural and ethnic groups. In addition, global validity parameters relating to comparability and quality control on cancer registration necessitate that cancer registries in a country should conform to CI 5 standards and that registries within countries should be registered with IARC. In Pakistan, the only registry that conforms to CI 5 standards is the Karachi South Cancer Registry. Though there may be issues relating to generalizability of data as the sampled population is culturally and ethnically distinct, there is a general agreement that the data outputs of the registry and IARC projections for Pakistan are valid to plan interventions at the national level at this point in time. 213 There is unanimous agreement that the top ten and the top four cancers in Pakistan would remain the same even if the hierarchical pattern changes, irrespective of the area where trends have been studied. The notable exception to this is the increase in incidence of oesophageal cancers in the west of NWFP and Balochistan along a belt that stretches from Iran, across areas all along to the Caspian Sea. Predispositions to this trend need to be determined. Notwithstanding that the Karachi South data may be sufficient to plan public health interventions at this point in time, 214 every effort should be made to consolidate and bring other regional registries to internationally acceptable standards. However, caution needs to be exercised as stimulating too many registries is neither feasible nor essential. It is better, by far, to have just a few that are good and conform to international standards than many that are not and better to extrapolate to comparable populations from a good registry than to draw inferences from a poor one on site. A review of the prevailing situation is useful in this regard. The Karachi South Registry has been extended to cover the Karachi Division. A Quetta Tumour Registry has been developed in collaboration with the Pathology Department of the Aga Khan University. In addition, the Armed Forces Registry based at the Armed Forces Institute of Pathology in Rawalpindi also has the same status. All these registries competing for CI 5 statuses already cover more than 70% of the respective catchment areas; the remaining sources of data are being tapped in order to acquire the 95-98% completion criteria required by IARC. Therefore, as part of the first phase of up-gradation and consolidation of cancer registration in Pakistan, resource allocation should be prioritized and ensured on an ongoing basis in order to facilitate continuous monitoring of cancers. In the next phase, registries could also be established in areas that centre on other representative populations. There could be several criteria for choosing other sites for developing registries in Pakistan. The availability of a large service dedicated to oncology is conventionally thought of as being a focal point where the necessary expertise and resources are generally available to
It is better to extrapolate to comparable populations from a good registry than to draw inferences from a poor one on site
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support a registry. Also key to the development of a registry is the availability of the capacity to characterize cancers, reflective in the availability of a well functioning and standardized laboratory; without this facility, it may be impossible to ensure quality and comparability of data. Ideally, within the geographical context of Pakistan, it is also necessary to develop at least one registry in every province so that local data could help provincial planners allocate resources within the province. This aspect is of special relevance in Pakistan, given that health is a provincial subject in the country. In view of the above-mentioned criteria, it is advisable to support efforts so that registries can be built on a few more representative populations. Within the framework, it is advisable to set up a registry in Peshawar; this effort is also warranted in view of the differing patterns in the prevalence of oesophageal cancers which are seen in the band of area to which NWFP belongs. Existing efforts at the Institute of Radiotherapy and Nuclear Medicine (IRNUM), therefore, need to be re-channelled towards developing a population-based registry. In addition, a population based registry needs to be set up in Lahore. Efforts in Lahore have paved the way for building a broad-based coalition led by experts at the Shaukat Khanum Memorial Cancer Hospital; this coalition is geared to developing a Lahore-based population registry for which the preliminary work, in terms of planning meetings, has already been completed. In addition, a consensus has been achieved around a position paper and a site visit conducted by nominated representatives of IARC. Every effort should be made to support these initiatives ensuring that these have institutional protective mechanisms to make them viable and sustainable over the long term. Existing and future efforts focused on establishing pathology- and oncologybased tumour registries should be aimed at eventually linking with, contributing to, or developing into population-based tumour registries. For example, the oncology-based registry currently being developed at PIMS, Islamabad should be structured in a manner, that would enable it to mature into a population-based registry for Islamabad; the alternative is to have it serve as a data collecting point for the long standing pathology-based registry at AFIP, Rawalpindi, which serves the same population and can more easily be developed into a population-based registry. The Karachi Cancer Registry, which has attained IARC Certification and is currently involved in capacity-building of many other registries in Pakistan, could serve as an official resource site for the development and strengthening of other cancer registries in Pakistan. This effort could be supported through WHO funding and other sources. There are several technical and ethical issues with cancer registration, especially with newly-evolving registries. Ethical issues relate to confidentiality and intellectual ownership of data, particularly in the case of sharing of hospital data with population registries, whereas technical issues centre on standardization and the capacity to characterize cancers in relation to uniformity in coding, staging and grading. It is proposed that a multidisciplinary task force be constituted to serve as an advisory and supervisory body to develop and implement guidelines relating to these matters. The WHO Cancer Coordinator for Pakistan has recently developed
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Preventive strategies and early detection are shown to reduce cancer mortality
the National Cancer Control Council. The Councils mandate is to facilitate the inclusion of all stakeholders in a consultative process, facilitate the development of consensus on technical matters and to uphold ethical values. It is proposed that both the mandate and representation of this Council be broadened. This Council should be entrusted with the task of upholding principles and ethics and providing guidelines on matters related to confidentiality and intellectual ownership. It should be structured to facilitate broad-based dialogue on technical matters related to quality control and standardization within the framework of cancer registration by entrusting this function to sub-committees. A set of transparent criteria should guide inclusion of stakeholders in this council; it should be mandatory for all data sources to be represented. Council members should be selected on merit, based on their previous contribution to the science of cancer prevention and control.
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Moreover, several weaknesses are inherent to the planning process within the domain of cancer prevention and control in Pakistan.
Table 7.1 Strategies for the eight most common cancers in Karachi females
Tumour ? ASIRs Frequency % 34.6 17.4 4.1 3.7 4.2 3.5 2.6 2.6 72.7 Primary prevention + ++ + + + + ++ ++ Early diagnosis ++ + ++ + ++ ++ Curative therapy ++ ++ ++ ++ ++ ++ Pain relief/ palliative care ++ ++ ++ ++ ++ ++ ++ ++
Breast? Mouth/pharynx? Cervix? Oesophagus Ovary Lymphoma Gall Bladder Skin? Total
? Listed in order of the eight most common tumours globally ? Curative for the majority of cases provided they are detected early + + effective; + partially effective; - not effective
There is an explicit understanding that clear benefits exist with implementing a cancer prevention and control strategy, regardless of the fiscal situation of the country since evidence-based guidelines exist to ensure the most efficient use of existing resources. Specific Action Agenda items on cancer prevention and control as part of this Action Plan have, therefore, evolved in the light of this evidence. Within this framework, prevention and control of cancers in Pakistan will be discussed under two broad categories mitigating exposure to risk and early detection or screening as they relate to individual cancers.
Table 7.2 Strategies for the eight most common cancers in Karachi males
Tumour ? ASIRs Frequency % 17.4 11.7 6.1 4.8 4.1 7.0 4.4 3.7 59.2 Primary prevention ++ ++ ++ ++ + + + + Early diagnosis + + + + + Curative therapy ++ ++ ++ ++ ++ + Pain relief /palliative care ++ ++ ++ ++ ++ ++ ++ ++
Mouth/pharynx? Lung Larynx Urinary bladder? Prostate Lymphoma Colon/rectum? Oesophagus Total
? Listed in order of the eight most common tumours globally ? Curative for the majority of cases provided they are detected early + + effective; + partially effective; - not effective
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The following section deals with cancers that are preventable by way of minimizing exposure to risks such as in the case of tobacco and areca nutrelated cancers, whereas the subsequent section deals with cancers where the potential for prevention exists through early detection as in the case of breast and cervical cancers. In the former case, the emphasis will be on risk reduction whereas in the latter, early detection strategies will be discussed in the context of individual cancers. However, in many cancers a combination of both these approaches is relevant.
Cancers
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Carcinogenic agents are used as part of the manufacturing process in several sites in Pakistan
Awareness needs to be created about risks to cancer in general. However there are presently no comprehensive health education initiatives focused on cancer prevention and control. The only effort at the national level has involved a mini electronic media intervention by the National Programme for Family Planning and Primary Health Care/Health Education Department involving 100 television spots aired for a duration of 52 seconds at a time, in the last five years.220 These television spots drew public attention to the early warning signs of cancer. However, this is not a sustainable activity as prevention of cancers is presently not part of the programmes mandate. Cancer associations and societies have also been involved in ad hoc efforts to develop patient information materials in selected hospitals; these efforts remain isolated without recognizable impact. It is, therefore, important that a comprehensive health education programme addressing lifestyle and environmental risks to cancer be developed. Cancer prevention must be integrated with the NCD behavioural change communication strategy. Healthcare providers at all levels need to be trained to reinforce health education messages and to play a role in creating awareness about early
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Poverty, ignorance, unemployment and the consequent desperation for a livelihood are issues that often overshadow concerns for safety in an occupational environment
cancer detection. Prevention and control of cancers should, therefore, be a part of the NCD training package referred to in Section 2.
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NEQS are reflective of international best practices and are applicable to municipal and industrial effluents, industrial gaseous emissions, motor vehicle exhausts treatment systems in industry and ambient air concentrations of various substances in the work environment. Alongside, the National Environmental Action Plan (NEAP) was approved in 2001, and subsequently, a support programme (NEAP-SP) was initiated by UNDP. Despite this elaborate chronology of events that paved the way for a seemingly sound environment for occupational health, neither have the NEQS been enforced in industrial settings, nor have any attempts been made to upgrade standards in this regard. As stipulated in the NEQS, industries are required to monitor their own gaseous and effluent discharge and report them to the Ministry of Environment as part of the Self-Monitoring and Reporting Programme (SMARP). Based on the industries self-assessment of their own effluent discharge, an Environmental Pollution Charge is meant to be levied on violators; this needs to be verified once a year by an inspection team from the Ministry of Environment. The strategy was devised in view of the limited resources at the disposal of the Ministry of Environment to monitor these units on a regular basis. However, the strategy was largely unsuccessful as only a few out of the 50,000 operating units within the country have been reporting their effluent discharge voluntarily, albeit on an irregular basis.221 The Ministry of Environment does, from time to time, collect samples for analysis from different sites; however, there are issues and limitations with its ability to analyze these samples with only one operating laboratory in Islamabad and another in Lahore. Clearly, this implies that the NEQS will have to be revised to redefine the role of independent and transparent thirdparty monitoring of effluent discharge. It is also important to invest in infrastructure facilities that are capable of specialized analysis necessary for such monitoring efforts. There are also ethical issues around the Environmental Pollution Charge which is levied on industries as part of the stipulations of PEPA. As part of this, industries that are known to release excess pollutants are required to pay additional charges. There are several issues with this strategy, firstly, selfmonitoring brings in an unacceptable level of bias; secondly, industries are free to pass on the burden of the added cost to the consumer, most importantly, this is aimed at minimizing effluents this is in clear violation of public health principles, which warrant that exposure to such effluents be contained. There is, therefore, a clear obligation on part of the Ministry of Environment to assume charge for enforcing NEQS in industrial settings; this will also provide an opportunity to assess risks to workers and to deliberate on measures to mitigate them. 7.4.3.b Containing risk to workers: several issues need to be addressed in order to contain exposure to carcinogenic agents in the workplace. The initial step is quantification of the magnitude of the issue. There are no data on the incidence of cancer in a defined workforce at higher risk of exposure to carcinogenic agents within an industrial setting. Such data can be available at no additional cost. A review of the Social Security System in Pakistan (discussed in Section 8) has shown that detailed records of all the workers
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secured under the scheme are available; these data can be analyzed to extrapolate cancer trends in high-risk populations. In addition, there is a need to establish causal associations of risk factors with cancers in a native Pakistani worksite setting so that precise targets for preventive interventions can be established with certainty. In this regard, case-control studies are of particular value in occupational settings and are also known to be costeffective. Another important aspect of work safety involves educating workers to take appropriate protective measures. These must be instituted in tandem with regulatory measures as regulation works better when combined with information dissemination, education and communication. During a visit to a factory where asbestos was in use, it was observed that most workers were not aware of the inhalation-related aspects of risk; masks were also not made available to them. Moreover, there has been no assessment of knowledge and attitudes of workers in a high-exposure setting, which would have implications for designing and enforcing relevant protective measures. There are several fundamental issues that will continue to undermine any efforts in this direction. Poverty, ignorance, unemployment and the consequent desperation for a livelihood are issues that often overshadow concerns for safety in an occupational environment. Currently, Pakistans labour laws outline the need for every worker to be protected from harmful substances in a work setting and imply that it is the liability of the employer to ensure this; however, there are several issues in enforcing the law. Stricter legislative measure will have to be adopted and enforced through transparent regulatory mechanisms in order to address these issues. Several gaps have been identified in chemical handling in industrial sites. Material Safety Data Sheets (MSDS) are usually not distributed with chemical containers in Pakistan. These are chemical information sheets intended for display on all chemical containers and boxes; they provide information about the health and safety effects of a chemical and outline safety precautions for its safe usage and storage. These sheets also include information on first-aid measures that need to be taken in case of accidental exposure. The supplier has a legal obligation to provide the client with this information once a purchasing decision has been made. It is mandatory for the facility owner/operator to ensure that all employees are familiarized with and have access to them. Failure to distribute MSDS reflects a lack of compliance with stipulated regulations and is in violation of prescribed rules. Clearly, there is a need to analyze why this has been the norm and what can be done to upgrade practices in this regard. The Lahore-based Centre for Improvement of Working Conditions and Environment has recently been involved with creating awareness about chemical safety; 222 they have also been involved with translating MSDS into Urdu. However, this is a provincial structure with limited outreach. It is essential for the Ministry of Environment to explore the feasibility of building partnerships and further strengthening such structures to achieve mutually compatible goals. It should be made mandatory for all containers that contain dangerous chemicals to be labelled properly and to be safely stowed. Individuals handling these chemicals should wear personal protective gear. In addition,
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there should be regular monitoring of those likely to be exposed. Monitoring air quality can help in alerting employees, thus preventing the inhalation of hazardous chemicals
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mammography units and the staffing implications, when compared with other urgent needs relating to the prevention and control of NCDs, indicate that this will not be a likely possibility within the foreseeable future. If Pakistans health sector ever evolves into a high resource situation, the feasibility of this ideal approach could then be evaluated. However, awareness needs to be created to ensure that the high-risk group inclusive of those with a personal or a family history of breast cancer, post-menopausal diffuse, nodular density on mammography, previous atypical ductal or lobular hyperplasia and a personal history of previous high dose chest radiation are screened on a regular basis by mammography, as recommended. The behavioural change communication strategy needs to focus on creating awareness about breast self-examination. Although evidence does not exist for survival advantage with breast self-examination, it is, nevertheless, the most cost-effective measure in terms of down-staging breast cancers at diagnosis.223,224 This approach should, therefore, be actively advocated through the media and in other appropriate settings. In addition, guidance must be provided to all categories of healthcare providers through the NCD training packages referred to in Section 2. The Pakistan National Cancer Control Project initiated by the WHO focal person on cancer, has outlined a series of guidelines for breast cancer screening.225 However, these guidelines need to be revisited in light of the consensus summarized in the above section. In addition, the age limit for screening defined in these guidelines will have to be redefined in view of evidence that shows an early age of onset of breast cancer in Pakistan. In addition, research is warranted to identify factors that lead to onset of breast cancer at a younger age. 7.4.4.b Cervical cancers: according to the recommendations of WHOs National Cancer Control Programme, Pakistan categorizes more closely with the low level of resources situation: scenario A with regard to cervical cancers. Population screening for cervical cancers is, therefore, not recommended in our setting. In addition, our Muslim faith abhors practices that are contributory to the risk of cervical cancer. The standard of care on cervical cancer screening demands that all sexually active women in a population be screened for cervical cancer, ideally by annual PAP smears. The National Cancer Control Project in Pakistan has issued guidelines on cancer screening for the general population. These recommend annual screening for all married women and women above the age of 25 by visual inspection of the cervix if facilities for a PAP smear are available and PAP smears every three years thereafter. The recommendations outline that if three consecutive PAP smears are normal, screening can be done after every five years. Whereas these recommendations are technically sound, there are issues with their application in our setting. Firstly, the recommendation of examining every female over the age of 25 is impractical and unnecessary in our culture. Secondly, only a minority of the public and private sector facilities offer PAP smear on a regular basis and we have no data to report on physician practices. Furthermore, although healthcare facilities in Pakistan are generally equipped with microscopes, it has been observed that only a few of these are in functional order. There are only a
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In Pakistan, there are an estimated 30,000 new cases of head and neck tumours annually
handful of trained cytotechnologists and a few pathologists with training in cytopathology in this country. Consequently, Pakistan neither has the resources nor the capacity within the health system to organize and sustain a screening programme of this nature. PAP smears are, therefore, relevant to tertiary care and selected secondary care settings where the necessary infrastructure and expertise is available to perform these. Within these settings, efforts should be made to create awareness among practicing physicians, particularly among gynecologists, to utilize every relevant opportunity to perform PAP smears on females. Visual examination per speculum could be more widely applicable compared with PAP smears. A number of studies from India, where carcinoma of the cervix is much more common, have reported that naked eye observation and iodine painting, as a first step towards picking out potential cases of carcinoma cervix, is cost-effective. A recent study from Bangladesh has shown that in cases identified by naked eye examination, an additional test of antibodies against HPV16/18 could identify cancer cases. However, given that 80% of the deliveries are conducted at home by Traditional Birth Attendants (TBAs), the application of this approach is also limited. However, gynaecologists, female doctors and paramedical staff coming in contact with women of childbearing age could be targeted to step up practices relating to visual inspection the cervix as part of the pelvic examination in general and antenatal examination in particular. Before one can assess the case for or against cervical cancer, an effort should be made to generate epidemiological data on the subject. Screening of lower risk women at excessively high frequencies must be avoided at all costs. The challenge is to identify high-risk populations. The high-risk group for cervical cancer may not necessarily be the same as in western settings, given the cultural and religious differences and, therefore, needs to be defined in the Pakistani context. This will allow early detection efforts in the future to be targeted more specifically to those at high risk of developing cervical cancer. It is more realistic and effective to screen high-risk women once or twice during their lifetime using a high sensitivity test with an emphasis on high coverage of the targeted population.226 7.4.4.c Cancer of the colo-rectum: an estimated 8,400 new cases of colorectal cancer are diagnosed on an annual basis in Pakistan.205 The standard of care relating to colorectal cancer screening demands that population screening should begin at the age of 50 and should be conducted annually by digital rectal examination and faecal occult blood screening; flexible sigmoidoscopy is recommended at five-yearly intervals. However, in our setting, there are issues with all the above-mentioned approaches as it has implications for the availability of equipment, infrastructure and trained personnel. In Pakistan, there are approximately 50 gastroenterology units with expertise to perform sigmoidoscopy. Even digital rectal examination cannot be routinely advocated for all individuals over the age of 50 as healthcare providers have limited capacity to perform and interpret the result; in addition, there are cultural issues relating to awareness about the need to perform it. Moreover, the heavy turnover in clinics and the lack of privacy to perform such a test makes it impractical.
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The public health response to screening of colorectal cancer in the foreseeable future will have to rest with early detection through symptom recognition. However, as in the former two cases, efforts should be made to create awareness among healthcare providers about the need to include this as a standard practice wherever resources, environment and expertise permit. 7.4.4.d Head and neck tumours: in Pakistan, there are an estimated 30,000 new cases of head and neck tumours annually.205 The standard of care demands that healthcare providers should take every opportunity to examine for cancers which may be apparent in these areas, particularly in high-risk cases. In addition, individuals should be taught to seek help for any suspicious lesions, especially in the mouth. This approach should target highrisk cases, inclusive of those that chew tobacco. The preventive approach to tobacco use advocates for complete tobacco cessation; however, for those who continue to use tobacco, self-examination for suspicious lesions is crucial. 7.4.4.e Prostate cancer: there are an estimated 11,000 new cases of prostrate cancer every year in Pakistan.205 The standard of care in the developed world demands that screening for prostate cancer should be carried out on an annual basis through digital rectal examination in all men above the age of 50 years.227 However, due to issues that have been discussed in the section on colorectal cancer, this is not a feasible approach. In the USA, it is standard practice to perform PSA on an annual basis; PSA screening, however, has not shown to have any survival benefit. Population-wide screening for prostate cancer is, therefore, not recommended. Identification of the high-risk group helps to screen those in whom the chances of developing prostate cancer are highest. The risk of prostate cancer is known to increase after the age of 65 years in those with a family history and among those having an environmental or occupational exposure to cadmium. High-risk screening should, therefore, be focused in these groups. Priming general surgeons and urologists to this approach is the key to stepping up high-risk screening for prostate cancer through digital rectal examinations and histological screening of prostates removed. It is important to develop targeted messages for this purpose. 7.4.4.f Hepatoma: the preventable risks to hepatoma are alcohol and hepatitis B infection. The prevention and control aspects of hepatoma arising as a result of hepatitis B infection are of a cross-cutting nature and can be divided into two broad categories; prevention of hepatitis B infection and prevention of occurrence of hepatoma once hepatitis B is established. The Ministry of Health has recently included hepatitis B vaccination in the Expanded Programme for Immunization (EPI). To meet the increasing demands for the vaccine, local production has been licensed, which is likely to impact retail price favourably. Active collaboration and ethical linkages with stakeholders, such as those with Safe Injection Global Network (SIGN) can enable the stepping up of health education efforts in this connection. 228 A routine effective screening test for hepatocellular cancer has not yet been developed. 229 However, once hepatitis B is established, the patient is at higher risk of developing hepatoma, which rises further with the onset of cirrhosis. Once cirrhosis is established, regular screening by ultrasound is
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recommended since that will enable early diagnosis of hepatoma. When alpha fetoprotein increases, there is no survival benefit in interventions and, therefore, this has not been recommended as a screening modality. 7.4.4.g Gall bladder: the south Asian population is more susceptible to gall stone formation.230 They have one of the highest rates in the world. Gall stones are a causal association for cancer of the gall bladder and amenable to surgical intervention. It may, therefore, be worthwhile to explore genetic susceptibility through appropriately structured studies. This section has reviewed current epidemiological data on cancer and the existing on ground programmes relating to their prevention, control and health promotion outlining their strengths and weaknesses. Based on this information, a strategy has been devised to guide future efforts aimed at cancer prevention and control in Pakistan. The Action Agenda items as part of this strategy have been listed below. However, as part of the Integrated Framework for Action, cancers have been grouped alongside other NCDs in an integrated model which combines a range of interventions and actions across other NCD domains. 7.5 Cancer - Action Agenda
? ? ? ? ? ? ? ? ? ? ? ?
Provide sustainable institutional support for mature cancer registries as a priority to facilitate continuous monitoring of cancers; extrapolate to comparable populations. Establish cancer registries in areas that centre on representative population. Preventions of cancers and early detection should feature prominently on the comprehensive NCD behavioural communication strategy. Establish a national Cancer Control Council which should be given the mandate of upholding ethics and principles and guidelines on technical matters. Conduct studies to bridge gaps in evidence relating to appropriate and cost-effective strategies for preventing common cancers. Institute proactive measures to contain potential risks to cancers in industrial settings. Ensure transparent enforcement of National Environmental Quality Standards in industrial settings. Identify causal associations of risk factors with cancers in the native Pakistani worksite setting to enable the delineation of precise targets for preventive interventions. Invest in educating healthcare providers in worksites to observe safety standards. Build capacity of health systems in support of cancer prevention and control. Integrate public health programme monitoring and evaluation with NCD surveillance. Prioritize pain relief and palliative care alongside prevention and control efforts. Integrate guidance on preventing cancers and early detection into health services as part of as part of a comprehensive and sustainable, scientifically valid, culturally appropriate and resourcesensitive CME program for all categories of healthcare providers. Build a coalition or network of organizations at the national, provincial and local levels facilitated by federal and provincial health services to add momentum to cancer prevention and control as part of a comprehensive effort for the prevention of NCDs.
Priority Action Areas Priorities within other Action Areas will be determined subsequently
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8
Injuries
8.1 Context
The prevention and control of injuries was recognized as an area for investment in the 1997 Health Policy of Pakistan and the 9th Five-Year Plan; however, this policy commitment could not be translated into a concerted public health course of action. Ironically, injury prevention and control has been omitted entirely from within the framework of the current Health Policy of Pakistan 2001. Injuries result in major economic loss to nations while inflicting a tremendous personal burden on the victims and their families.231,232 About five million people are estimated to have died of injuries in the year 1990, accounting for 9% of the global deaths; more than 90% of these occurred in low- and middle-income countries.4 It is projected that motor vehicle crashes (road accidents) will be ranked third worldwide and second in the developing countries in order of disease burden in the year 2020 compared with their present ranking at number nine. A recent World Bank report identified south Asia as the region with the greatest projected increase in road traffic injuries over the next 20 years.233 The study predicts that it will take about 40 years before a decline in road injuries is expected in the region unless steps are taken now to improve road safety. Injuries have traditionally been regarded as random, unavoidable accidents; however, with improved understanding of the underlying reasons and nature of injuries, we now know that injuries, like other diseases, tend to affect identifiable high-risk groups and follow a predictable chain of events. Interventions among high-risk groups can, therefore, prevent injuries. Experiences in high-income countries attest to this fact. For example, in USA, injury prevention strategies account for two of the 10 most successful public health interventions of the last century. Seatbelt use alone has saved more than 147,000 lives in that country from 1975-2001.234 In injury literature, therefore, the use of the word accident is discouraged.235 For the purpose of this document, therefore, the expression road traffic crash (RTC) will be used for what is generally referred to as a road traffic accident. In cases where prevention fails, mortality and morbidity can be minimized by providing optimal acute care and rehabilitation.
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About 25% of the emergency room visits in hospitals are related to injuries
describe the behavioural determinants of road traffic injuries. However, indepth prevention-friendly data are still hard to find and intervention trials for injury prevention are non-existent. A literature review carried out in the late 90s reviewed the types of injuries occurring in Pakistan. The study reported that motor vehicle injuries, homicides, assaults, work-related injuries, poisonings and firearm injuries were the predominant forms of injuries occurring in the country.236 In addition, the study reported lack of reliable data and under-reporting of workrelated injuries and suggested that Pakistan must institute an information system to monitor trends in injuries, evaluate their true impact and develop national safety standards. The National Injury Survey of Pakistan was conducted in 1997.237 This was a retrospective survey based on self-reporting of injuries among a representative sample of 1539 households; the survey described injuries in terms of morbidity, mortality and disability. The incidence of serious injuries was reported at 41.2 per 1000 persons per year.238 Transport-related injuries were the most common cause (36%), followed by exposure to inanimate mechanical forces (28%), falls (23%), intentional self-harm, interpersonal violence, injuries due to smoke inhalation, burns, exposure to electrical current, extreme ambient temperature and radiations as well as envenomation and injuries to patients due to medical/surgical errors. Exposure to inanimate mechanical forces was caused by agricultural machinery, non-powered hand tools and injuries as a result of situations in which a body part was caught, crushed or pinched between objects. Thirty six percent of the total injuries were sustained on roads and on roadsides, 34% had occurred at home, 7.3% at farming sites, 5% in playgrounds, 2.3% in schools, 4.7% at worksites, 4% in offices or shops and 6.7% in other places.
In another population-based study carried out in the rural Northern Areas of Pakistan,239 falls, burns and RTCs were identified as the commonest causes of injuries; burns being the most common injury among women and in children less than five years of age. The incidence of morbidity and mortality due to injuries in that population was 1531 and 59 per 100,000 persons per year, respectively. A retrospective study (based on verbal autopsy) conducted to assess cause-specific mortality rate among the urban poor of Karachi identified injuries as a cause of death in 15% of the patients. Of note, road traffic injuries were the third most common cause of death among men (after
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circulatory disorders and TB) while burns were the fourth leading cause of death among women (after circulatory disorders, maternal causes and tuberculosis).240,241 Another study based on ambulance data in Karachi defined the epidemiology of violent/intentional injuries in Karachi. According to the study, the ambulance service transported 4091 intentionally injured persons during the 29-month period from October 1993 to January 1996. Ninety-five percent were males; 74% were 20 to 40 years of age 58% died before reaching the hospital. Firearms were the most common mode of injury (83%).242 A study looking at causes of childhood injuries (age = 15 years) identified motor vehicle crashes as the most common cause of injuries (80%), followed by falls (5%), burns (5%) and drowning (3%). A significant number of injured children (15%) died either at the scene of the accident or during transportation to the hospital. Large vehicles (buses, minibuses and trucks) were involved in 54% of these childhood road traffic injuries. Almost onethird (33%) of the burns took place in the kitchen at home, and half (51%) of all drowning cases occurred in the sea. The study concluded that a majority of the children transported by ambulance service were pedestrian victims of RTCs. Prevention efforts aimed at stricter enforcement of driving laws and family/child education geared towards pedestrian safety could potentially reduce morbidity and mortality. 243 Pedestrian behaviours with respect to RTCs have been studied in the city of Karachi.244 The investigators selected 10 of Karachis highest-risk locations for pedestrian RTCs and observed 250 pedestrians for each of three activities crossing the street, walking on the street, and walking on the sidewalk. They concluded that pedestrians in Karachi take identifiable risks while crossing a road/street. Some of these behaviours are compounded by encroachments on streets and sidewalks. Large commercial vehicles account for a disproportionate number of road traffic accident fatalities in Karachi. A study done in Karachi evaluated the potentially dangerous bus driving and commuting practices that increase the risk of road accidents and the effect of traffic police on such practices. 245 The study showed that of the disembarking passengers, a third did not wait for the bus to stop, more than half stepped off in the centre of the road and 84% did not look out for traffic. Among the embarking commuters, more than a third got on moving buses, while two-thirds climbed on buses packed to their outer foot boards. At the bus stops, 30% of the buses did not stop completely, 46% stopped away from the stop and 79% stopped in the centre of the road. Where traffic police were present, buses were more likely to race and to cut off other vehicles than where police were absent. The study concluded that risky behaviour is common among both Karachi bus drivers and bus commuters and that traditional efforts to regulate bus traffic through traffic police are ineffective. Facility-based studies conducted in Pakistan have also shown that about 25% of the emergency room visits in hospitals are related to injuries, whereas onethird of the surgical beds and almost 50% of the neurosurgical beds in tertiary care facilities are occupied by patients who have sustained injuries.246
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In the year 1999, there were around 1.4 million road traffic crashes in Pakistan; of these, 7000 resulted in fatalities
These studies present a convincing argument in favour of making injury prevention and treatment a public health priority. In this regard, many interventions are available and easy to implement. For others, there is a need to know more. In addition, more in-depth studies need to be done in the area of establishing the intent of an injury event. None of the studies carried out thus far, including the National Injury Survey, has evaluated this perspective. Many injuries, especially those caused by falls, firearms, electrocution and burns could well be an act of violence and, therefore, basing public health interventions on the assumption that these events are invariably unintentional will not address the key causal factors that are, nevertheless, amenable to preventive interventions. Injury surveillance is a key component of an injury prevention programme. Surveillance of injuries must be integrated with a comprehensive populationbased NCD surveillance system. Population data can be supplemented by multiple data sources (facility-based data, reliable police and newspaper reports and data from other appropriate sources). The following section deals with a review of the situation as it relates to injury prevention and control in Pakistan with a view to identifying gaps that have implications for public health interventions; within this framework, injuries have been classified into RTCs, occupational injuries, falls and interpersonal violence. The discussion on RTCs is relatively more detailed as they are the main contributor to the burden of injuries in addition to being relatively better studied in this grouping.
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of deaths in road crashes per 100,000 persons, in a specific time period. Between 1956 and 1997, this had increased five-fold. The Road Traffic Injury Study showed that the police under-report 18% of the road traffic fatalities and 72% of the road traffic injuries. This implies that police data collection needs to be improved and strengthened by verification through other supplementary sources of information. The National Transport Research Centre has been involved in several research studies over the last decade in an attempt to illustrate the overall burden of RTCs in Pakistan and to identify potential causes of such crashes. Research in collaboration with Finnroad OY, xvi Finland, has also recognized that estimation of RTCs based on police records is likely to be an underestimation because of inherent systems and practices within the police reporting system that lead to under-reporting of RTCs. The police report an accident only when a fatality has occurred; this results in under-estimation of crashes. Finnroad OY reported that less than 10% of the RTCs are reported.10 This trend has been corroborated by another study done in Karachi looking at the under-reporting of severe road traffic injuries in the traffic police-based data system. Using capture recapture method, the investigators estimated that while police records identified a large number of deaths (56%), most of the severe injuries (18 out of 19) remained unaccounted for.241 This also results in an over-estimation of fatal crashes. This is evidenced by a reported fatal accident ratio of 40% for Pakistan in the same study. The National Transport Research Centre reports a fatal rate of 28% based on its independent assessments. Clearly, this trend in reporting of fatal accidents seems to be falsely high when compared with data from other parts of the world which averages around 3%.249 In view of the afore-mentioned considerations, plausible projections on the burden of RTCs in Pakistan have, therefore, been drawn from other sources. An analysis extrapolated results of several regional studies and accommodated reasonable inferences based on police records for the year 1999. These projections highlighted the magnitude of the burden of injuries for the year 1999, estimating that within that period, there were around 1.4 million RTCs in Pakistan; of these, 7000 resulted in fatalities.10 Facility-based data show that RTCs contribute significantly to workload in hospitals. Road traffic crashes are the commonest cause of head trauma. Mild, moderate and severe head injury has been observed in 52%, 30% and 18% of patients respectively, in various neurosurgical centres over a period of four years.250 Several factors contribute to the occurrence of RTCs; among these are factors relating to the user, inclusive of the driver, pedestrian and passenger; contributory causes that relate to the vehicle in terms of its design, fitness and loading and factors inherent to the road itself such as infrastructure and road furniture. Case studies carried out by NTRC provide useful insights into the dynamics of these crashes.
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Finland-based international road design and safety consultants; member of the International Road Federation.
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cities. The Pakistan State Oil (PSO) in collaboration with 3M,xvii has recently established a partnership with city municipalities of Islamabad, Lahore, and Karachi with the overall objective of improving road signage and markings. Toyota has visibly been disseminating public service messages, through newspapers, to promote seatbelt use on the roads. Every effort should be made to support such initiatives within an ethical and appropriate publicprivate partnership framework. Other private sector initiatives, such as those undertaken by Shell, are also aimed at improving road safety. They target company employees and are in compliance with the companys safety stipulations. Such methodologies structured for defined populations could be of use, once modified for a larger audience. Their potential for replication and within that framework, the role of the non-profit private sector, should be explored. Some NGOs such as the Association of Road Users of Pakistan (ARUP), the Traffic Safety Council of Pakistan and others can play a useful role in this connection. There is also a need to introduce prevention strategies into the primary and secondary school systems. These include bicycle safety, pedestrian safety and education of drivers. Road safety needs to be tabled prominently on the health education and health promotion agenda. A multi-sectoral approach through the involvement of all stakeholders can maximize the impact of this intervention.
8.3.3 Roads
A high proportion of RTCs in Pakistan occur on major intercity trunk roads. Studies conducted in Punjab have revealed that 27% of the total fatal crashes occur on N-5.xviii,255 However, there are no studies, which compare prevalence and dynamics of RTCs between cities and highways. Such information needs to be generated as it is critical to the development of preventive measures suited to each setting. Pakistans modest network of highways includes 17 major highways with a total mileage of 8845 kilometres spanning four provinces. The turnover on these highways varies; from an average of 2450 vehicles (Taxila toll data) and 12,589 (Jhelum toll data) to 36,560 vehicles (Ravi toll data). 256 Recent efforts aimed at improving the safety and administrative standards on major highways has resulted in the establishment of an efficient electronic data collection system. This database has enabled an assessment of high turnover and high-risk highways with considerable precision. 8.3.3.a Road construction and furniture: flaws with road construction, maintenance and road furniture are an important contributory factor to RTCs. The Lahore-Rawalpindi Motorway segment passing through the salt range is an example. Soon after its completion in 1997, the number of crashes on M2 in that particular segment rose dramatically owing to the sharp bends and curves and steep inclines of the Motorway as it cuts through the salt range. The speed limit in that section had to be dropped from the originally defined 100 kilometres per hour, eventually to 25 kilometres per hour before a decline in the crash rate was observed.
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International traffic signs and road marking contractors. Lahore-Peshawar Grand Trunk Road.
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Examples from two other resistant trouble spots also help to substantiate that road design has a major part to play in the dynamics of RTCs. Several traffic black spots have been identified along Pakistans highways. Two of the most notorious amongst these are the Mansoor Bend, located at a distance of 100 kilometres from Islamabad on N-5 and the Bakrala Bend situated in proximity to Gujar Khan on N-5. These black spots were accountable for a significant number of fatal accidents on corresponding highways.257 To address this issue, the National Logistics Cell (NLC),xix and the National Highway Authority (NHA) conducted a major intervention, as part of which road signage around bends was considerably improved and cats eyes, chevrons and road markings were installed. These measures decreased the incidence of RTCs; prior to this intervention, 18 fatal crashes had been reported over a one-year period (2001-2002) from Bakrala and Mansoor Bend sites. These resulted in 59 fatalities and left 93 injured at the time of the crash. Subsequent to the intervention, the number of accidents within a year (2002-2003) fell from 18 to three, whereas there were only two fatalities (inclusive of one pedestrian); eight individuals were injured as a result of these crashes.258 Every effort should be made to identify other black spots and to implement appropriate safely measures in such settings. There have also been anecdotal reports of barriers on roads causing crashes; these are usually temporarily installed by the general police force for security monitoring. However, the magnitude of this issue has not been quantified. In addition, no guidelines have been issued to the police relating to the use of this apparatus in heavy traffic turnover sites, and no safety standards stipulated, in this regard. Barriers need to be replaced by police posts in key sites; where their installation is mandatory, guidelines for safe installation should be issued. The above-mentioned discussion related principally to highways. However, within cities, the most commonly injured victims are pedestrians; in this context, the road design needs to consider two things namely, separation of pedestrians from traffic and traffic calming measures. Work done in other parts of the world has shown that designating pedestrian only areas and streets, widening of sidewalks, as well as removal of encroachments from sidewalks to facilitate walking can reduce injuries. Pedestrian training through educational sessions at schools and colleges could inculcate safe walking practices at younger age. Area-wide traffic calming measures aimed at controlling the maximum speed through frequent traffic signals, roundabouts etc., have been found to reduce the injury rates and must be promoted.
8.3.4 Vehicle
8.3.4.a Vehicle overloading: vehicles, especially heavy vehicles, are a contributing factor for RTCs in Pakistan particularly relevant to our setting is vehicle overloading and vehicle design. Both passenger and cargo load can contribute to overloading. Passenger overloading, commonly observed during rush hours, makes passengers vulnerable to being injured. The solution to this issue rests with making public transport more accessible and widely
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available. Detailed discussion on this aspect falls outside the scope of this document. Cargo overloading damages roads, making them unsafe for driving. This issue cannot be addressed in the absence of tough legislation enforced by strict and transparent regulatory mechanisms. Legislative measures within this framework have been referred to in a subsequent section. With the National Highway and Motorway Police (NH&MP) patrolling major highways, it is expected that there will be stricter enforcement of such regulations. Also crucial to this is the availability of the infrastructure necessary to weigh and measure and anticipate the loaded weight on vehicles. In Pakistan, several vehicle cargo weighing stations situated at different locations along main highways are capable of serving this purpose. A review of their locations reveals that eight,xx weighing stations are currently operational whereas another eight,xxi are expected to be operational soon. As is evident from the locations and their coverage, these stations are inadequate to cater to the needs of the heavy traffic turnover. An assessment needs to be made of the capacity of existing stations to meet the expected needs and the public health potential of up-scaling this capacity. 8.3.4.b Vehicle design: the design of the vehicle is another contributory factor to RTCs. Company-built designs are usually safe and the law protects them from being altered. The major issue in this context pertains to locally manufactured vehicles, which usually do not conform to safety standards. Manufacturing of such vehicles involves inappropriate use of cast iron with sharp contours, large hoods, bumpers and jutting projections; such features make the vehicle dangerous on impact. In addition, poor quality of cast iron used for the outer structure makes the vehicle more vulnerable to collapse on impact. Local small production units are not covered under any law such as the Factory Act of 1934 governing industrial units; they are, therefore, outside the jurisdiction of the legal framework. It is imperative, therefore, that the design of locally manufactured vehicles should be regulated by law and patented, its quality assured and passenger safety and crash prevention be paramount while deciding on these factors. It is known that the introduction of safety features in automobile design (laminated windshields, collapsible steering columns, interior padding, lap and shoulder belts, side marker lights, head restraints, leak resistant fuel system, increased side door strength, better brakes and airbags) helps reduce vehicle crash fatality rate (per kilometres travelled) by 40%. Only three of these innovations are known to have added less than $10 to the price of a car.259 The design of locally manufactured vehicles needs to be improved in order to make them safer on the roads. However, in doing so, locally tailored safety features need to be developed. Making seatbelts mandatory on all vehicles can significantly improve the safety of car passengers and must be promoted.
Noshki, Nokundi and Lakhpass (Baluchistan); Kohat Tunnel (N.W.F.P); Gaddani, Steel Mill and Sukkur Bypass (Sindh); Sangjani (Punjab) and one portable weighing station. xxi Attock Bridge, Aimenabad and Pattoki (Punjab); Rohri Bypass, Super Highway Toll Plaza, Bulhari and Ranipur (Sindh); and Kohat Tunnel (NWFP). South Portal is expected to be operational soon.
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In the urban areas, where many crashes are caused by passengers falling off from moving vehicles, injuries can be prevented by mandatory door closing policy for commercial vehicles.
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National Highway and Motorway Police (NH&MP) in February 2001. Over a period of two years starting from June 2001, NH&MP was handed over five new motorways/highways,xxiii as a result of which it now controls 25% of the motorway and highway mileage in Pakistan. The new national highway and motorway trafficking system is more organized and seems more effective compared with the previous arrangement with regular traffic police. Adequate staff is deployed to cover a smaller highway segment; these deployments are for a shorter duration and a fair incentive and reward is packaged for officers. Compared with earlier practices where one officer was deployed to take charge of an area spanning 100 kilometres with one vehicle at his disposal, working on a 12-hour shift, NH&MP deploys four motor vehicles, four police officers, one supervisor on the wheels and two motorbikes for every 40-kilometre beat in an eight-hour shift. This system is sustainable, despite the incurrence of substantial administrative costs as it uses toll collection to generate revenue. However, the impact of this intervention in terms of reduction in RTC-related mortality and morbidity has not been assessed comprehensively; this would have enabled a more tangible comparison of the costs per life saved. Such assessments in the future are likely to be complicated by the previous trend of under-reporting of RTCs. This has resulted in an apparent increase in reporting of crashes since NH&MP has taken over. However, preliminary assessments indicate that a significant decrease in the incidence of road traffic mortality and morbidity can be attributable to the institution of this system. 261 The National Highway and Motorway Police has also developed guidelines and tools to assist drivers and pedestrians. These tools are intended to provide locally relevant guidance and to increase the knowledge level of those on the road with the overall objective of improving safety on roads. However, these tools remain under-utilized. It is important to assess the acceptability and feasibility of utilizing these tools to enhance their use for creating awareness and altering behaviours. Mandatory toll collection at check-points is a useful opportunity to interface with drivers and circulate such materials and handouts. The National Highway and Motorway Police is also capable of providing emergency services at the roadside; for this purpose, they are provided with mobile first-aid kits and are trained in emergency care settings. However, there needs to be an assessment of the first-aid training given to them. Moreover, the quality of the first-aid assistance that can be provided is not efficient because of the absence of available ambulances and cranes for a given sector, which are essential for speedy evacuation of victims. In addition, an inventory of hospitals and medical service points should be made available to police officers to help them identify the closest point of contact with medical help from a given location. Whereas there is a general and reasonable impression that NH&MP has improved the patrolling situation on selected highways, Pakistan is far from
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Peshawar to Lahore GT Road (N-5); Lahore to Lodhran (N-5); Karachi to Jamshoro and Hala (Super Highway); Rawalpindi to Lahore Motorway (M-2) and Pindi Bhattian to Faisalabad Motorway (M-3).
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having achieved the ultimate in highway safety. Precise issues inherent to this police force need to be clearly delineated and addressed. Regular monitoring and evaluation of this force needs to be undertaken from administrative, performance and fiscal perspectives so that its impact vis a vis costs incurred can both be justified and maximized. In addition, the public health potential for linking with this network needs to be fully realized so that tangible public health benefits can be achieved by linking with this system. The potential within the existing NH&MP database to serve as an ancillary surveillance mechanism for RTCs needs to be assessed, and if feasible, established. It would be useful, therefore, to have the Ministry of Health and/or its representatives with pubic health experience represented on the governing body and administrative structure of this institution. The National Highway and Motorway Police serves only 25% of the highways in Pakistan, with 75% still being patrolled by the traditional police force. It can, at best, be stretched to the entire motorway and highway systems in Pakistan; however, there will still be the need to upgrade traffic police systems within cities. It is, therefore, essential to upgrade this system in parallel; such efforts should also be sensitive to training and resource requirements of traffic policing both in the urban and rural areas. Ensuring safety on roads is a multidisciplinary challenge with implications at different levels. It is suggested that a committee should be constituted on road safety under a National Safety Commission. This committee must have adequate representation from all stakeholders and should preferably be chaired by individuals with a background in public health and with active representation from the Ministry of Health. The committee should foster a collaborative environment between various stakeholders who can potentially play a part in road safety; this includes the vehicle registration authorities, licensing authorities, Motor Vehicle Examiner, NHA, NH&MP, healthcare system, general public representatives and transporters.
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and encouraging workers to observe safety standards while at work are known to reduce the risk of injury. The latter should incorporate the promotion of healthy lifestyles. In addition, studies should assess the feasibility and applicability of measures that reduce the stress that comes with lack of control over daily tasks and unhealthy physical environments in the Pakistani setting. One of the effective means of achieving workers safety is through legislation and its enforcement to ensure safe work places. Ironically, there are currently no laws for enforcing occupational health and safely standards within Pakistan. An Ordinance was drafted in 1998 for stipulating safety standards in worksites but was subsequently shelved for reasons beyond the scope of this discussion. It is imperative that such efforts be resumed with the objective of formulating a comprehensive legislative framework in working towards occupational health and safety. Pakistan will also benefit from a national agency such as the Occupational Safety and Health Association (OSHA) to set workplace standards and investigate workplace-related morbidity and mortality events.
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It has been noted that despite the availability of a comprehensive database of all the secured workers under this scheme, and the potential that exists within that framework to study them as a cohort, no attempt has been made to study the trends of disease within this population. Every effort should be made to study trends so that evidence could be generated for prioritizing public health interventions within appropriate settings. This can also serve as an ideal surveillance mechanism for monitoring trends of work-related injuries and to get insight into the causal factors. Relevant to the mandate of the present initiative, it needs to be recognized that it provides curative services only; neglecting the preventive and control related aspects of diseases altogether. The system does not integrate the concept of Wellness in Health, which underlies the need to work in partnership with individuals in their worksites in order to optimize their health, fitness and quality of life. Integrating health education could be relatively simple in this setting as captured audiences are available. It is imperative to pay careful attention to this missed opportunity. Clearly, this system needs to be broader-based; in particular, integration with the agriculture sector is crucial, which is where more than 48% of Pakistans workforce is employed. The NISP reported machine injuries as the second commonest cause of injuries in Pakistan; many of these injuries (28%) were inflicted on agricultural sector workers. However, in contrast, there are no legislative measures applicable to this issue; clearly this gap needs to be bridged. Instituting measures to broaden the base of Social Security will result in an increase in the number of workers targeted on the one hand, and will achieve the purpose of integrating preventive health with its mandate, on the other. This structure and its applicability is useful not just in the context of workrelated injuries but also for the prevention and control of cancers and other diseases that result due to occupational exposure. These have been discussed in Section 7.
Kite flying festivals such as Basant are known contributors to injuries in Pakistan
There are several other labour welfare organizations and structures within the country; these include the Employees Old-Age Benefit Institution (EOBI), the Workers Welfare Fund, the National Training Bureau and the Labour Welfare Department whose mandate is to inspect factories to ensure safe working conditions. Despite the existence of such extensive organizations and structures, there are no systems in place to comprehensively address worksite safety. It needs to be recognized that such environments present an opportunity to target a captive audience. Every effort must, therefore, be made to integrate preventive health into the mandates of such organizations.
8.5 Falls
The National Injury Survey of Pakistan has identified falls as being the third commonest cause of injuries in Pakistan, accounting for 23% of the total injury burden. Rooftops, trees and animal backs were identified as being the commonest sites from where falls occurred. Kite flying festivals such as Basant are a known contributor to injuries in Pakistan and India.265 However, this issue has not been quantitatively assessed; in addition to injuries, there are also increased reports of electrocutions during this period due to the use
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of metal wires for flying. There is, therefore, the need to enforce strict regulatory measures in this regard. Unsafe environments within homes are a major cause of falls for the elderly, resulting in fractures in many cases.266,267 In Pakistan, a further understanding of the causes of falls is warranted to plan appropriate prevention strategies for various age groups, in varying social and geographical groups. Legislation for safe buildings exists in Pakistan. Regulations relating to proper guarding and fencing of rooftops, details relating to the design, height and shape of stairs, and specifications relating to requirements to secure balconies and terraces have been clearly specified. Existing building codes need to have stricter enforcement and implementation.
8.6 Violence
Violence can be categorized into self-harm (suicide/parasuicide), interpersonal violence and collective violence (where one large, organized group attacks another group).268 All types of violence are common in Pakistan. According to one estimate, the suicide rate has quadrupled in the past 14 years.269 Suicide is one of the three leading causes of death among people aged 15-35 of years. There are scant data relating to suicides in Pakistan; however, available evidence suggests that suicide rates may be similar if not higher than the global average. Studies carried out in Pakistan have shown that 54-61% of the patients presenting to hospital emergency departments with acute poisoning and suicidal attempts suffer from psychiatric illnesses; depression and personality disorders are the most common diagnoses among these patients.270, 271 Studies show that the prevalence of suicide is higher in males with a peak incidence in the 20-29 years of age. 272,273 However, suicidal attempts and ideation are commoner in females compared with males (36% vs. 56%). 274 Measures need to be instituted to collect reliable data, which would serve the basis of developing public health strategies suited for the prevention of suicide. Similarly, interpersonal violence, especially violence against women, is well known. Among 150 women interviewed at healthcare facilities in Karachi, 34% had been subjected to physical abuse a strong association between domestic violence and depression has also been demonstrated. 275 In a more recent study conducted in a public sector tertiary hospital in Karachi, 33% of the 70 men interviewed reported ever slapping their wives.276 Another study showed that the lifetime prevalence of marital physical abuse was 49.4%, in which slapping, hitting or punching was most often reported (47.7%).277 A report has suggested that in the year 1998-99, more than 99 women were killed in the name of honour killings alone. 278 The NISP reported that between 1994 and 1999, more than 3560 women were hospitalized after being attacked at home with fire, gasoline or acid; however, this represents just the tip of the iceberg. Child abuse, another form of interpersonal violence, is also common in Pakistan. While parents may think that it is better for the child, overwhelming evidence in literature shows that physical punishment and abuse actually harm the physical and psychological wellbeing of a child. A study looking at this trend in Karachis schools found that 70% of the children had been
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Between 1994 and 1999, more than 3560 women were hospitalized after being attacked at home with fire, gasoline or acid
physically abused by their parents in the year prior to the interview; being slapped (67%) was the most common form of physical abuse, followed by hitting with a shoe (13%), throwing an object (11%), pushing or shoving (11%), hitting with a stick (9%) and choking (3%). Interestingly, men who physically abuse their wives were six times more likely to abuse their children. There is anecdotal data on abuse of the elderly; the underprivileged in a household are also victims to this trend. The definition of this can be expanded in Pakistans context to include domestic and worksite help. Nondomestic interpersonal violence is also common in Pakistan. Violence of one political group versus another or one tribe versus another is well known. However, the exact magnitude of the burden needs to be determined. Many NGOs are working in this area, largely with the aim of creating awareness relating to the magnitude of this issue and providing assistance to those who suffer at the hands of domestic violence. The roots of this problem are embedded in the complex interplay of cultural and social factors and at times, stem from misinterpretations of religious teachings and cultural norms. Several strategies can be instituted for addressing this issue. The World Report on Violence published by WHO discusses these in detail. 279 Such interventions have implications for both individuals and societies and include addressing individual risk factors and measures to modify risk behaviours. Influencing personal relationships, working to create healthy family environments, and providing professional help and support for dysfunctional families is also part of this approach. At the societal level, this includes monitoring public places such as schools, workplaces and neighborhoods and taking steps to address problems that might lead to violence besides addressing gender inequality, and adverse cultural attitudes and practices. Addressing broader cultural, social and economic factors that contribute to violence and instituting measures to address these also necessitate that the gap between the rich and poor is bridged and that equitable access to goods, services and opportunities is ensured.
8.7 Burns
Various studies in Pakistan have identified burns as a common cause of injury, especially among women. Risk factors such as loose inflammable clothing, stoves at the ground level and bursting of kerosene stoves are some of the reasons. It is also believed that many of the burns are intentional. Tough legislative measures are necessary to ensure product safety in relation to stoves and to improve the design of newly-constructed kitchens. In addition, preventive strategies should feature as a part of health education interventions; this should also include public education in the immediate management of burns (such as rinsing with cold water).
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in Pakistan so that the potential for public health interventions can be determined and appropriate strategies instituted. This section has reviewed current epidemiological data on injuries and the existing on ground programmes relating to their prevention, outlining their strengths and weaknesses. Based on this information, a strategy has been devised to guide future efforts aimed at injury prevention. The Action Agenda items as part of this strategy have been listed below. However, as part of the Integrated Framework for Action, injuries have been grouped alongside other NCDs in an integrated model which combines a range of interventions and actions across other NCD domains.
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? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?
Develop a sustainable and comprehensive system for injury data collection in Pakistan. Integrate injury surveillance with a comprehensive population-based NCD surveillance system. Supplement this by instituting a mechanism for utilizing multiple source data (e.g., facility-based data, police reports, reliable newspaper reports and data from other appropriate sources). Establish a National Safety Commission an interdisciplinary group of stakeholders with the aim of improving safety at all levels. Establish a committee on road safety to foster a collaborative environment and facilitate intersectoral action for road safety. Integrate injury prevention as part of a comprehensive NCD behavioural change communication strategy. Improve road safety education through health communication systems with a particular focus on the high-risk group. Identify traffic black spots; develop and implement appropriate safety measures in such settings. Issue guidelines on safe installation of barriers. Enact and enforce legislation on locally manufactured vehicles. Regulate drivers training and licensing. Develop and implement rules of the National Highway Safety Ordinance; upgrade provincial ordinances; upgrade Motor Vehicle Ordinance 1965. Develop a comprehensive policy, enact and enforce legislation for occupational health and safety. Develop product safety standards for household useables. Include preventive health in the mandate of organizations dealing with worksite safety. Enforce seatbelt and helmet laws. Enforce effective legislation on building safety. Evaluate NH&MP from a performance and fiscal perspective. Study patterns of occupational injuries and their determinants with a view to defining precise targets for preventive interventions. Formally evaluate interventions to reduce all forms of violence in Pakistan. Improve trauma care to the extent that a credible, cost-effective analysis suggests. Build capacity of health systems in support of injury prevention and control. Integrate public health programme monitoring and evaluation with NCD surveillance. Build a coalition or network of organizations at the national, provincial and local levels facilitated by federal and provincial health services to add momentum and legitimacy to injury prevention and control as part of a comprehensive effort for the prevention of NCDs.
Priority Action Areas Priorities within other Action Areas will be determined subsequently
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Mental illnesses
9.1 Context
Pakistan is a milieu where poverty, unemployment, illiteracy, malnutrition, gender biases and break-up of social support systems compound the stresses of urbanization and acculturation. In this setting, the countrys health system is not ideally primed to take on the challenge that the escalating burden of mental illnesses presents. These austere conditions are a playing ground for superstitious and supernatural convictions and often exorcism, which augment both stigma and discrimination and contribute to isolating the mentally ill. These considerations pose serious impediments to any comprehensive efforts aimed at promoting mental health and preventing mental illnesses in Pakistan. Public health efforts, therefore, need to be conceptualized in the context of these realities. Global statistics on mental health are indeed alarming. Twenty-five percent of the worlds population suffers from a mental disorder at some stage during the course of their lives whereas 450 million individuals are estimated to be currently suffering from a mental illness. The leading contributors, inclusive of depression, schizophrenia, drug and alcohol abuse represent four of the 10 leading causes of disability worldwide and account for 12% of the global burden of disease. 280 These diseases exhort a considerable toll, both on the sufferer and the family. Individuals suffer from the distressing symptoms of the disorder in addition to being victims of unfair discrimination and stigmatization. This is compounded by inadequate and inaccurate information about mental illnesses and the traditional practice of treating the mentally ill in isolated asylums. On the other hand, the family has to bear the emotional, physical and economic stress of providing care and coping with behaviours;281,282 this has implications for potential at work, social relationships and time. 283 Against this backdrop, it is important to recognize and develop the potential that exists to prevent a range of mental illnesses. Health is traditionally regarded as being synonymous with physical health; mental health remains poorly understood and ill-deciphered in many parts of the world, particularly in the developing countries. However, it must be recognized that mental disorders are closely linked to physical illnesses,284 and impose a range of consequences on the course and outcome of chronic co-morbid conditions. 285,286 Fundamental concepts in caring for the mentally ill have been revolutionized in the last decades concepts of lunacy and care of the lunatic have been replaced by the comprehensive mental health model. This is centred on safeguarding the rights of the mentally ill, reducing stigma and discrimination, integrating mental health with primary healthcare
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Prevalence of common mental disorders in the rural areas is reported at 15% in men and 46% in women
and de-institutionalisation and rehabilitation of the mentally ill in the community. This approach has implications for support functions in a number of areas including policy building, manpower and material development and research. A systematic integrated approach to preventing mental illnesses and promoting mental health with active roles of the healthcare provider, the community, legislators and policy makers is key to this framework. Being the first in WHO Eastern Mediterranean Region (EMRO) to have set up a National Programme for Mental Health (NPMH) in the year 1986, Pakistan has fared comparatively well in its response to this challenge compared with several other developing countries, 40% of whom do not have a mental healthy policy and 30% of whom do not have national mental health programmes. The Ministry of Healths commitment is reflected in the adoption of a policy framework in the shape of initiation of NPMH and the subsequent promulgation of the Mental Health Ordinance in the year 2001.287 However, Pakistan can still be categorized amongst 90% of the developing countries that do not have a mental health policy for adolescents and children; furthermore, until now, it could also be grouped with 27% of the same that did not have a system for mental health surveillance.
9.2 Data on mental illnesses in Pakistan 9.2.1 Population-based data on major and minor mental illnesses
The 1987 approximations relating to the burden of mental illnesses in Pakistan underscored the need to take these up as a priority issue; estimates indicated then, that there were one million severely ill and 10 million mildly mentally ill within the country.9 Subsequently, however, epidemiological surveys on sampled populations indicated that the situation was far graver. A series of three community-based epidemiological surveys of rural and urban populations of Pakistan found high prevalence of common mental disorders, especially among women. These studies incorporated sound scientific methodologies for conducting community-based surveys utilizing validated screening tools that had been developed for the Pakistani population.288 In the Pakistani culture, individuals with minor mental disorders frequently express their stress as somatic complaints; therefore, if a screening instrument is based primarily on psychological symptoms, many cases of neurotic disorders are likely to be missed. This understanding prompted the use of the Bradford Somatic Inventory (BSI), which was developed from symptom reports by psychiatric patients in Pakistan; these enquired about somatic symptoms in the local language, taking into account local cultural idioms of distress. The prevalence of common mental disorders in the urban areas was reported at 10% among men and 25% among women. 289 Higher prevalence was reported in the rural areas; data from a survey conducted on a rural population in Chitral reported a prevalence of 15% among men and 46% among women.290 This prompted the authors to resurvey another rural sample with a view to validating results from Chitral. Hence, employing the same methodology, data from the Susral village in Gujar Khan helped to validate earlier data by reporting prevalence rates of 25% among men and 66% among
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Women experience increased levels of stress compared with men both in the urban and rural areas
women. 291 The report has serious implications given that 66% of the population in Pakistan lives in the rural areas.292 Classically, poor social conditions in the urban areas of developing countries are considered to be the underlying factor responsible for higher psychiatric morbidity observed in these settings.293 However, there are few paired studies of rural-urban populations in the same geographical region to allow a direct comparison. Notwithstanding that the series of psychiatric surveys carried out in Pakistan were not designed to serve as a study of rural-urban migration, several explanations of the increased psychiatric burden in rural populations can be extrapolated from these studies. However, many of these remain speculative and generate several hypotheses. Detailed studies of rural to urban migration will help to shed light on factors responsible for the poor mental health status of people living in rural areas with important implications for preventive strategies. In all the aforementioned surveys, women were found to experience increased levels of stress compared with men both in the urban and rural areas; this is in conformity with data from all over the world, where women are known to have increased psychiatric morbidity; 294 however, the gap appears wider in Pakistan. Factors relevant to women such as lack of control over their lives, low literacy rate, poverty, large family sizes, overcrowding and poor physical health have all been identified as risk factors.295 In view of the high prevalence of mental illnesses in the country, there is an urgent need to develop data sources to monitor their trends. Efforts have been ongoing as part of NPMH to include a uniform recording system for key mental illnesses into the Health Management and Information System (HMIS). As an initial step, appropriate indicators have been developed and integrated with the HMIS in five districts as part of a pilot intervention. 296 This arrangement will provide facility-based data and must be continued and supported as planned. However, it is also essential to monitor trends through a population-based surveillance mechanism. Within this context, studies done to date and referred to above are important with regard to any future attempts since they can serve as a baseline. Although they provide evidence for urgent public health action, they have their limitations in being generalizable to the entire population in Pakistan, which is heterogeneous and socio-culturally diverse. Integration of baseline information and methodology into the surveillance system should, therefore, be paralleled with efforts to expand its base.
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9.3 Framework for prevention of mental illnesses and mental health promotion
Healthcare providers in Pakistan are generally aware that those with major mental illnesses such as depression, psychosis, drug dependence and mental retardation need specialized psychiatric care. However, awareness relating to the needs of those with minor psychiatric ailments remains rudimentary, both among patients themselves and health professionals. The bulk of the chronically ill with persistent and vague somatic symptoms continue to access general practitioners for care. In reality, a majority of these suffers from high prevalence mental disorders. Contrary to popular belief, mental illnesses can be amenable to preventive interventions. The concept of primary prevention, however, has limited application in this context, as few causal associations have been established with direct implications for primary preventive interventions. These include causal associations of iodine deficiency with mental retardation, 303 birth trauma with epilepsy, 304 and pregnancy with depression. 305,306 Primary prevention strategies within this framework encompass the prevention and treatment of malnutrition, iodine deficiency, worm infestation, infections, drug abuse and preventing depression during pregnancies. These issues are already being targeted through appropriate public health strategies in the health sector. However, these diseases constitute a fraction of the burden of mental illnesses. The vast majority, inclusive of depression and
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Treatment of mental illnesses is cost-effective and can be prescribed and dispensed in any setting
schizophrenia, occur as a result of the combined influence of genetic and environmental factors interacting at specific periods during an individuals lifetime. Lack of a specific causal association, coupled with difficulties in ascertaining the specific time of progression from the asymptomatic to symptomatic stage, makes it difficult to institute specific primary preventive measures. It is for this reason that the prevention-related emphasis in such diseases is on secondary prevention. Secondary prevention strategies play important role in common psychiatric illnesses. Compelling scientific evidence indicates that 60% of the patients of substance abuse, 73% epilepsy patients and more than 50% patients with schizophrenia recover with treatment and do not relapse, if treatment is maintained. 307 Treatment of these illnesses is affordable, can be prescribed and dispensed in any setting and is cost-effective, compared with treatment for other NCDs.308 Over the last two decades, Pakistans efforts in mental health promotion and disease prevention have been guided by WHO, which has played an important role in assisting countries by providing them with necessary guidance in the wake of the escalating burden of mental illnesses. This commitment was lately reflected in the dedication of the theme of the World Health Day and the World Health Report in the year 2001 to mental illnesses. This report outlined a set of scientifically valid and evidence-based solutions to addressing the current and future burden of mental illnesses.xxiv Following on these recommended solutions, and building on the World Health Day 2001 theme of Stop Exclusion: Dare to Care, the WHO Mental Health Global Action Programme adopted the slogan Close the Gap: Dare to Care; this initiative provided a strategic framework to bridge the gap between what is needed and what is available. Within this Action Plan, several areas have been based on the WHO-recommended framework for action. These focus on awareness-creation, capacity-building within government institutions and professionals to develop and implement evidence-based policies and programmes; supporting adequate financing of mental health; reducing stigmatization and discrimination; promoting community mental healthcare; supporting mental health research; ensuring the availability of psychotropic drugs at the basic healthcare level and fostering multi-sectoral linkages.
Provide treatment as part of primary care; make psychotropic drugs available; give care in the community; educate the public; involve communities, families and consumers; establish national policies, programmes and legislation; develop human resources; link with other sectors; promote community mental health; develop indicators; support more research.
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developing countries. The conceptual framework of NPMH steered a subworking group to develop the official document for the Government of Pakistan.9 This was adopted in 1987 as the Seventh Five-Year Plan. This initiative was spearheaded by the Institute of Psychiatry, Rawalpindi: the WHO Collaborating Centre for Mental Health in Pakistan. The adoption of NPMH signified a policy decision made by the Government of Pakistan to integrate mental health with primary healthcare. Issues with its subsequent implementation notwithstanding, NPMH heralded a new era in mental health in Pakistan, outlining the need for universal provision of mental healthcare and substance abuse services by their incorporation in primary healthcare, a vision for a strategic integrated framework replacing an ad hoc approach to mental healthcare and a need for a greater focus on community mental health care. Specific strategies for achieving these objectives included capacitybuilding of healthcare providers, incorporation of mental health into training curricula, strengthening existing institutions, broadening the base of service delivery, streamlining referrals, ensuring the availability of drugs and intersectoral collaboration. Basing its decision on available epidemiological prevalence estimates, the potential for preventability and cost-effectiveness of preventive interventions, NPMH outlined priority areas for public health interventions in mental health for Pakistan. These areas include depression, psychosis, drug abuse and mental retardation. Many of the objectives of NPMH have since been actively pursued and have resulted in the evolution of several demonstration pilot projects; these will be discussed in the subsequent sections under their respective heads. However, the most significant achievement of the programme related to its advocacy dimension, which culminated in the promulgation of the Mental Health Ordinance 2001, replacing the earlier Lunacy Act of 1912. This legislative framework has a firm grounding in scientific principles, integrating inputs from a range of local stakeholders. If implemented in true spirit, this instrument of law has the potential of significantly impacting on mental health and care of the mentally ill in Pakistan. The salient features of this Ordinance are prevention and health promotion, protection of the rights of the mentally ill, development and establishment of new national standards of care and investment in support functions.309 For the first time after the promulgation of this Ordinance, asylum-based isolation and segregation of the mentally ill has been replaced by the concept of community mental healthcare. In addition, a number of stakeholders relevant to the care of the mentally ill were identified and their roles and responsibilities were outlined. Moreover, clarifications were provided on the contentious and much-abused period of detention-related issues. The admission, leave and discharge criteria were defined and a section was added to highlight the human rights of the mentally ill. The Ordinance mandated the establishment of a high-powered Federal Mental Health Authority (FeMHA) responsible for monitoring and evaluation of mental health in Pakistan. The terms of reference of the Authority have been clearly stipulated to oversee issues related to the implementation of the Ordinance. The Authority is responsible for developing a code of practice and guidelines for implementing the Ordinance. Due priority will be given to on-
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For the first time, asylumbased isolation and segregation of the mentally ill was replaced by the concept of community care
job training relating to the implementation of the Ordinance to health professionals, police, and other stakeholders. There is also a need for strengthening and harmonizing working relationships with the police through intensified networking and exchange of information; this should focus on improving awareness of police relating to mental health issues and current mental health legislation. In addition, efforts should be made to improve police knowledge relating to prevention and management of violent incidents in people with mental illnesses.
9.4.2 Community care, information dissemination and reduction of stigma and discrimination
There is a global consensus on the need to foster community care for the treatment and rehabilitation of mentally ill patients with the use of all available resources; this replaces the earlier focus on institutional custodial care. Community care is known to be more advantageous with regard to the outcome and quality of life of individuals with chronic mental disorders; in addition, it is also in agreement with respect for human rights. In Pakistans context, achieving this objective necessitated a paradigm shift in mental healthcare; this was given legislative authorization with the promulgation of the Mental Health Ordinance 2001. Community care for the mentally ill is also socially acceptable, given that family structures are generally supportive in our cultures. However, a successful shift towards community care requires accessibility to health workers in the community and the existence of rehabilitation services, crisis support, protected housing, and sheltered employment at the community level. As part of NPMH, consensus has been achieved over a policy framework to guide a set of activities that will contribute to achieving these objectives. Progress in achieving these objectives will, in turn, determine the successful implementation of the Ordinance. To lead the changes outlined in NPMH, several demonstration projects were set up by the Institute of Psychiatry, Rawalpindi, which is the WHO Collaborating Centre for mental health research and training in Pakistan. One of the earliest demonstration projects was set up in Gujar Khan in 1986.xxv This community mental health project was carried out in a planned series of phases with active inputs of local community leaders and healthcare providers. This involved training of around 800 primary care physicians and 3500 newly identified healthcare givers as defined in this framework; in addition, a community education project was set up with schools being the principal point of entry. This demonstration project and others that followed on a similar pattern developed a training module intended to be introduced into the work-plan of LHWs. However, this attempt did not generate the administrative and operational dialogue with the respective department, which could have facilitated the introduction of mental health into the workplan of the LHWs on a sustainable basis. These experiences will, nonetheless, help to guide the introduction of mental health components into the workplan of LHWs in future.
xxv A rural sub-district of the metropolis of Rawalpindi, with a population of just under one million.
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Native faith healers remain an important source of care for the mentally ill in Pakistan
A mid-term impact evaluation of the Gujar Khan project with a control site comparison was conducted in the year 1991, five years after the initiation of this activity. Starting with similar baselines in both the intervention and the control sites, there appeared to be a significant and sustained rise in the detection and treatment rates of mental illnesses and the use of psychotropic drugs in the intervention districts compared with the control sites. This was evidenced by a review of ledgers that captured primary care data from both these sites. In addition, a positive trend was also observed in the general health indicators in the intervention site. 310 School mental health interventions were also developed as a component of the community mental health project in Gujar Khan and other projects initiated later on a similar model. The objective of these interventions was to raise awareness about mental health issues among school children. Postintervention evaluation with pre-intervention and control group comparisons of a school health intervention in the district of Rawlpindi demonstrated the success of the school health intervention.311 The intervention resulted in improved levels of awareness relating to mental health issues; the effect of the programme permeated into the community beyond the sections that had direct access to school education; however, the message was diluted as it spread out from source. These demonstration projects were a novel development and provided a reasonably sound base to plan further activities on. The experience prompted the Institute of Psychiatry, Rawalpindi: the WHO Collaborating Centre for mental health to develop a formal Government of Pakistan-Ministry of Health project proposal (PC-1) for replicating the demonstration experiences in five other districts in order to pilot this design in provincial settings Jhelum (Punjab), Sukhur (Sindh), Pishin (Balochistan), Dera Ismail Khan (NWFP) and Mirpur (AJK) were chosen as pilot districts. This PC-1 packaged a budget projected over three years and included allocations for healthcare provider trainings, community interventions, media awareness campaigns and evaluations. Though this project has been officially approved, there are operational issues with tapping into the already committed PSDP resources. Lack of systems and procedures and operational difficulties are impediments to its successful implementation. The examples discussed illustrate important efforts that have been channelled towards developing community models of mental healthcare relevant to Pakistans setting. Future efforts must be built on these foundations. Within this context, several aspects merit consideration. Firstly, the strengths and gaps of the model and the potential to further consolidate and integrate it within the framework of the comprehensive integrated programme for NCDs needs to be assessed with a view to up-scaling this at the national level. A broader-based consensus would be crucial to this approach. There is also a need to develop a larger population-based representative sample to enable improved understanding of the determinants of mental health and to guide the development, modification and evaluation of intervention studies on an ongoing basis. Secondly, there is a need to invest in developing public health infrastructure to enable the implementation of such projects on a sustainable
Awareness about mental illnesses will help to reduce both stigma and discrimination
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basis. Furthermore, any future efforts at the school level should be integrated with a comprehensive school health programme. Public awareness is an important adjuvant to community mental healthcare; educating the general population, community activists, leaders and personnel involved in healthcare delivery at all levels creates awareness about the community care approach and other choices in care, enables the system to harness their support and primes the desired response to mental healthcare at all levels. In addition, it helps to reduce barriers to treatment and care by increasing awareness about mental disorders and the potential that exists to treat these illnesses with implications for the recovery process. Most importantly, awareness creation can help to reduce stigma and discrimination. However, such campaigns need to be guided by a thorough assessment of community concerns, existing beliefs, practices, attitudes and concepts and need to be refined on an ongoing basis through the assessment of their impact and evaluation of the process. The World Mental Health Day can be used as a platform for awareness creation. Public health measures including exercise, self-help and simple problem solving, sleep and hygiene are conducive for a mentally healthy society and need to be promoted as a priority. Mental health education campaigns, integrated with awareness campaigns for other NCDs should be focused on the information-related needs of the community and should be aimed at modifying, wherever necessary, existing beliefs, practices, attitudes and concepts; in addition, they should also be focused on symptom recognition and access to healthcare. Furthermore, these efforts should be part of a much larger and sustainable effort. It is also imperative to protect the interests of special groups including prisoners, refugees and displaced persons, women, children and those with disabilities. The prevalence of mental illnesses has been reported high in long term prison inmates in Pakistan.312 Linkages need to be established or improved with prison departments and staff in accordance with the Mental Health Ordinance 2001. Increased access to mental health services for refugees and displaced persons has to be ensured. Work of the NGO Horizon,313,314 is a useful example in this regard. Moreover, there is a need to invest in improving mental health of women, children and people with disabilities. Within this framework, it is essential to support and strengthen NGOs that contribute to advocacy and support to special groups.
Infrastructure for mental health remains rudimentary in Pakistan against the backdrop of the 10 million individuals that require services
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administrators at the district level within the demonstration sites; training modules have been developed for this purpose. There are also informal reports of these modules being utilized for training in other parts of the country.316 This effort has recently been evaluated preliminary results are reported to be encouraging; however, there is a need to develop a system for ongoing evaluation of public health interventions in order to assess their impact. There is a clear need to build upon such efforts, and to draw voluntary efforts into the formal training loop. Simple, easy-to-understand mental health modules need to be introduced into a sustainable and scientifically valid CME programme model integrated across the range of NCDs. Majority of the mentally ill tends to seek care at the local level, accessing traditional practitioners, local private providers and those within the primary healthcare system. Training that aims to impart a few basic skills to these healthcare providers has the potential of improving the detection, referral and management of common mental disorders. In the above-mentioned categories, training can logistically be best imparted to those within the public sector primary healthcare system as they have structured training systems. Training opportunities for other categories need to be defined.
Basic Health Unit is the most peripheral facility of the healthcare system; planned to serve 5-10,000 people over a catchment area of 15-25 square miles. Each BHU is staffed by one medical officer and support staff.
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build their capacity so that they serve as both treatment and rehabilitation sites. The National Programme for Mental Health spelt out an urgent need to scale up professional capacity in the area of mental health, making the case for this approach in view of the then existing situation as it related to professional capacity. Today, there are an estimated 2.3 psychiatrists for a population of one million. The College of Physicians and Surgeons of Pakistan is presently producing an average of 10 psychiatrists per year. This falls far short of what needs demand. There is, therefore, a need to support and provide training opportunities to young doctors likely to take up psychiatry as a long-term career option. An increase in numbers will enable trained psychiatrists to seek employment opportunities at the district and tehsil levels and will help in bridging the gap in professional capacity at the grassroots level. The framework of NPMH provided a mandate to establish and strengthen professional capacity in mental health. This mandate enabled the initiation of undergraduate and postgraduate training for doctors, psychologists, nurses, community mental health nurses and community workers. More than 65 psychiatrists have been trained to-date; many psychiatrists are now cascading out this training in Karachi, Hyderabad, Quetta, Peshawar, Lahore and Multan. Despite the lack of financial support through formal sources, such efforts have played an important part in capacity-building and training. This is evidenced by a significant increase in number of psychiatrists from 120 in 1987 to 342 in 2002.9 A majority of these, however, remain centred on large urban areas. In addition, nurses, psychologists and community mental health workers have also been trained as part of this initiative. The methodology employed as part of trainings and the training materials will be valuable to the health professional capacity-building initiative for NCDs as part of the Action Plan. Psychologists play an important role in providing comprehensive mental healthcare within any setting. With the presently qualified 52 psychologists in the country, this role is being missed out on. In addition, the present capacity to produce around 40 psychologists per year by training institutions in Rawalpindi, Lahore and Karachi also falls short. There is, therefore, a need to scale up capacity to train more psychologists within the country and to involve them in community initiatives. The National Programme for Mental Health has also developed practical training modules for nurses and community psychiatric nurses; curricula have been developed and adapted for the undergraduate and postgraduate levels. A two-year postgraduate diploma for psychiatric nursing has been initiated in nurses training colleges in the country and so far 92 psychiatric nurses have qualified. Social workers can also play an important part in community psychiatry; however, there are no formal public sector programmes modelled to harness their potential in order to provide care for the mentally ill in communities; they are also not regarded as a formal cadre of professionals. As part of NPMH, linkages were developed with the National Rural Support Programme (NRSP), which has a nationwide network of community organizations to assist with development activities. This linkage will enable
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community mental health to be plugged into the work-plans of village activists in remote rural areas. The potential that exists within this linkage needs to be maximized. A discussion on human resource development for comprehensive mental healthcare in Pakistans context will not be complete without discussing the role of native faith healers and referring to pathways to care. Faith healers are widely recognized as moral and spiritual guides in our country and are consulted by community members both in the rural and urban areas for a variety of ailments. Studies reveal that they are an important source of care for the mentally ill in the subcontinent.317 In addition, studies carried out in the native Pakistani setting have provided useful insights into their practices and have outlined gaps in their knowledge, which can be potential targets of intervention; these studies have established that it is possible and feasible to collaborate with them. 318 Their endorsement and referral for psychiatric care is envisaged as being valuable to concepts being promoted as part of this Action Plan. Such a course of action is in line with evidence-based approaches that spell out the need for developing indigenous approaches based on religious, cultural and psychosocial values. However, this must be preceded by a validation of methodologies employed for this purpose.
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The role of professional societies and NGOs in advancing the cause of mental health is critical
This has implications for capacity-building of care givers, counselling and providing support and rehabilitation and vocational services within the institutional structure. It also needs to be recognized that such institutions have the capacity and the mandate of generating and allocating resources for the care of the mentally ill, given appropriate orientation, training and guidance. It is also essential to take into account, the activities and scope of other NGOs such as Karawan-e-Hayat, War Against Rape, Dast-e-Shafqat, Bedari, Rozan, Sahil, Human Rights Commissions and others with a similar mandate. An assessment of their capacity and the current outreach with regard to their relevance to being contributory to larger objectives set within this Action Plan, need to be determined. Such NGOs must be drawn into the implementation loop and their potential harnessed. The role of professional societies such as the Pakistan Psychiatric Society in advancing the cause of mental health is pivotal. A greater focus on the public health approach and endorsement of efforts outlined in this Action Plan are critical in this regard. This section has reviewed current epidemiological data on mental illnesses in Pakistan and the existing on ground programmes relating to their prevention, control and health promotion outlining their strengths and weaknesses. Based on this information, a strategy has been devised to guide future efforts aimed at prevention of mental illnesses and promotion of mental health. The Action Agenda items as part of this strategy have been listed below. However, as part of the Integrated Framework for Action, mental illnesses have been grouped alongside other NCDs in an integrated model which combines a range of interventions and actions across other NCD domains.
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9.5 Mental Health - Action Agenda ? Integrate prevention and control of mental illnesses with a comprehensive strategic NCD prevention, control and health promotion framework. Derive guiding principles from the National Programme for Mental Health. ? Prioritize integrated community mental healthcare, integration of mental health with primary healthcare and elimination of the stigma and discrimination associated with mental illnesses and substance abuse. ? Integrate surveillance of mental illnesses in the comprehensive population-based NCD surveillance system. Build on and seek guidance from previously conducted similar efforts. ? Develop sustainable public health infrastructure to support community mental health initiatives. ? Create awareness about mental health as part of an integral component of NCD behavioural change communication strategy. ? Draw all categories of healthcare providers and community activists into the loop to develop a comprehensive community care model for the mentally ill. Derive guidance from relevant demonstration projects in the Pakistani settings. ? Integrate school health efforts aimed at mental health promotion within the framework of a comprehensive NCD prevention school health programme. ? Invest in building the requisite human resource necessary for implementing the Mental Health Ordinance 2001. ? Strengthen and harmonize working relationships with law enforcing agencies through intensified networking and exchange of information. ? Integrate mental health into health services as part of a comprehensive and sustainable, scientifically valid, culturally appropriate and resource-sensitive CME programme for all categories of healthcare providers. ? Create appropriate training opportunities for all categories of healthcare providers. ? Develop capacity at the secondary and basic healthcare levels in harmony with capacity-building efforts in the community. ? Broaden the base of existing facilities and develop new facilities for treatment and rehabilitation of substance abuse. ? Ensure availability of essential psychotropic drugs at all healthcare levels. ? Build capacity of health systems in support of prevention and control of mental illnesses. Integrate public health programme monitoring and evaluation with NCD surveillance. ? Build a coalition or network of organizations at the national, provincial and local levels facilitated by federal and provincial health services to add momentum and legitimacy to prevention and control of mental illnesses as part of a comprehensive effort for the prevention of NCDs. ? Support FeMHA to develop a code of practice and guidelines for implementing the Mental Health Ordinance. Support on-job training regarding Ordinance implementation for health professionals, police, and other stakeholders. ? Improve availability of special facilities for people with substance abuse who cannot be managed in general facilities. ? Protect the interests of special groups (prisoners, refugees and displaced persons, women, children and individuals with disabilities). Support and strengthen NGOs that contribute to advocacy and extend support to special groups. ? Promote need-based research for contemporary mental health issues.
Priority Action Areas Priorities within other Action Areas will be determined subsequently
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Process Indicators
Output Indicators
Outcome Indicators
Integrated Action Items (Common to Cardiovascular Diseases, Diabetes, Tobacco Use, Chronic Respiratory Diseases, Cancer, Injuries and Mental Illnesses)
C2
A common population surveillance mechanism for all NCDs (with the exception of cancer). The model includes population surveillance of main risk factors that predict many NCDs and combines modules on population surveillance of injuries, mental health and stroke.
135
Process Indicators
members from the media, public health specialists, national programme managers, NGOs, community activists, local opinion leaders, etc. Workshops and consultations to define measurable objectives Consultations to link programme assessment and process evaluation with risk factor surveillance Development of a high visibility behavioural change communication plan incorporating strong social marketing approaches Media Interventions Development of linkages with media Integration of social marketing concepts with media interventions Definition of target messages
Output Indicators
Linkage of programme assessment and process evaluation with risk factors surveillance
Outcome Indicators
Proportion of adults with knowledge relating to the risks of cancer* Proportion of adults with knowledge relating to the warning sign of cancer* Proportion of individuals with knowledge relating to the risks of diabetes* Proportion of at-risk individuals screened for diabetes** Proportion of individuals using seatbelts in cars** Proportion of individuals using helmets while on motorbikes** Proportion of individuals having suffered a Road Traffic Crash** Proportion of individuals requiring medical treatment for injuries** Proportion of individuals aware of the cardiovascular disease risks * Proportion of inactive persons** Median level of physical activity** Proportion of individuals eating less than 5-7 servings a day of fruits and vegetables** Mean BMI** Mean waist circumference** Mean blood pressure levels** Proportion of overweight and obese individuals** Proportion of individuals screened for high blood pressure** Proportion of individuals with high blood pressure** Proportion of individuals on treatment for high blood pressure**
Media Interventions Hours of average exposure per year to various educational messages Percentage of target population reached by various activities Number of electronic media interventions per year
Development of strategies for communicating messages and selection of mediums Development of messages and vignettes
Number of print media interventions per year Number of news releases Increase technical capacity to set up/ organize/implement social marketing campaigns
Community Interventions Assessment of community needs Profiling of community resources Definition of community activists and leaders Development of linkages with social development organizations Development of linkages with primary healthcare systems, National Programme for Family Planning and Primary Health Care and local NGOs Workshops/consultations to develop the methodology for community interventions
Community Interventions Number of coalitions built Number of community meetings held Number of members present in meetings Relevant community stakeholders absent from meetings Number of partners supporting and not supporting decisions Number of advocacy actions taken Tools of intervention developed
136
Process Indicators
Workshops/consultations to develop the tools of intervention
Output Indicators
Number of preventive activities initiated, groups targeted; number of individuals participating Development of a locally applicable and relevant intervention strategy Type and extent of resources committed by various partners New trained persons with technical skills New information systems to assess community skills
Outcome Indicators
Proportion of individuals with knowledge relating to mental illnesses and their prevention*
C3
137
Process Indicators
Output Indicators
Outcome Indicators
Common Process Indicators Activities to garner public support for legislation/regulation essential to the prevention and control of NCDs Media accounts highlighting the need for legislative and regulatory measures Multi-stakeholder dialogue between the Ministry of Finance, Customs, economists, multilateral donors and bilateral lending agencies Fiscal and policy research
Common Output Indicators Existence of plans of actions for advocacy groups Review reports and minutes from parliamentary committees Mechanism and resources for enforcement of legislation Participation in hearings Existence of new legislation/regulations Legislation/regulations enforced
Common Outcome Indicators Existence of new legislation/regulations* Legislation/regulations enforced* Public consumer support for legislation/regulations*
Meetings with public and members of the Parliament Public consumer support for legislation/regulations Policy and technical submissions in support of legislative and regulatory changes Proposals to legislators Establishment of task forces and working groups to support parliamentary committees Specific Indicators Mental Health Ordinance 2001 Development of national standards and guidelines for care and treatment of mentally ill patients Number of psychiatric facilities established for assessment, treatment, rehabilitation and after-care of mentally disturbed patients Number of community-based mental health services established Number of mentally disturbed patients admitted for assessment and treatment Number of court cases relating to mentally disturbed patients being processed by a court of protection
138
Process Indicators
Output Indicators
Number of visits by board of visitors to jail inmates Number of forensic psychiatric services established Number of cases admitted and retained in facilities according to various sections of the Ordinance Number of managers appointed to handle assets of mentally ill patients
Outcome Indicators
Legislative and/or regulatory measures to reduce dependence on revenues generated from tobacco
Decreased dependence on revenues generated from tobacco Reduced production of tobacco in the market
Legislative and/or regulatory measures to discourage tobacco cultivation and assist with crop diversification
Withdrawal of direct and indirect subsidies Provision of technical assistance for the cultivation of equally remunerative crops Ensuring insurance protection Tobacco crop diversification Assisting with income support for tobacco farmers until the process of diversification is complete and sustainable
Legislative and/or regulatory measures for gradual phasing out of all types of advertising Legislative and/or regulatory measures to develop a price policy for tobacco products Legislative and/or regulatory measures to subject tobacco to stringent regulations such as those governing pharmaceutical products
139
Process Indicators
Output Indicators
Enhanced market intelligence Supporting the effective implementation of laws that exist on smuggled contrabands
Outcome Indicators
Legislative and/or regulatory measures to regulate the import of areca nut Legislative and/or regulatory measures to ensure occupational health and safety
Revision of NEQS Redefinition of the role of independent and transparent third party monitoring of effluent discharge Development of infrastructure capable of specialized analysis necessary for such monitoring efforts Improved understanding of safety in industrial settings Mandatory use of Material Data Safety Sheets
Upgrade legislation on building regulations and its implementation Legislative and/or regulatory measures to ensure safety in the design of locally manufactured vehicles Development of rules of the National Highway Safety Ordinance; upgrading of the Motor Vehicle Ordinance of 1965 and relevant provincial ordinances
Development and implementation of rules of the NHSO 2000 Upgrading of provincial ordinances Upgrading of the MVO 1965
Legislative and/or regulatory measures relating to training of drivers/licensing Development of product safety standards
Existence of regulations relating to training of drivers and their enforcement Product safety standards developed and implemented
140
Capacity assessment at various levels Building technical capacity and training assessment at various levels Description of data sources Development of proposals Development of tools to collect information/data Training courses given or taken to enhance skills Definition of most relevant indictors for monitoring and evaluation
Existence of qualified personnel, resources and equipment Reallocations to research Areas where research has been conducted Technologies transferred or given Feedback of information to health authorities Publications prepared through acquisition of data Information provided to media Presentations and seminars for public, health professionals and policy makers Number of individuals and professionals reached with results
* **
141
Acronyms
ACE (Inhibitor)Angiotensin Converting Enzyme AJK Azad Jammu and Kashmir AKUH Aga Khan University Hospital ARUP Association of Road Users of Pakistan ASIR Age-specific incidence rate ASR Age-standardized rates ATS American Thoracic Society BDN Basic Development Needs BHU Basic Health Unit BMI Body mass index BPH Benign Prostatic Hyperplasia CAD Coronary artery disease CARMEN Conjunto de Acciones para Reduccion Multifactorial de Enfermedades Non Transmissible (Set of actions for multifactorial reduction of NonCommunicable Diseases) CDC Centers for Disease Control and Prevention CI5 Cancer incidence in five continents CINDI Countrywide Integrated NonCommunicable Disease Intervention CME Continuing medical education CNG Compressed Natural Gas CNS Central nervous system CO Carbon monoxide COPD Chronic obstructive pulmonary disease CRD Chronic respiratory disease CVD Cardiovascular disease DALYs Disability adjusted life years DCO District Coordinating Officer ECG Electrocardiogram EOBI Employees Old Age Benefit Institution EPI Expanded Programme for Immunization FCTC Framework Convention on Tobacco Control FIFA Federation of International Football Association GDP Gross Domestic Product GNP Gross National Product GYTS Global Youth Tobacco Survey HDL High-density lipoprotein IARC International Agency for Research on Cancer IFA Integrated Framework for Action IGT Impaired glucose tolerance IRNUM Institute of Radiotherapy and Nuclear Medicine JPMC Jinnah Postgraduate Medical Centre LHV Lady Health Visitor LHW Lady Health Worker MDGs Millennium Development Goals MoU Memorandum of Understanding Material Safety Data Sheet Motor Vehicle Ordinance Rule Non-Communicable Disease National Environment Action Plan National Environment Action Plan Support Programme NEQS National Environmental Quality Standards NGO Non-governmental organization NH&MP National Highway and Motorway Police NHA National Highway Authority NHLBI National Heart, Lung and Blood Institute NHSO National Highway Safety Ordinance NICVD National Institute of Cardiovascular Diseases NLC National Logistic Cell NPMH National Programme for Mental Health NTRC National Transport Research Centre NWFP North-West Frontier Province PAMH Pakistan Association of Mental Health PC-1 Pakistan Planning Commission Project Proposal-1 PCB Pakistan Cricket Board PEPA Pakistan Environmental Protection Act PEPO Pakistan Environmental Protection Ordinance PHC Primary healthcare PIA Pakistan International Airlines PIMS Pakistan Institute of Medical Sciences PMA Pakistan Medical Association PPE Personal protective equipment PREMISE Prevention of REcurrences of Myocardial Infarction and StrokE PRSP Poverty Reduction Strategy Paper PSA Prostate-specific antigen PSO Pakistan State Oil PTC Pakistan Tobacco Company RHD Rheumatic heart disease RTC Road traffic crashes SMARP Self-monitoring and reporting SMS Swift Mail Service TFI Tobacco-Free Initiative THQ Tehsil headquarters UNDP United Nations Development Programme UNEP United Nations Environmental Programme WHO World Health Organization WHO EMRO World Health Organization Eastern Mediterranean Regional Office WHO JPRM World Health Organization Joint Programme Review Mission WHO WPRO World Health Organization Western Pacific Regional Office WTO World Trade Organization MSDS MVR NCD NEAP NEAP-SP
Glossary
Accountability: accountability results when decision makers at all levels fulfill their obligations and are made answerable for their actions. Setting explicit objectives and defining how progress towards them will be monitored makes it easier to achieve accountability. Advocacy: in the present context, the action taken by health professionals and others with perceived authority to influence the decisions of communities and governments. Age-standardized prevalence: age-standardized prevalence presents one summary figure for a total population of different age groups. Age is a variable for which adjustment is required because of its marked effect on morbidity and mortality. Age-adjusted death rate: the number of deaths occurring per 100,000 populations per year; calculated in accordance with a standard age structure to minimize the effect of age differences when rates are compared between populations or over time. Aspergillus: a type of fungus. Assessment: in the present context, the obligation of a public health agency to monitor the health status and needs of its community regularly and systematically; one of the three core functions of public health. Astrocytoma: most common type of primary brain tumour; also found throughout the central nervous system. Asymptomatic: not having any complaints or discomfort of a disease at present. Atherosclerosis: a pathological condition affecting the medium-sized and larger arteries, especially those that supply the heart (the coronary arteries), the brain (the carotid and cerebral arteries), and the lower extremities (the peripheral arteries), as well as the aorta; underlies the occurrence of heart attacks, many strokes, peripheral arterial disease, and dissection or rupture of the aorta. Attributable: the quality or characteristic that can be assigned to the element of interest. Average cost: total cost divided by total quantity. It provides the cost per unit. Beeri: a handmade form of cigarette made by the consumer by wrapping tobacco in Temburni leaves; although the quality of tobacco used is smaller than in the cigarette, the tar yield, nicotine and concentration of carcinogens released exceed that of an average cigarette. Behavioural change: an intervention approach that uses public information and education to promote behavioural patterns favourable to the population as a whole; also includes interventions (e.g., counseling) at the group or individual level for the same purpose. Behavioural patterns: in the present context, habits of living that influence health. (e.g., diet, physical activity, smoking). Blood cholesterol: the blood concentration of a family of lipid or fatty molecular compounds obtained directly from the diet or produced in the body from fatty dietary components; a necessary factor in development of atherosclerosis (see atherosclerosis); subtypes of cholesterol differ in their relation to CVD risk, with high-density lipoprotein (HDL) cholesterol considered good and low-density (LDL) cholesterol considered bad. Brand switching: consumer changing the item that he/she is using with another similar product of a different company. Burden of disease: the total significance of disease for society beyond the immediate cost of treatment. It is measured in years of life lost to ill health as the difference between total life expectancy and disabilityadjusted life years. Capacity-building: in the present context, capacity-building is the development of the technical expertise to plan, implement and evaluate interventions aimed at preventing or controlling non-communicable diseases in a variety of settings. Areas of expertise in capacity-building include problem identification, epidemiological and behavioural risk factor analysis, coalition-building, programme implementation, knowledge of intervention methodologies, process, impact and outcome evaluation, and the ability to obtain ongoing support and funding through administrative and legislative means, beyond the life of any particular source of funding. Carcinogens: items related to the cause of cancer. Cardiovascular disease(s): may refer to any of the disorders that can affect the circulatory system, but often means coronary heart disease (CHD), heart failure and stroke, taken together. Cardiovascular disease prevention: a set of interventions designed to prevent first and recurrent cardiovascular disease events (e.g., heart attack, heart failure and stroke). For cardiovascular diseases, primary prevention refers to detection and control of risk factors, whereas secondary prevention includes long-term case management for survivors of CVD events. Cardiovascular health promotion: a set of interventions designed to reduce a populations risk for CVD through policy, environmental, and behavioural changes; also supports other approaches that apply to people who have suffered recognized CVD events (e.g., by facilitating public access to emergency care or by fostering social/environmental and behavioural changes that reinforce secondary CVD prevention); sometimes identified with primordial CVD prevention; complements CVD prevention. Cardiovascular health: a combination of favourable health habits and conditions that protect against development of cardiovascular diseases. Case fatality rate: the proportion of cases of a disease event ending in death within a defined interval. Case-control study: in this study, people diagnosed as having a disease (cases) are compared with persons who do not have the disease (controls). The purpose is to determine if the two groups differ in the proportion of persons who had been exposed to a specific factor or factors. Causal association: we can define causal association by saying that A causes B. Certain theories describe an association to be causal if, (i) A is prior to B (ii) a change in A correlates with a change in B, (iii) this correlation is not because of another element e.g., C, D etc. Cerebral: related to the brain. Cluster randomization: in cluster randomization the population is divided into groups (clusters) and then a random (unsystematic, indiscriminate) sample of these groups or clusters is selected. Coalition-building: the establishment of a temporary alliance of fractions, parties, individuals or groups for a specific purpose. Community: a specific group of people, often living in a defined geographical area, who share a common culture, values and norms and are arranged in a social structure according to relationships which the community has developed over a period of time. Members of a community gain their personal and social identity by sharing common beliefs, values and norms, which have been developed by the community in the past and may be modified in the future. They exhibit some awareness of their identity as a group and share common needs and a commitment to meeting them. Community mobilization: a process aimed at enabling communities to understand and control the circumstances affecting their lives. It acknowledges that agents of change can be found wherever the decisions that affect peoples ability to influence their lives are made and implemented. Comprehensive public health strategy: an approach to a major health problem in the population that identifies and employs the full array of potential public health interventions, including health promotion and disease prevention.
Coronary heart disease: heart disease caused by impaired circulation in one or more coronary arteries; often manifests as chest pain (angina) or heart attack. Cost-intensive: measures needing high costs. Cross-sectional study: in the present context, a type of research study in which both risk factors and diseases are ascertained at the same time usually employing clinical tests, interviews and measures of exposures. Depression: mental state of depressed mood characterized by feelings of sadness, despair and discouragement. Diabetes (or diabetes mellitus): a metabolic disorder resulting from insufficient production or utilization of insulin, commonly leading to cardiovascular complications. Dietary imbalance: a pattern of dietary intake that lacks a desirable combination and overall intake to foods and nutrients to promote good health (e.g., excessive intake of saturated fat, salt, total calories). Disability-adjusted life expectancy: the number of healthy years of life that can be expected on average in a given population. It is generally calculated at birth, but estimates can also be prepared at other ages. Healthy life expectancy has the advantage of capturing all causes of disability across a population and relating these to life expectancy defined by mortality. Disability-adjusted life years: the number of healthy years of life lost due to premature death and disability. Disease prevention: disease prevention covers measures not only to prevent the occurrence of disease, such as risk factor reduction, but also to arrest its progress and reduce its consequences, once established. Domestic violence: trauma resulting from fight between members of a household. It usually manifests in the form of use of power by male against the female residents of a house. Dyslipidaemia: a condition in which there are abnormal levels of lipid and lipoproteins in blood and the ratio of various types of lipoproteins is also not normal. Effectiveness: a measure of the extent to which a specific intervention, procedure, regimen or service, when deployed in the field in routine circumstances, does what it is intended to do for a specified population. Efficiency: the capacity to produce the maximum output for a given input. Effluents: the discharges of production. Embryonic cell tumours: a type of cancer that arises from germ cells. Embryonic: related to the embryo (the foetus). Endemic: the constant presence of a disease or infectious agent within a given geographical area or the usual prevalence of a given disease within such area. Epidemiology: the study of the causes and prevention of disease in populations or communities, making it the main source of evidence for public health decision making. Evaluation framework: a description of how a programme is to be evaluated. Evaluation of a programme: an assessment of how a programme achieves its effects. It includes evaluation of the amount of resource inputs used, as well as a description of activities implemented and of outputs (intermediate outcomes, proximal impacts) of the programme. Evidence-based medicine: the use of agreed-upon standards of evidence in making clinical decisions for treating individual patients or categories of patients. Evidence-based public health: the use of agreed-upon standards of evidence in making decisions about public health policies and practices to protect or improve the health of populations. Experimental design: an experimental design seeks to ensure the initial statistical equivalence of a comparison (control) group and one
programme (experimental) group through the random assignment of individuals to each group. Experimental study: in an experimental study, the investigator directly controls conditions. In the field of epidemiology, an experimental study is one in which a population is selected for an intervention and the effects of the intervention are measured by comparing the outcomes in the experimental group with those in the control group. Ideally, the allocation of individuals to experimental and control groups is random. Extrapolate: assume and predict on the basis of available information. Fiscal: measures related to tax and tax policies. Gastroenterology: the branch of medical science that deals with diseases of the digestive system i.e., esophagus, stomach, intestine, pancreas, liver and gall bladder. Generalizability: the level at which the findings of a result can be attributed to a bigger population or the whole population of concern. Glial cancers: cancers arising from neurological tissues. Guidelines: systematically developed statements traditionally used to reinforce best practices. Health: a state of complete physical, social and mental well-being and not merely the absence of disease or infirmity. Health disparities: differences in the burden and impact of disease among different populations, defined, for example, by sex, race or ethnicity, education or income, disability, place of residence, or sexual orientation. Health education: health education comprises consciously constructed opportunities for learning involving some form of communication designed to improve health literacy. It includes improving knowledge and developing life skills that are conducive to individual and community health. Health promotion: the combination of educational and environmental supports for action and conditions of living conducive to health. The actions may be those of individuals, groups or communities, of policymakers, employers, teachers or others whose actions control or influence the determinants of health. The purpose of health promotion is to enable people to gain greater control over the determinants of their own health. In health promotion, health is seen as a resource for everyday life, not the objective of living. Health is a positive concept, emphasizing social and personal resources, as well as physical capabilities. Heart attack: an acute event in which the heart muscle is damaged because of a lack of blood flow from the coronary arteries, typically accompanied by chest pain and other warning signs but sometimes occurring with no recognized symptoms (i.e., silent heart attack). Heart disease: any affliction that impairs the structure or function of the heart (e.g., atherosclerotic and hypertensive diseases, congenital heart disease, rheumatic heart disease, and cardiomyopathies). High blood pressure: a condition in which the pressure in the arterial circulation is greater than desired; associated with increased risk for heart disease, stroke, chronic kidney disease, and other conditions; blood pressure is considered high if systolic pressure (measured at the peak of contraction of the heart) is greater than or equal to 140 mm Hg or if diastolic pressure (measured at the fullest relaxation of the heart) is greater than or equal to 90 mm Hg. High-risk approach: in the present context, an intervention strategy that targets only people with the highest levels of recognized cardiovascular disease risk factors for the purpose of reducing their level of risk to that of the most favourable level in the population; distinct from and complementary to the population-wide approach. Hukka: a device for smoking tobacco that is alike the Middle Eastern hubble bubble. Tobacco is heated in a pot and is made to pass through water cisterns before being inhaled through a long tube; the device is used for communal smoking. Hyperplasia: an excess proliferation of cells of the human tissues resulting in an abnormal increase in the size of the tissues.
Hypertension: see high blood pressure. Hypertensive heart disease: abnormality in the structure and function of the heart caused by long-standing high blood pressure; often manifests as heart failure. Impact: in the present context, the total, direct and indirect effects of a programme, service or institution on the health status and overall health and socio-economic development. Implementation plan: a list of activities to be organized or carried out, in a set order and according to a schedule, to accomplish a certain goal. The plan stipulates who does what and when, and may include information on the costs associated with each phase of the work. Implementation is also the act of converting programme objectives into actions, such as through policy changes, regulation and organization. Implications: assumption or reference that is drawn from certain findings or results. Incidence: the number of new cases of disease occurring in a population of a given size within a specified time interval. Indicator: a variable with characteristics of quality, quantity and time. It is used to measure, directly or indirectly, changes in a situation and to appreciate the progress made in addressing it. It also provides a basis for developing adequate plans for improvement. Individual approach: see high-risk approach. Input: resources such as money, materials and the time and skills of staff and volunteers. Institution: an organization or association established for the promotion of some object, especially one of public or general utility. INTER-HEART Study: a global case-control study to identify the risk factors for acute myocardial infarction in different ethnic populations. The Study is sponsored by WHO, World Heart Federation and International Clinical Epidemiology Network. Inter-sectoral action: in inter-sectoral action, the health sector and other relevant sectors collaborate to achieve a common goal. For practical purposes, inter-sectoral and multi-sectoral actions are synonymous. Inter-sectoral collaboration: a recognized relationship between part or parts of different sectors of society which has been formed to take action on an issue to achieve outcomes in a way which is more effective, efficient or sustainable than might be achieved by one particular sector acting alone. Intervention: an activity or set of activities aimed at modifying a process, course of action or sequence of events, in order to change one or several of their characteristics such as performance or expected outcome. Leukaemia: disease condition resulting from an abnormal proliferation of cells in the bone marrow leading to an increased number of circulating white blood cells. Life expectancy: the number of years of life that can be expected on average in a given population. Lifestyle: a way of living based on identifiable patterns of behaviour which are determined by the interplay between an individuals personal characteristics, social interactions, and socioeconomic and environmental living conditions. Living conditions: the everyday environment of people, where they live, play and work. These living conditions are a product of social and economic circumstances and the physical environment all of which are largely outside the immediate control of the individual. Malignancy: tumour in which the abnormal (cancerous) cells are transferred via different routes in the body at a rapid pace, invading and destroying normal tissue and the functions of that tissue. Malnutrition: any disorder of nutrition. It may be due to unbalanced or insufficient diet or defective assimilation or utilization of food.
Mania: psychiatric disorder characterized by agitation, hyperexcitability, hyperactivity and increased speed of thought and speech. Market intelligence: level of knowledge and information of various stakeholders in the market. Mass media: all the impersonal means by which visual and/or auditory messages are directly communicated to the public. Examples of mass media include television, radio and newspapers. Modifiable characteristics: factors that are amenable to change (e.g., diet, physical activity, and smoking), in contrast to those that are intrinsic to the individual (e.g., age, sex, race, genetic traits). Monitoring: regular observation of changes in some condition, either in a population or an individual, such as health status, or in an environment, such as levels of pollution, in order to determine whether an initiative is proceeding according to plan. Monitoring includes keeping track of achievements, staff movements and deployment, supplies, equipment, and money spent. The information gained from monitoring is used in evaluating the initiative. Morbidity: knowledge of the illness or diseased condition in a population. Various ratios are calculated to ascertain the morbidity level. Mortality: rate of death expressed as the number of deaths occurring in a population of a given size within a specified time interval. Naswar: orally used snuff. Network: the number and types of social relations and links between individuals and/or institutions that may provide access to or mobilize social support. Neurotrauma: injury involving brain or brain tissue (e.g., injury to head or spinal cord). Nicotine Replacement Therapy (NRT): a type of pharmacological treatment used as an aid to smoking cessation. It includes devices such as trans-dermal (applied on skin) patches, nicotine gum, nicotine nasal sprays and inhalers. Obesity: usually defined in terms of body mass index (BMI), which is calculated as body weight in kilograms (1 kg = 2.2 lbs) divided by height in meters (1 m = 39.37 in) squared; adults with a BMI of greater than or equal to 30.0 kg/m2 are considered obese, and those with a BMI of 25 29.9 kg/m2 are considered overweight. In children, overweight is defined as BMI greater than the 95th percentile value for the same age and sex group. Oncology: the branch of medical science that deals with the detection, identification and treatment of cancer. Opportunistic screening: the presumptive identification of unrecognized disease or defect by tests, examinations or other procedures which can be applied rapidly to sort out apparently well persons who probably have a disease from those who probably do not. This is done in a passive way at a health setting without having to go out to look for cases. Orifices: openings, mouths, outlets. Outcome: in the present context, a change in current or future health status or health-related behaviour that can be attributed to an intervention. In the field of health, the desired result or impact of a policy measure or other health intervention would be a positive change in health status or health behaviour. Outcome assessment: an outcome assessment is used to determine the short-term effects of an intervention on an identified population. Output: the products, services and other items, such as clinical preventive guidelines, regulations, tax law provisions, directly produced by a programme or organization. Overweight: see obesity. Paediatric: related to children. Passive smoking: inhaling cigarette, cigar, or pipe smoke produced by another individual. It is composed of second-hand smoke (exhaled by
the smoker), and side stream smoke (which drifts off the tip of cigarette or cigar or pipe bowl). Peripheral arterial disease: mainly atherosclerosis of the extremities; especially important in the lower extremities; also called peripheral vascular disease. Physical inactivity: lack of habitual activity sufficient to maintain good health, resulting in an unfavourable balance between energy intake and expenditure and fostering the development of overweight or obesity and other risk factors for heart disease and stroke. Planning: the process of defining needs, establishing priorities, diagnosing causes of problems, assessing resources and barriers, and allocating resources to achieve objectives. Policy: an agreement or consensus among relevant partners on the issues to be addressed and on the approaches or strategies needed to deal with the issues. Policy and environmental change: in the present context, an intervention approach to reducing the burden of chronic diseases that focuses on enacting effective policies (e.g., laws, regulations, formal and informal rules) or promoting environmental change (e.g., changes to economic, social, or physical environments). Policy framework: a conceptual structure based on consensus among major stakeholders that shows the relationship. Population-based data: health data that pertain to a defined, usually large, population (e.g., vital statistics, surveillance, results of population surveys). Population-wide approach: an intervention strategy that targets the population as a whole with regard to the risk levels of various subgroups; distinguished from and complementary to the high-risk approach. Prevalence: the frequency of a particular condition within a defined population at a designated time (e.g., 5.5 million men living with hypertension in 1994 or 34% of the population found to use tobacco in a survey conducted in Pakistan). Prevention: in the present context, approaches and activities aimed at reducing the likelihood that a disease or disorder will affect an individual, interrupting or slowing the progress of the disorder or reducing disability. Primary prevention reduces the likelihood of the development of a disease or disorder. Secondary prevention interrupts, prevents or minimizes the progress of a disease or disorder at an early stage. Tertiary prevention focuses on halting the progression of damage already done. Prevention research: in the present context, such research aims to prevent disease and promote health by developing and disseminating strategies applicable to public health programmes and policies. Preventive dose: the intensity and duration of appropriate public health interventions needed to achieve their goals; similar to the dose and duration of medical treatment sufficient to control or cure an illness. Primary health care: essential health care made accessible at a cost a country and community can afford, with methods that are practical, scientifically sound and socially acceptable. Primary prevention: a set of interventions, including the detection and control of risk factors, designed to prevent the first occurrence of noncommunicable diseases among people with identifiable risk factors. Primordial CVD prevention: a set of interventions targeting people without risk factors or CVD (including the maintenance or restoration of favourable social and environmental conditions and the promotion of healthy behavioural patterns) to prevent development of risk factors. Priority populations: in the present context, groups at especially high risk of cardiovascular diseases (e.g., those identified by sex, race or ethnicity, education, income, disability, place of residence, or sexual orientation). Process evaluation: an assessment of how a programme achieves its effects. This includes evaluation of the amount of resource inputs used, as well as a description of activities implemented and of outputs (intermediate outcomes, proximal impacts) of the programme.
Profile: a set of data, often presented in graphic form, that portrays the most significant features of a situation, such as the extent to which individuals or groups exhibit certain traits or characteristics. Programme: a set of projects designed to achieve common, long-term goals. Programme evaluation: a periodic review and assessment of a programme to determine, in light of current circumstances, the adequacy of its objectives and its design, as well as its intended and unintended results. Project: a group of planned activities linked by common short- to longterm objectives and managed by a single centre of responsibility. Promotion: a representation about a product or service by any means, whether directly or indirectly, including any communication of information about a product or service and its price and distribution, that is likely to influence and shape attitudes, beliefs and behaviours about the product or service. Psychosis: a behavioural disorder in which mental functioning is sufficiently impaired to interfere grossly with a patients capacity to meet the ordinary demands of life. Psychotropic drugs: drugs which exert an effect upon the mind, capable of modifying mental activity. Qualitative data: qualitative data are categorical rather than quantifiable observations, and often involve descriptions of attitudes, perceptions, intentions and activity. Quality of life: quality of life is defined as individuals perceptions of their position in life in the context of the culture and value system where they live, and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept. Randomized controlled trial: an experimental study of an intervention, most often a medical treatment, in which study participants are randomly assigned to treatment or comparison groups; much less often, communities rather than individuals are the units used to form treatment and comparison groups. Rehabilitation: an intervention approach designed to limit disability among survivors of cardiovascular disease events and reduce their risk for subsequent events. Retinal complications: damage to the nervous layer of the eye. Retrospective: a comparison with regard to the presence of certain elements in the past. Risk: the likelihood of incurring a particular event or circumstances. Risk assessment: in the present context, a measure to determine the chance or probability of acquiring a disease. The excess risk caused by exposure to a given factor is calculated by incidence rates of disease in exposed and non-exposed populations. Risk behaviour: in the present context, a behavioural pattern associated with increased frequency of specified health problems; for example, high salt intake, smoking, and binge drinking are all associated with CVD. Risk factor: in the present context, an individual characteristic associated with increased frequency for specified health problems; for example, high LDL cholesterol, high blood pressure, and diabetes are all associated with CVD. Risk factor detection and control: in the present context, an intervention approach that targets people with identifiable risk factors; includes both screening or other methods of detection and long-term disease management through changes in lifestyle, behaviour and medication, when necessary. Schizophrenia: a type of major mental disorder. Screening: in the present context, the identification of unrecognized disease or defect by the application of tests, examinations, or other procedures which can be applied rapidly to sort out apparently well persons who probably have a disease from those who probably do not. A screening test is not intended to be diagnostic.
Secondary prevention: in the present context, a set of interventions aimed at survivors of acute NCDs events (e.g., heart attack, heart failure, stroke etc) or others with known NCDs in which long-term case management is used to reduce disability and risk for subsequent NCDs events. Sigmoidoscopy: a procedure to examine the lower part of the intestines (sigmoid colon). Skill: the ability to use knowledge effectively and readily in the performance of a task. Smoke-free areas: areas where smoking or holding a lighted cigarette, cigar or pipe, berri, huqqa, chillim is banned. Social marketing: the development and implementation of programmes aimed at influencing people's ideas through the use of techniques and approaches similar to those employed in the marketing of goods and services, such as market research, product planning, communication and distribution. Stakeholders: parties who have a common interest in a project and have agreed in principle to support it. Depending on their affiliation, they will provide assistance with technical, material, financial or human resources. Strategy: a plan of action that is designed to achieve long-term goals, taking into account the resources available and barriers anticipated, as well as possibilities for collaboration among relevant stakeholders.
Stroke: sudden interruption of blood supply to the brain caused by an obstruction or the rupture of a blood vessel. Sub-clinical disease: presence of one or more forms of disease detectable only by special examination and not recognizable from signs or symptoms expressed by the affected person. Surveillance: a regular collection, summarization and analysis of data on a continuous basis. In the present context, surveillance involves the identification of high-risk groups in the population, understanding of mode of spread of disease and reduction or elimination of its transmission. Survey: see cross-sectional study Survival: remaining alive for a specified period. Symptomatic: feeling and showing the discomfort and complaints of disease. Validity parameters: sensitivity and specificity are the two main aspects of validity. Sensitivity of a test is defined as the ability of a test to identify correctly, those who have the disease. Specificity is defined as the ability of a test to identify correctly, those who do not have the disease. Venomous: poisonous.
Core Team
Dr. Sania Nishtar President and Executive Director Heartfile; Islamabad, Pakistan Dr. Khalif Bile Mohamud WHO Representative in Pakistan Islamabad, Pakistan Ejaz Rahim Cabinet Secretary Cabinet Division, Government of Pakistan Dr. Ashfaq Ahmed Deputy Director General, International Health Ministry of Health, Government of Pakistan Prof. Samad Shera President Diabetic Association of Pakistan; Karachi, Pakistan Matiullah Khan Senior Joint Secretary Ministry of Health, Government of Pakistan Dr. M. Shafiquddin Chief Planning Health Ministry of Health, Government of Pakistan Dr. Fareed A. Minhas Consultant Psychiatrist, Institute of Psychiatry Rawalpindi General Hospital; Rawalpindi, Pakistan Prof. Nasiruddin Azam Former Principal Khyber Medical College; Peshawar, Pakistan Dr. Ghazala Rafique Senior Lecturer, Department of Community Health Aga Khan University; Karachi, Pakistan Mohammad Nasir Khan Federal Minister for Health Ministry of Health, Government of Pakistan Tariq Farook Secretary Health Ministry of Health, Government of Pakistan Maj. Gen. (Rtd) Mohammad Aslam HI (M) Director General Health Ministry of Health, Government of Pakistan Prof. Naeem A. Jaffery Vice Chancellor Zia ud Din Medical University; Karachi, Pakistan Dr. Zafar Mirza Coordinator The Network for Consumer Protection; Islamabad, Pakistan Prof. Azhar M. A. Faruqui Executive Director National Institute of Cardiovascular Diseases; Karachi, Pakistan Dr. Faisal Sultan Consultant Physician Shaukat Khanum Memorial Cancer Hospital; Lahore, Pakistan Dr. Abdul Ghaffar Public Health Specialist World Health Organization; Geneva, Switzerland Prof. Kazi A. Shakoor Director Jinnah Postgraduate Medical Centre; Karachi, Pakistan Dr. Yasmeen Bhurgri Associate Professor, Pathology Unit Aga Khan University; Karachi, Pakistan
Cardiovascular Diseases
Prof. Shahryar A. Sheikh Consultant Cardiologist Lahore, Pakistan Prof. Mohammad A. Mattu Chief of Cardiology Pakistan Institute of Medical Sciences; Islamabad, Pakistan Maj. Gen. (Rtd) Ashur Khan Consultant Cardiologist Hearts International; Rawalpindi, Pakistan Maj. Gen. Mohammad Afzal Commandant Armed Forces Institute of Cardiology; Rawalpindi, Pakistan Prof. Abdus Samad Consultant Cardiologist Karachi, Pakistan Prof. Kalimuddin Aziz Professor Emeritus National Institute of Cardiovascular Diseases; Karachi, Pakistan Brig. Azhar Kyani Consultant Cardiologist Armed Forces Institute of Cardiology; Rawalpindi, Pakistan Prof. Khalida Soomro Chief of Cardiology Civil Hospital; Karachi, Pakistan
Dr. Mohammad Ishaq Consultant Cardiologist, Department of Advanced Cardiology National Institute of Cardiovascular Diseases; Karachi, Pakistan Dr. Manzoor Ahmed Executive Director, Consultant Cardiologist Capital Hospital; Islamabad, Pakistan Dr. Naveed Akhtar Chief of Cardiology KRL General Hospital; Islamabad, Pakistan Dr. Salma Majeed Rajpoot Medical Officer, Department of Cardiology Pakistan Institute of Medical Sciences; Islamabad, Pakistan Dr. Shaukat M. Malik Consultant Cardiologist Islamabad, Pakistan Dr. Syed Fazle Hadi Executive Director and Consultant Cardiologist Pakistan Institute of Medical Sciences; Islamabad, Pakistan Dr. Tazeen H. Jafar Assistant Professor and Chief of Nephrology Department Aga Khan University; Karachi, Pakistan Prof. Syed Hamid Shafqat Consultant Cardiologist Pakistan Cardiac Society; Karachi, Pakistan Maj Gen. (Rtd) Masud ur Rehman Kiani Chief Consultant Cardiologist Hearts International Hospital; Rawalpindi, Pakistan Prof. M. Hafizullah Chief of Cardiology and Consultant Cardiologist Peshawar, Pakistan Prof. Nusrat Ara Chief of Cardiology and Consultant Physician Rawalpindi General Hospital; Rawalpindi, Pakistan
Brig. M. M. H. Nuri Chief of Cardiology Armed Forces Institute of Cardiology; Rawalpindi, Pakistan Prof. Hafeez Akhtar Former Chief of Medicine Pakistan Institute of Medical Sciences; Islamabad, Pakistan Prof. Mansoor Ahmed Chief of Cardiology Liaquat National Hospital; Karachi, Pakistan Prof. Khan S. Zaman Consultant Cardiologist National Institute of Cardiovascular Diseases; Karachi, Pakistan Dr. Salma H. Badruddin Associate Professor, Department of Medicine Aga Khan University; Karachi, Pakistan Prof. Nazir Memon Chief of Cardiology Department Liaquat University of Medical and Health Sciences; Hyderabad, Pakistan Dr. Javed Ismail Research Coordinator, Department of Clinical Epidemiology Aga Khan University; Karachi, Pakistan Dr. Khabir Ahmad Coordinator, Clinical Epidemiology Unit Aga Khan University; Karachi, Pakistan Dr. Asma Badar Public Health Officer Heartfile; Islamabad, Pakistan Dr. Shafqat M. Zaidi Physician Zaidi Medical Centre; Chakwal, Pakistan
Diabetes
Prof. Samad Shera President Diabetic Association of Pakistan; Karachi, Pakistan Dr. Zia ul Hassan Consultant Physician, Department of Diabetes and Endocrinology Khattak Medical Centre; Peshawar, Pakistan Dr. A. H. Amir Endocrinologist, Department of Endocrinology and Diabetes Hayatabad Medical Complex; Peshawar, Pakistan Dr. Ghazala Rafique Senior Lecturer, Department of Community Health Aga Khan University; Karachi, Pakistan Dr. Ijaz Sohail Deputy Medical Superintendent District Headquarters Hospital; Rawalpindi, Pakistan Dr. Jamal Zafar Consultant Physician Pakistan Institute of Medical Sciences; Islamabad, Pakistan Dr. Lubna Zuberi Assistant Professor, Department of Endocrinology and Diabetes Aga Khan University; Karachi, Pakistan Dr. Saeed ul Majeed Convenor National Organization of Family Doctors; Peshawar, Pakistan Prof. Shahid Mehmood Consultant Physician Hameed Latif Hospital; Lahore, Pakistan Dr. Abdul Jabbar Assistant Professor, Department of Endocrinology Aga Khan University; Karachi, Pakistan
Cancer
Dr. Azhar Qureshi Former Chief of Department of Oncology Pakistan Institute of Medical Sciences; Islamabad, Pakistan Dr. Bilal Naqvi Consultant Oncologist Shaukat Khanum Memorial Cancer Hospital; Lahore, Pakistan Prof. Naeem A. Jaffery Vice Chancellor Ziauddin Medical University; Karachi, Pakistan Dr. Faisal Sultan Consultant Physician Shaukat Khanum Memorial Cancer Hospital; Lahore, Pakistan Dr. Farhana Badar Epidemiologist Shaukat Khanum Memorial Cancer Hospital; Lahore, Pakistan Dr. Farkhanda Ghafoor Research Officer, National Health Research Complex Pakistan Medical Research Council; Lahore, Pakistan Dr. Irfan A. Vaziri Assistant Professor, Oncology Unit Aga Khan University; Karachi, Pakistan Dr. Misbah Masood Principal Medical Officer Shaukat Khanum Memorial Cancer Hospital; Lahore, Pakistan Dr. Najamuddin Consultant Radiologist Shaukat Khanum Memorial Cancer Hospital; Lahore, Pakistan Dr. Natasha Anwar Molecular Biologist Shaukat Khanum Memorial Cancer Hospital; Lahore, Pakistan Dr. Qasim M. Buttar Senior Registrar, Oncology Unit Pakistan Institute of Medical Sciences; Islamabad, Pakistan Dr. Shahid Hameed Consultant Oncologist Shaukat Khanum Memorial Cancer Hospital; Lahore, Pakistan Dr. Shakeb A. Younus Consultant Oncologist Shaukat Khanum Memorial Cancer Hospital; Lahore, Pakistan Brig. M. Luqman Deputy Commandant and Chief, Department of Histopathology Armed Forces Institute of Pathology; Rawalpindi. Pakistan Dr. Yasmeen Bhurgri Associate Professor, Pathology Unit Aga Khan University; Karachi, Pakistan Dr. Zeba Aziz Professor, Oncology Unit Allama Iqbal Medical College; Lahore, Pakistan Dr. Junaida Hatchar Associate Professor of Biostatistics Aga Khan University; Karachi, Pakistan Dr. Abdul Qayyum Consultant Oncologist Pakistan Institute of Medical Sciences; Islamabad, Pakistan
Dr. Alia Zaidi Consultant Pediatric Oncologist Shaukat Khanum Memorial Cancer Hospital; Lahore, Pakistan
Dr. Burhan A. Khan Senior Registrar, Oncology Unit Pakistan Institute of Medical Sciences; Islamabad, Pakistan
Injuries
Dr. Abdul Ghaffar Public Health Specialist World Health Organization; Geneva, Switzerland Dr. Shahzad A. Khan Senior Research Officer Heartfile; Islamabad, Pakistan Helena I. Saeed Deputy Director National Police Bureau; Islamabad, Pakistan Dr. Imran S. Khan Associate Professor, Department of Orthopedics Pakistan Institute of Medical Sciences; Islamabad, Pakistan Mumtaz H. Malik Assistant Chief, Highway Safety National Transport Research Council; Islamabad, Pakistan Dr. Nisar Ahmed Chief Medical Officer National Highway and Motorway Police; Islamabad, Pakistan Dr. Tayyeb I. Masood Public Health Officer Health Services Academy; Islamabad, Pakistan Dr. Rakhshanda Perveen Executive Vice President SACHET; Islamabad, Pakistan Dr. Zulfiqar Cheema Senior Superintendent Police, National Police Academy; Islamabad, Pakistan Dr. Ahsan Aurangzeb Postgraduate Trainee, Department of Neurosurgery Pakistan Institute of Medical Sciences; Islamabad, Pakistan Dr. Faisal Mansoor Deputy Director National Institute for Handicapped; Islamabad, Pakistan Dr. Ehtesham Ghani Postgraduate Trainee, Department of Neurosurgery Pakistan Institute of Medical Sciences; Islamabad, Pakistan
Mental Health
Prof. Malik H. Mubbashar (SI, HI) Vice Chancellor University of Health Sciences; Lahore, Pakistan Prof. Mussarat Hussain Professor, Psychiatry Unit Jinnah Postgraduate Medical Centre; Karachi, Pakistan Dr. Najma Najam Vice Chancellor Fatima Jinnah Women University; Rawalpindi, Pakistan Dr. Khalid Saeed Associate Professor, Institute of Psychiatry Rawalpindi Medical College; Rawalpindi, Pakistan Dr. M. Yunus Khan Consultant Psychiatrist Islamabad Private Hospital; Islamabad, Pakistan Dr. Saeed Farooq Chief, Psychiatry Department Lady Reading Hospital; Peshawar, Pakistan Dr. Asma Humayun Assistant Professor, Institute of Psychiatry Rawalpindi Medical College; Rawalpindi, Pakistan Dr. Asad Tamizuddin Consultant Psychiatrist, Institute of Psychiatry Rawalpindi General Hospital; Rawalpindi, Pakistan Dr. Fuad Khan Psychiatrist Shafique Psychiatry Clinic; Peshawar, Pakistan Dr. Ghulam Rasool Assistant Professor Bolan Medical College; Quetta, Pakistan Dr. Najma Aziz Psychiatrist Federal Government Services Hospital; Islamabad, Pakistan Dr. Zulfiqar Ali Department of Psychiatry Combined Military Hospital; Peshawar, Pakistan Dr. Riaz Ahmed Medical Specialist District Headquarters Hospital; Attock, Pakistan Prof. Fareed A. Minhas Chief, Institute of Psychiatry Rawalpindi Medical College; Rawalpindi, Pakistan Prof. Dr. Khalid Mufti Principal Khyber Medical College; Peshawar, Pakistan Dr. Mowaadat Rana Chief, Psychiatry Unit Military Hospital; Rawalpindi, Pakistan Dr. Laeeq Mirza Psychologist Shifa International Hospital; Islamabad, Pakistan Dr. Aftab Khan Psychiatrist Islamabad, Pakistan Dr. Mazhar Malik Chief, Department of Psychiatry Fauji Foundation Hospital; Rawalpindi, Pakistan Dr. Nassar S. Khan Chief, Psychiatry Department Services Hospital; Lahore, Pakistan
Dr. Saniya Akhtar Consultant Psychiatrist KRL Hospital; Islamabad, Pakistan Dr. M. Idrees Psychiatrist Hayatabad Medical Complex; Peshawar, Pakistan Dr. Munir Slatch Registrar, Institute of Psychiatry Rawalpindi General Hospital; Rawalpindi, Pakistan
Rashida S. Niazi Clinical Psychologist, Institute of Psychiatry Rawalpindi General Hospital; Rawalpindi, Pakistan Shazia Haris Clinical Psychologist Islamabad, Pakistan Iram Gul Lecturer, Behavioural Sciences Fatima Jinnah Women University; Rawalpindi, Pakistan
NCD-Related Areas
Hamid Yar Hiraj State Minister for Health Ministry of Health, Government of Pakistan Dr. Abdul M. Rajpoot Chief, National Health Policy Unit Ministry of Health, Government of Pakistan Dr. Ahmed A. Mirza Executive Director, Medical and Marketing Highnoon Laboratories Ltd; Lahore, Pakistan Dr. Qasim Ayub Deputy Director, Biomedical and Genetic Engineering Division AQ Khan Research Laboratories; Islamabad, Pakistan Dr. Assai Ardakani Medical Officer World Health Organization; Islamabad, Pakistan Dr. Tasleem Akhtar Executive Director Pakistan Medical Research Council; Islamabad, Pakistan Dr. Capt. Mohammad Raza Director Health Services Academy; Islamabad, Pakistan Dr. Sarwar J. Zuberi (Late) Editor Journal of Pakistan Medical Association; Karachi, Pakistan Dr. M. I. Chaudhary WHO Operations Officer, Punjab World Health Organization; Lahore, Pakistan Maj. Gen. Abdul Q. Usmani Secretary Health, Azad Jammu and Kashmir General Headquarters; Rawalpindi, Pakistan Dr. Jahangir A. Khan Chief Research Officer Pakistan Medical Research Council; Islamabad, Pakistan Prof. Tariq Nishtar Chairman, Pakistan Red Crescent Society (NWFP) Peshawar, Pakistan Abdul Jalil DFA Health Ministry of Health, Government of Pakistan Dr. Fahim Arshad Malik Deputy Director General, Department of Planning and Development Ministry of Health, Government of Pakistan Dr. Zahid Larik Deputy Director General, Department of Family Planning and Primary Health Care Ministry of Health, Government of Pakistan Dr. Faizullah Kakar Epidemiologist World Health Organization; Islamabad, Pakistan Dr. Haroon Jehangir Deputy Director General, Department of Nutrition Ministry of Health, Government of Pakistan Dr. Sohail K. Hashmi Secretary Pakistan Medical and Dental Council; Islamabad, Pakistan Dr. Khalida Kazmi Senior Research Officer Pakistan Medical Research Council; Islamabad, Pakistan Dr. Saima Hamid Instructor Health Services Academy; Islamabad, Pakistan Dr. Junaida Sarfaraz Instructor Health Services Academy; Islamabad, Pakistan
Research Team
Dr. Shahzad A. Khan
Senior Research Officer Heartfile; Islamabad, Pakistan
Yasir A. Mirza
Manager IT Heartfile; Islamabad, Pakistan
Umer Kamal
Research Officer Heartfile; Islamabad, Pakistan
Shahina Maqbool
Consultant Editor Heartfile; Islamabad, Pakistan
Azhar Iqbal
Research Officer Heartfile; Islamabad, Pakistan
Aamra Qayyum
Research Assistant Heartfile; Islamabad, Pakistan
Kathy Douglas Team Leader, Behavioural Risk Factor Surveillance World Health Organization; Geneva, Switzerland
Diabetes
Prof. Franklin White President, Pacific Health and Development Sciences Victoria, Canada Dr. Amanda I. Adler Diabetes Trials Unit Oxford Centre Diabetes Endocrinology Metabolism; Oxford, UK Dr. Felix Burden Consultant, Community Diabetologist Birmingham, UK Dr. Gojka Roglic Technical Officer, Diabetes Programme World Health Organization; Geneva, Switzerland Prof. John Turtle Professor Emeritus of Medicine University of Sydney, Australia Prof. Nishi Chaturvedi Professor of Clinical Epidemiology Imperial College; London, UK Prof. Clive Cockram Professor of Medicine The Prince of Wales Hospital, Hong Kong Prof. Paul Zimmet Director International Diabetes Institute; Canfield, Victoria, Australia Prof. Pierre Lefebvre Professor Emeritus of Medicine, University of Liege President, International Diabetes Federation, Belgium Prof. Ramachandran Director, Diabetes Research Centre Hospital for Diabetes; Chennai, India Prof. Rhys Williams Professor of Clinical Epidemiology University of Wales; Swansea, UK Prof. Knut Borch-Johnson Professor of Clinical Epidemiology Aarhus University; Gentofte, Denmark Prof. Sir George Alberti Professor Emeritus of Medicine University of Newcastle Medical School; Newcastle, UK
Cancer
Prof. Franklin White President, Pacific Health and Development Sciences Victoria, Canada Dr. Cecilia Sepulveda Coordinator, Cancer Control Programme World Health Organization; Geneva, Switzerland Dr. Andreas Ulrich World Health Organization; Geneva, Switzerland Prof. Vikram Bhadrasian Chief, Section of Applied Radiation Biology and Radiotherapy International Atomic Energy Agency; Vienna, Austria
Injuries
Dr. Abdul Ghaffar Public Health Specialist, Global Forum for Health Research World Health Organization; Geneva, Switzerland Dr. Mohammad Daya Associate Professor, Department of Emergency Medicine Oregon Health and Sciences University; Portland, USA Dr. Phillip Graitcer Adjunct Professor, Rollins School of Public Health Emory University; Atlanta, USA Dr. Rich Waxwieler Centers for Disease Control and Prevention; Atlanta, USA Dr. Stephen Luby Medical Epidemiologist, Foodborne and Diarrheal Branch, Centers for Disease Control and Prevention; Atlanta, USA Dr. Junaid A. Razzak Assistant Professor, Department of Emergency and Center for Injury Control, Emory University; Atlanta, USA Prof. David Bishai Associate Professor, Health Economics John Hopkins University; Baltimore, USA Prof. Gopolokrishnan Gururaj Chief, WHO Collaborating Centre for Injury Prevention National Institute of Metal Health and Neurosciences; Bangalore, India Dr. Adnan Hyder Assistant Professor, Centre of Injury Research and Policy John Hopkins Bloomberg School of Public Health, USA
Mental Health
Prof. Norman Sartorius Former Director, Division of Mental Health World Health Organization; Geneva, Switzerland Dr. Benedetto Saraceno Director, Department of Mental Health and Substance Abuse World Health Organization; Geneva, Switzerland Dr. Ahmad Mohit Regional Advisor for Mental Health WHO, EMRO; Cairo, Egypt Prof. Eve C. Johnstone MRC Research Administrator/Data Management Royal Edinburgh Hospital; Scotland, UK Sir David Goldberg Professor Emeritus, Institute of Psychiatry Kings College; London, UK Dr. David B. Mumford Director of Medical Education and Reader in Cross Cultural Psychiatry University of Bristol; Bristol, UK Prof. Racheal Jenkins Director, World Health Organization, Collaborating Centre and Chief of Section of Mental Health Policy Kings College, London, UK Prof. Ian Hickie Director, Brain and Mind Research Institute University of Sydney, Australia Dr. Keith G. Bender Consultant Psychiatrist Royal Perth Hospital; Perth, Australia