Over the last few weeks, Pakistani doctors have staged several strikes and taken to the streets to protest. The most recent strike ended on Monday morning after a 20-day work stoppage.
The chief demand of these physicians, most of them young and based at public facilities in Punjab Province, has been the establishment of a formal pay structure-one allowing for regular promotions to higher pay scales-already available to other public servants in Pakistan. "I have personally seen doctors who have served for more than 18 years and still remain in the same pay scale," one young doctor wrote several days ago.
The doctors' discontent, however, represents only one symptom of the disease afflicting Pakistan's troubled medical field.
Recall, for example, the much-publicized case of Imanae Malik. This three-year-old girl died at Doctors Hospital in Lahore in 2009 after an ER doctor (who her parents claim was half asleep) injected her with too much anesthesia-even though Malik had been admitted for a small burn on her hand (Malik's father now runs a website that catalogues dozens of other allegations of mistreatment at the same hospital). Or consider the seven newborns who burned to death last month in a fire caused by a short circuit in the nursery of another Lahore hospital. Grieving parents alleged that the hospital had no fire extinguishers, and witnesses reported that hospital staff ran away from the burning room instead of attempting to save the babies (hospital spokespeople later clarified that extinguishers were present, but staff didn't know how to use them).
Unfortunately, such medical malpractice and negligence are legion in Pakistan. One recent report tells of a surgeon who left a pair of scissors inside a man's stomach; of a doctor who removed a teenager's appendix when the actual diagnosis was colorectal cancer; and of physicians' constant failure to detect common jaundice in newborns, leading to many deaf and brain-damaged babies. Little wonder the striking doctors have not garnered overwhelming public support; some Pakistanis have denounced them as "heartless" and even as "miscreants"-an epithet the nation often invokes against terrorists.
Incompetence may be partially to blame, yet these problems are largely attributable to a severely overburdened and underresourced medical profession. In most rural areas, there are more than 1,200 patients for every doctor; another estimate finds that, nationwide, there are 18,000 people for every doctor. These are profound paucities for one of the world's sickest nations. No country has more polio cases, only Nigeria suffers more stillbirths, and only five nations have more tuberculosis patients. A third of Pakistan's population is undernourished, and nearly half of it lacks access to safe water. Meanwhile, according to an Al Jazeera study, up to 16 percent of Pakistanis suffer from mental illness-and the ratio of severely-ill patients to doctors is 2,000 to 1. Not surprisingly, doctors speak of having to work for 28 days per month and up to 30 hours in a row.
Unfortunately, government support is woefully insufficient. Only 0.2 percent of the 2012-13 federal budget is expected to be allocated to the health sector (this compares to 24 percent for the United States). In fiscal year 2010-11, a mere 0.27 percent of GDP went to health. A doctor fresh out of medical school working for a public sector facility receives about $250 per month, claim those who have gone on strike; by comparison, a court stenographer receives nearly $700 (last year Islamabad announced doctors' salaries would be increased to about $530 a month; it's unclear if this change has gone into effect).
With overworked, underpaid medical workers facing a constant stream of patients, the Hippocratic Oath is often turned on its head. According to doctors speaking anonymously, harried medical staff-in their haste to get to the next patient-become careless and leave surgical materials (from cotton to the aforementioned scissors) inside patients' bodies. And in their desperation to earn more income, physicians often tamper with pathology reports to justify surgery-which can generate lucrative fees-even if prescribing medication is the proper course.
Predictably, in light of this sad state of affairs, Pakistani doctors often voice a desire to leave the country. Many have already done so-and quite a few have come to the United States. According to a New York Times study, doctors account for the fourth most common profession of Pakistan-born U.S. workers. The Association of Physicians of Pakistani Descent of North America (APPNA)-which just held its annual convention at the cavernous Gaylord Convention Center near Washington, DC-is one of the larger Pakistani diaspora organizations in America.
Still, many choose to continue practicing in Pakistan, despite the problems-and the risks. I recently spoke with a young vascular surgeon based at one of the country's better public hospitals. His main concern is not a low salary or high caseload, but rather his own safety. He told me that frustrated people-denied care, or forced to endure long waiting periods-often roam around the hospital looking for doctors to beat up. The problem is so severe, he said, that he wears his telltale scrubs only when absolutely necessary.
Ultimately, Pakistan's medical crisis exemplifies the disparities between the nation's public and private sectors. The most overburdened and underpaid doctors-and those on the picket lines-work for public institutions. Private medical care is generally more expensive but of better quality and more sufficiently resourced than public care (the private Doctors Hospital, where Imanae Malik died, is one of the few exceptions).
A stark illustration of this public-private divide is ambulatory services. Several years ago, the Karachi mayor's office presented me with a glossy publication highlighting the city government's accomplishments. One photo depicted a fleet of new and sleek government-issued ambulances. Yet today, they likely no longer exist. According to media reports last month, Karachi's few public ambulances have been abandoned due to technical problems, "and are rusting away somewhere." A bevy of private ambulance operators have filled this vacuum. They include the Edhi Foundation, run by octogenarian philanthropist Abdul Sattar Edhi, which manages hundreds of ambulances. Across the nation, the supply and capacity of private ambulances far outstrip those of publicly provided ones. (Sindh's health minister has even suggested that public ambulances have been used for shopping excursions instead of emergency response.)
Pakistan's medical crisis is unlikely to be resolved unless the Pakistani government takes several unprecedented steps. One is to allocate more public funding to the health sector-an adjustment that may not please Pakistan's powerful military, which for years has enjoyed a disproportionate share of the national budget. Another is to actually implement (as opposed to merely formulate or approve) public policies that seek to improve the health of the Pakistani people.
Unfortunately, Islamabad seems to be moving in a very different direction. Last year, the government passed the 18th constitutional amendment, which devolves many central government functions to the provinces. The responsibilities and resources of Pakistan's federal health ministry have been passed on to provincial governments-which lack the capacities to take on such a vastly expanded portfolio.
Additionally, Pakistan's private sector is playing an increasingly prominent role in medical care; it presently accounts for about 80 percent of outpatient health care visits. On one level, given the crisis in public care, this is a welcome development. Promising new initiatives abound, including one called Naya Jeevan. For a nominal monthly fee, this program offers low-income domestic household workers and uninsured factory laborers access to private health care services.
However, the growth of private medical care is of no use for the millions of poor and unemployed who can afford neither the high standard costs of private care nor the subsidized costs levied by the likes of Naya Jeevan. And expanded private health services offer little consolation to the overburdened public sector doctors who must minister to Pakistan's public care-dependent ill and impoverished.
The takeaway? As is often the case, the Pakistani masses-and those charged with helping them-are the biggest losers.
Michael Kugelman is the South Asia associate at the Woodrow Wilson International Center for Scholars in Washington, DC. He can be reached by email at firstname.lastname@example.org and on Twitter @michaelkugelman.
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In mid-June, after the fifth drone strike in two weeks, militant leader Hafiz Gul Bahadur of North Waziristan resorted to taking hostages. No Americans being readily available, Bahadur decided that the Western-funded effort to eradicate polio would suffice, declaring a ban on vaccinations until U.S. drone strikes cease. Militant leader Mullah Nazir of South Waziristan soon followed suit, announcing his own ban on June 26th.
From Bahadur's perspective, there is something to the argument that drone strikes do more damage than polio. North Waziristan suffered from only 14 new polio cases last year, even as U.S. drone strikes killed over 250 of its residents, many of them armed militants allied with Bahadur. Of course, that these same militants are in fact largely responsible for both the mayhem and the public health crisis in Waziristan likely doesn't enter into Bahadur's calculations. As it stands, however, the polio vaccination campaign in the Federally Administered Tribal Areas (FATA) matters more to outsiders than it does to the tribal areas' residents themselves, and as such it provides a tempting target for militant groups desperate for any kind of leverage over the United States.
Bahadur's and Nazir's bans fit into a broader pattern of Pakistani militants using intimidation and violence to halt polio vaccination campaigns in FATA. Militants have long spread rumors that the vaccines are part of a Western conspiracy to sterilize or poison Muslims, leading to high rates of vaccination refusal. Extremist groups have specifically targeted health workers for kidnapping or assassination, killing the head of the polio vaccination campaign in Bajaur in 2007.
The United States stands behind both drone strikes and health programs in FATA, blurring the lines between the two. This has always created tension, as seen in the debate over USAID's on-again/off-again demand that its programs in FATA be overtly branded as "from the American people," even as those carrying out such programs are labeled as spies and targeted by militants. Suspicions of U.S.-funded health programs have been compounded by revelations that CIA informant Dr. Shakil Afridi attempted to collect information on Osama bin Laden's family in Abbottabad under the guise of a vaccination campaign.
Pakistan's remaining polio sanctuaries have become closely linked with anti-Western militancy and pose a growing challenge to the worldwide effort to eradicate polio. Globally, this effort has succeeded in reducing the annual incidence of polio from over 350,000 cases in 1988 to less than 700 in 2011. The eradication campaign has foundered with the increase in militancy in Pakistan, however, as polio cases there have risen each year since 2005. Last year Pakistan was responsible for more cases than any other country, most of which were concentrated in the Pashto-speaking areas along the Afghan border, including Waziristan.
Polio can easily spread from the tribal areas to elsewhere in the country. Labor migration and conflict have resulted in regular movement between Waziristan and Karachi, where polio has repeatedly surfaced. From the sprawling port city's volatile slums the disease can spread onward, back to India, Bangladesh, and other countries which earlier rid themselves - at least temporarily - of polio. This potential danger was underscored in late 2011, when the World Health Organization traced China's first polio outbreak in ten years back to Pakistan.
In addition to Pakistan, polio remains endemic only in Afghanistan and Nigeria. In all three countries it occurs nearly exclusively in Muslim areas home to anti-Western insurgencies. Polio persists here for two reasons: militants deny vaccination teams access to areas under their control and parents refuse to let their children be vaccinated. Both of these can be traced back to fears that vaccination is part of an anti-Muslim plot. These fears, however laughable they may appear to outsiders, need to be taken seriously.
The global campaign must be transformed into a Muslim-led effort if it is to eradicate polio from these remaining sanctuaries. Through no fault of their own, the World Health Organization's director for Global Polio Eradication, Dr. Bruce Aylward, and representative in Pakistan, Dr. Guido Sabatinelli, are no longer the most effective choices for the campaign's visible leadership. Polio has been eradicated in Muslim-majority countries as varied as Indonesia, Saudi Arabia, and Tajikistan, leaving behind a capable cadre of public health officials who could take over such posts.
Western funding and technical support will remain necessary,
but it should be discretely channeled through the World Bank or World Health
Organization. The United States in particular must publicly disassociate itself
from the vaccination effort. The Organization of Islamic Cooperation needs to
help provide funds for polio eradication, securing at least token donations
from all its poorer member states and significant amounts from the wealthier
members. Polio concerns all Muslim-majority countries; if eradication continues
to falter it is only a matter of time before the annual Hajj pilgrimage, attracting
hundreds of thousands of Muslims from across the world, becomes a site of polio
At the national level, Pakistan must continue its efforts to brand polio vaccination as Islamic. Some progress has already been made in securing the support of religious and nationalist leaders such as Imran Khan and Fazlur Rehman. International religious figures popular among FATA Pashtuns, including Dr. Zakir Naik of India and Imam Abdul Rehman al-Sudais of Saudi Arabia should also be encouraged to lend public support to Pakistan's eradication efforts. If jihadist figures such as Hafiz Saeed of Lashkar-e-Taiba are willing to pose for photo-ops giving oral vaccination drops to three year olds, that too would be helpful.
For FATA residents to care about polio vaccination, this public relations campaign should be expanded to include health issues with a more immediate and devastating impact. In 2002, the World Health Organization found that tetanus was responsible for over a fifth of all infant mortality in FATA. Taking into account population and birth rate estimates, this suggests a rough figure of at least two thousand infants in FATA dying every year from tetanus alone, which is easily prevented with proper vaccinations for expecting mothers. The same militants who have banned the anti-polio campaign have also kept health workers from saving these and the thousands of other children who die from preventable diseases in FATA. The tribal areas' residents should be enlisted in the effort to pressure militants to cease banning health programs as a weapon in their struggle against the Pakistani Government and the United States. To do this requires speaking to their concerns and assuaging their fears of foreign-funded vaccination campaigns.
Events along the remote Afghanistan-Pakistan border have a global impact for two reasons: terrorism and polio. Despite Bahadur's and Nazir's threats, U.S. drone strikes will continue in Waziristan, and perhaps the tribal areas will eventually fade as a center of anti-Western terrorism. In order for polio eradication to succeed, however, it must be separated from the United States and its drone strikes. It will be much easier to make the polio eradication campaign Islamic than it will be to erase anti-Western sentiment in FATA and other polio-endemic areas. Only by handing over the reins - and the credit - for polio eradication to Muslims, will Waziri, Pakistani, and American children together live in a polio-free world.
Sean Mann is currently in the Masters of Science in Foreign Service program at Georgetown University. He speaks Pashto, and recently spent a year conducting research on the border areas of Afghanistan and Pakistan.
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My article criticizing certain rituals in the Shi'a Muslimtradition in Pakistan's Express Tribune on December 8 spurred a firestorm ofcontroversy, as a number of commentators deemed it inappropriate or worse. Myargument was that religious adherents need to repudiate rituals that infringeon collective rights, and which can escalate sectarian conflict; these includethe rituals during the commemoration of Muharram, that can involve men and evenchildren flagellating themselves withknives on chains, and processions of bleeding men as a display of adoration forthe martyred Imam Husain (this is byno means reflective of all Shi'a practice, but is widely practiced amongSouth Asian Shi'a).
The controversy grew more intense on Twitter, and evennotable commentators such as NasimZehra asked for an immediate apology from the Tribune on grounds that thearticle was "outrageously offensive."To her credit, Ms. Zehra later noted thatafter the apology the matter should be closed. However, hate mail from all over followed,including several messages to the president of the University of Vermont (whereI teach) asking for my dismissal, a surprising torrent against free speech evenfrom highly educated writers. The university noted that the article was wellwithin the confines of free speech and was in fact condemning violence. Insteadof admonishing me, the university offered me police protection.
Under pressure from sponsors and amid fears that other mediahouses would use this episode to spur a consumer boycott, Tribune decided tofirst edit and then completely remove the article, and noted that I was"banned" from writing in their pages again. My intention was never to rebukeShi'ism itself, but rather such rituals whose practice further leads toacrimony between Shi'a and Sunnis. Furthermore, a ritual with so much bloodbeing spilled in a procession can be a public health issue, and has been repeatedlyquestioned and curtailed in Iran, Syria, and Lebanon.
Ireposted the article on my site with a clear apology for specificstatements which were, in retrospect, inflammatory for Pakistan's religioussensibilities. The newspaper's "ban" on my writing was later edited out of the apology statement posted onthe Internet, but this episode left me deeply troubled about the state ofjournalistic independence in Pakistan. The country has a vibrant civil societyand promising career track for journalists and independent writers, but therehas been a rapidrise in abductions and murders of journalists whose views were consideredantithetical to certain religious perspectives.
This episode highlighted for me a larger issue of mediafreedom in a country which often prides itself in having private TV channelswith fiery talk shows blasting politicians. Yet religious debate, often socontentious and even violent in Pakistan, remains off limits. Pakistan as asociety needs to understand that the right to offend in journalism is afundamental right. I don't mind getting hate mail despite the norms of freespeech, but what surprised me was that educated people questioned my right tocriticize a cultural practice by referring to it as "hate speech." I wasrepeatedly asked what my point was if criticism could further cause conflict. Stillanother asked, "could you criticize Jewish rituals the same way in America?" Thiskind of reaction could have taken place in many Muslim societies -- and Sunnisare equally culpable on such matters as Shi'a.
Pakistan's infamous blasphemylaws are a result of exactly this kind of oversensitivity and pattern ofraising ire following any hint of criticism about religious rituals or edicts.The valorization of extreme religious edicts by the State has unfortunatelybeen successful in co-opting the sensibilities of even many educated citizens. Thisin turn has strengthened the religious establishment's efforts toinstitutionalize a radical inertia within the political system. Perhaps unwittingly, liberal commentators whowould rather avoid tougher issues of dissent scorned my article, and by doingso strengthened the same kinds of arguments that fanatics use to marginalizeminorities or their opponents.
Ironically, in my article, I clearly stated that lawsagainst hate speech must be enforced. Speech that directly urges violence towardsany particular person or group of people must be avoided at all costs. Yet tounderstand sectarian conflict, which is often compared to "cancer," we have tolook at both proximate and systemic causes. Just as one treats cancer withchemotherapy, groups like Lashkar-e-Jhangvi(LeJ) need to be hunted down for terrorist crimes. But we also need to searchfor systemic causes of sectarian strife, which in Pakistan can be traced totheology in both Shi'a and Sunni doctrines as well as political interventionand alleged statesupport for sectarian groups like LeJ or Sipah-e-Sihaba Pakistan (SSP).
In a pluralistic society, the limits of what is allowed insuch cases can be debated and questioned, and laws can be passed and changedthrough democratic processes. For example, there are laws in some Europeancountries against questioning the historical validity of the Holocaust, but inthe United States, such historical questioning is protected by the firstamendment to the U.S. constitution (despite the repeated accusations by many Pakistanisthat American law and politics reflect undue Jewish influence). While Idisagree with the limitations on free speech in Europe, there is at least aworkable legislative pathway for repeal of these laws. In Pakistan, the prospectof any legislative change to errant laws is stifled by precisely the kindof bullying about religious sensitivity exhibited in this episode.
The duty of any socially conscious writer is to push theenvelope and challenge people to question their assumptions. This will makepeople uncomfortable, but incremental social change always happens through sucha dialectical process. If people were always trying to stray from controversy socialchange would never take place. Cultural sensitivity is far too often used as anexcuse for maintaining the status quo in places like Pakistan, and this needsto change if the country is ever to overcome the polarization that continues toimpede communitarian peace.
Saleem H. Ali is professor ofenvironmental studies at the University of Vermont's Rubenstein School ofEnvironment and Natural Resources and the director of the Institute forEnvironmental Diplomacy and Security at the James Jeffords Center for PolicyResearch. He can be followed @saleem_ali
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Pakistan is in the midst of a massive outbreak of dengue fever. With tens of thousands of patients affected, mostly under the age of 15, dengue is arousing much chaos and paranoia. While dengue is fatal in few cases (less than 1%), it results in a severe bleeding disorder in about 20% of cases (due to a dramatic reduction in patients' platelets), and in many cases, symptoms such as fatigue and depression persist long after the acute infection has subsided. Therefore it is a source of severe debilitation and its rapid spread is a source of great public panic. Dengue has spread like wildfire throughout the country, with cases being reported in all four provinces. However, modern means of transportation (cars, trains, airplanes) mean that not only can an infectious disease spread easily within the borders of a given nation-state, pathogens can overcome both geography and nationality with much ease. Consider the H1N1/swine flu pandemic of 2009 which within a matter of three months spread to 214 countries and territories, affecting millions, and causing about 18,036 deaths. The flu pandemic spurred the recognition of the need for cross-border collaboration to curtail the spread of infectious diseases. However, these important lessons have not been recognized by the governments of India and Pakistan, which share a 2,308km long border.
While Pakistan's border with India is certainly not as open as the one it shares with Afghanistan or China, reflected by the transit of polio cases across these two fronts, it is certainly far from airtight. Research into the subtypes of the dengue virus has shown that the strains circulating recently in India and Pakistan are similar, and an epidemic caused by one strain is usually followed by an epidemic with a similar strain across the border. Such a relationship was clearly reported in the temporally linked epidemics of Delhi and Karachi in 2006. Therefore, there is substantial evidence indicating cross-border spread of dengue, and possibly indicating the spread of other infections as well. Modern means of transport, which have far more mileage than the tiny wings of a mosquito, have made it much easer for infections such as dengue to spread from one side of the border to the other. The threat of cross-border HIV infection has also been reported, and is an important one to keep in mind as the painful memory of the Mumbai attacks recedes, thawing diplomatic relations, thus reopening the door for more people-to-people contact. Furthermore, a case of polio was recently detected at the Attari-Wagah border, raising fears of the spread of polio to the Indian side of the border.
In spite of the overwhelming need for collaboration in health and infectious diseases between India and Pakistan, no official channel is in place to conduct such an exchange. Currently, the Attari-Wagah border is used as a quarantine of sorts to vaccinate children crossing the border to prevent the spread of polio infection. During the H1N1/swine flu pandemic, the train that crosses the border - the Samjhauta Express - is frequently fumigated with insecticide. Custody was sought of animals being transported to India such as pigeons, donkeys and dogs for fear of spread of diseases ‘eradicated from India'. While the issue of cross-border infection has been used for rhetorical purposes, no constructive step to overcome this deficit has so far been taken from either side. While Pakistan has sought medication and insecticide from India to combat the dengue epidemic, there is no robust mechanism to ensure that such positive exchanges can occur on a regular basis.
Pakistan and India face similar public health challenges. Both are third world countries faced with similar geography, population demographics, and infectious diseases such as pneumonia, measles, malaria, and tuberculosis, accompanied by widespread malnutrition. Pakistan and India are also two of only four countries in the world where polio remains endemic, though India has made substantial progress in eradicating polio within its borders this year. Importantly, dengue is also a challenge shared by both Pakistan and India, which in itself is reason enough for close cooperation to occur.
Pakistan's healthcare system is decrepit by any standard. Healthcare remains a luxury reserved for those who can afford expensive services provided by largely privatized providers. Furthermore, the formerly federal responsibilities of coordinating healthcare and health-related services have recently been devolved in both India and Pakistan. This devolution poses similar challenges to Pakistan and India, since the lack of internal systematization of health information precludes international collaboration. According to Dr. Sania Nishtar, president of the Pakistani NGO Heartfile and a leading authority on health systems in the developing world, "The inadvertent fragmentation of health information as a result of health devolution in Pakistan is further undermining the country's ability to share information with its neighbors." However, she suggested a way forward to overcome the disintegration of a central health in order to facilitate international collaboration. "Options are available, however, to cast an institutional construct that will enable Pakistan to step up its capacity so that the country is compliant with International Health Regulations, 2005", she added.
The lack of collaboration between Pakistan and India with regard to infectious diseases is only reflective of the thorny history shared by these two countries and the level of prevalent distrust on both sides of the border. The World Health Organization is a large platform with regional organizations that help countries collaborate in their neighborhood. However, in a move representing a snapshot of the bigger picture, Pakistan opted to be a member of the Eastern Mediterranean region as opposed to the more natural South-East Asia region, which is headquartered in New Delhi. This move away from the South-East Asia region was political and was made so that Pakistan does not have to compete with India, which dominates the regional organization. Therefore, composite dialogue carried out bilaterally by Pakistan and India is the only platform for a health partnership to be forged. A fresh start needs to be sought to elevate the relationship from quarantining birds and other animals on the border to sharing research, disease surveillance data, vector control strategies and health communication material with institutional support. However, this can only occur under the umbrella of wide ranging confidence-building measures. Not only will it be extremely difficult to initiate collaboration, but the sustainability of any initiative might be an even greater issue given that it will always remain hostage to politics.
Haider Warraich, MD, is a research fellow at Harvard Medical School. He is a graduate of the Aga Khan University in Karachi, Pakistan, and the author of the novel, Auras of the Jinn.
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The monsoon rains have historically brought mixed fortunes to Pakistan. While they help spur the cultivation of crops, changing demographics and population distribution have given rise to recurring catastrophes the rains leave in their wake. As Pakistan suffers from another cycle of floods in both rural and urban areas, recent weeks have seen the explosion of a dengue fever epidemic in central Punjab. In the past two weeks alone, more than 6,000 cases have been reported, with the majority occurring in Lahore. At least 40 deaths have now also been reported. The extent of the epidemic is such that schools in Punjab have been closed for the last ten days.
Dengue fever is a mosquito-borne viral infection. While most cases present with non-specific symptoms such as fever and muscle aches, in about 1 percent of cases, the disease progresses to a more dangerous condition called "dengue hemorrhagic fever." In this condition, the normal human clotting process becomes deranged, resulting in spontaneous bleeding in patients, leading in some cases to death. In the appropriate context, dengue can be diagnosed without the help of any advanced laboratory tests. However, treatment options are limited only to supportive measures, such as providing anti-fever and pain medication, as well as using transfusions to combat platelet deficiency, though no "cure" or vaccine exists.
Dengue fever epidemics have become a cyclical nightmare in Pakistan over the last several years. The infection was quite rare in South Asia before the turn of the century, but starting in the last decade, dengue epidemics have become a regular occurrence, usually peaking in September and October. As the population in Pakistan grows or people move around in search of economic opportunity or safety from militant violence, settling in many places into overcrowded urban slums on the outskirts of cities like Lahore.
These slums are hotbeds of contamination, given that the proliferation of these ramshackle neighborhoods outpaces that of adequate infrastructure development. With hygienic practices already poor, they grow worse in such settings, where public sanitation is often subpar. The best measure to prevent dengue can be by halting the reproduction of mosquitoes or preventing mosquito bites. Mosquitoes reproduce in stagnant water, and unless widespread measures are taken to drain such collections or fumigate mosquito-prone areas, the insects continue to proliferate, helping spread infections.
The current armed conflict in Pakistan has also been a key driver of disease. The plains of Punjab provide a home to millions of internally displaced refugees who have moved away from the war-torn northeastern and tribal regions, bringing with them an increase in disease. Furthermore, war itself is known to be one of the most potent fomenters of infectious disease: Studies have shown that "complex emergencies" can cause a several-fold increase in infection rates.
But aside from these direct environmental factors fueling the spread of dengue, another potential cause of the infection's appearance might well be climate change. Like most other infections spread by an intermediary organisms (like mosquitoes), dengue transmission increases with atmospheric temperature and humidity, since higher temperatures and moisture optimize mosquito breeding.
Complicating this problem further is emerging evidence that Pakistan's mosquitoes are developing resistance to insecticide that is used to eliminate them.
Unfortunately, many of the factors contributing to dengue outbreaks, from poor hygiene and sanitation to climate change, are risk factors common to most infectious diseases. If no major changes occur, Pakistanis could be exposed to a host of epidemics, such as measles, pneumonia, and cholera.
One important reform would be to empower public health specialists to develop overarching strategies to reduce factors leading to transmission. However, the medical community in Pakistan is focused on other things, with young doctors in Punjab on strike for long periods of time this year protesting low wages. Given that there is such resentment among trainees, who form the backbone of the clinical work force, it is likely that these protests are also adversely affecting the response to the current epidemic, as there are fewer doctors available to try and stem the crisis.
Since neither cure nor vaccine exists for dengue fever, prevention is the only option to control the human and economic cost of the epidemic. While the local media has criticized the government's response, one has to consider that they are over whelmed by several public health crises spanning the length and breadth of the country simultaneously, such as the widespread floods, ongoing polio transmission and rampant malnutrition. Nevertheless, improving hygiene and sanitation, in addition to helping better-manage public infrastructure development and population growth, remain the only long term solutions for preventing dengue, and other infections, from breaking out.
Haider Warraich, MD, is a research fellow at Harvard Medical School. He is a graduate of the Aga Khan University in Karachi, Pakistan, and the author of the novel, Auras of the Jinn.
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In Pakistan, you could probably live for years and never meet anyone with HIV/AIDS. Yet the fact that the virus is not often in the public eye does not mean that HIV/AIDS is not a problem in Pakistan. It is known to infect tens of thousands of Pakistanis, a figure that is certainly a gross underestimate due to both sexual taboos surrounding the disease and the often low social status of many of its victims. And while HIV/AIDS does not attract the kind of notice it once did in the developed world, in Pakistan the scourge has only recently been given more attention.
HIV/AIDS is believed to have been introduced to Pakistan by migrant workers returning from the Middle East. These workers, who went to the Gulf states on work permits, would frequently engage in risky behavior while abroad. Workers, however, needed medical screening in order to renew their work permits, and if one tested HIV-positive during screening, he was sent packing on the first flight back home -- in most cases without even being informed of his HIV status.
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United States-Pakistan relations have been in free fall since the successful raid by Special Operations Forces on May 2nd killed Osama bin Laden and several others in Abbottabad, Pakistan. Now an investigation by the Guardian has revealed details of an intelligence operation in the months prior to the raid that attempted to use a fake vaccination campaign to confirm the terrorist leader's whereabouts. The operation, which reportedly failed, attempted to use the pretext of a free Hepatitis-B vaccination to collect DNA on those living inside Bin Laden's suspected compound, hoping to match it with the DNA of his relatives. However, while few details about the operation are known, one thing is certain: its existence will cause serious damage to legitimate domestic and international health campaigns in Afghanistan and Pakistan.
Immunization programs in Pakistan already have a hard time convincing many to get vaccinated. In 2007, a polio-vaccination campaign in northern Pakistan failed to immunize 160,000 children, due to rumors that the vaccine was an American attempt to sterilize children. The rumors were at least partially spread by local clerics, who claimed that the polio-immunization drive was "a conspiracy of the Jews and Christians to stunt the population growth of Muslims." Some vaccination teams were even beaten after locals heard the rumors. In another case, a Pakistani doctor was killed in 2007 after working to fight anti-vaccine propaganda in Bajaur agency. And the risk to health workers has increased drastically in recent years. According to the Aid Worker Security Database, which tracks attacks against national and international humanitarians, only two aid workers working in Pakistan reported being the victim of attacks in 2004, while by 2010 that number had risen to 28. Furthermore, the Red Cross claimed this month to have observed a spike in attacks against humanitarians, fueled in part by anger over the Abbottabad raid. Simply put, it has never been more dangerous to be a health worker in Pakistan.
Similar distrust towards health workers exists in Afghanistan. Taliban fighters have always had an uneasy relationship with vaccination teams and aid workers, suspecting they are government or Western spies. In 2007, Taliban fighters kidnapped one vaccination worker in Uruzgan province during a polio-vaccination campaign. They beat him and only released him after he promised to stop vaccinating children. It is not just vaccination efforts that are harmed by the rumors: less than a year ago a group of international and Afghan aid workers were hiking back from a three-week medical mission in the Hindu Kush mountains when they were captured and executed by gunmen. A Taliban spokesman took credit for the attack, claiming that the aid workers were spies.
Insecurity has a serious negative effect on health care in rural communities. The greater the personal risks, the greater the appeal for both national and international health workers to stay within the safety of major cities, venturing out only in large convoys. This so-called "bunkerization" diminishes the ability of health campaigns to target rural communities -- often those most in need of primary health care. The best way to overcome bunkerization is through building relationships with communities and local elites, allowing for the free movement of health workers in a region -- exactly the kind of thing undermined by the CIA's apparent operation.
Given the precarious relationship between health workers, militants, and civilians in many areas of both Afghanistan and Pakistan, the existence of a fake vaccination program ran by the CIA is likely all the evidence many need to accuse all vaccinators and health workers of spying. The end result will be fewer families willing to have their children vaccinated, and more attacks on health workers providing any manner of medical care to communities. Some people will no doubt say that the operation was a reasonable and necessary attempt to confirm bin Laden's location, and that nobody was directly put at risk as a result. Tell that to the next vaccination team in Abbottabad.
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More than 1 billion people in the developing world lack access to clean water, with this number slated to rise to more than 2 billion by 2020. According to UNESCO, 2.3 billion people suffer from water-related diseases, 5 million of whom die each year. However, the burden of water scarcity is not shared equally. According to Rajendra Pachauri, chair of the intergovernmental panel on climate change (IPCC), "At one level the world's water is like the world's wealth. Globally, there is more than enough to go round. The problem is that some countries get a lot more than others. With 31 percent of global freshwater resources, Latin America has 12 times more water per person than South Asia."
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Last December, I traveled to Peshawar, ground zero in Pakistan's fight against polio. As the capital of Khyber-Paktunkhwa (KP) and the Federally Administered Tribal Areas (FATA), this is where the debilitating disease needs to be stopped in order to prevent an explosive outbreak, one that can nonetheless be easily prevented by a cheap and safe vaccine. Of the 144 children across Pakistan paralyzed by polio in 2010, over half were from FATA, and 17 percent were from KP. As a senior program officer at the Bill and Melinda Gates Foundation, my goal in going to Peshawar was to hear firsthand what was being done to bring polio under control, and see what more could be done to ensure that it disappears altogether, as it has in much of the rest of the world.
Over the past two decades, polio has been reduced by 99 percent globally. Yet the disease continues to paralyze children in Pakistan because the vaccine is not getting to every child. Why? In KP and FATA there are two main reasons. First, more than 25 percent of children in FATA are not being reached consistently because of a protracted and deadly conflict with insurgents. Another 10 percent of children are missed either because vaccinators fail to reach every home or parents refuse to immunize their children.
On January 25, however, the federal government stepped up its fight to end polio. Pakistan's President Asif Ali Zardari launched a National Emergency Action Plan for Polio Eradication, laying out a national blueprint to eliminate polio from the country. This includes formal plans for tracking progress on polio objectively and regularly, setting up national and provincial task forces, and engaging Pakistan's leadership in polio eradication activities. Two days later, His Highness Sheikh Mohammed bin Zayed, Crown Prince of Abu Dhabi, and Bill Gates announced a partnership to help polio vaccines reach 32 million children in Pakistan. Then, British Prime Minister David Cameron announced that his country would double its contribution to polio eradication, helping vaccinations reach an additional 45 million children around the world.
Despite all this good news, however, eliminating polio in Pakistan is not going to be easy. An incident that occured January 22nd offered a stark reminder of why, when a health worker in North Waziristan was kidnapped and killed while returning home from promoting polio immunization, demonstrating that security remains a daunting challenge to anti-polio efforts. And even a few small gaps in the vaccination campaign can undermine progress across the board. To keep the disease in check, Pakistan needs to achieve and sustain high levels of immunity in the population; any pockets that are left unvaccinated will serve to re-ignite the epidemic. Avoiding such holes requires that health workers who administer the vaccine are well trained and supervised, that vaccines arrive on time, and that immunization activities are closely monitored. When coverage falls below 90 percent, special efforts will be needed, either to re-vaccinate a given area or determine which children were left out the first time around.
One key component in both these efforts will be political will at all levels. In FATA and KP, I've seen important progress as the top political and administrative leadership have come solidly together behind a plan to stop polio. In FATA, the Pakistani Army's medical corps is closely involved in helping to support immunization activities, and committees have been set up to liaise with other civilian health workers. The next step will be to lay out detailed micro-level plans that get vaccinators into areas where they could not go before. In areas controlled by insurgents, their leaders are also being approached in the hopes that they will allow vaccinators to safely and easily access children.
The Pakistani government and its U.N. partners are also working closely with religious leaders to ensure polio vaccines and other immunizations are accepted by the population. Some parents have refused polio vaccines because of misconceptions about the effects of polio vaccination -- for example that they could cause infertility. But the outreach is yielding results: The proportion of families in accessible areas who refuse vaccination dropped from 3 percent to 0.06 percent in the December 2010 campaign.
The benefits of the polio program go beyond preventing the spread of just this crippling disease. Following the "super flood" in Pakistan last year, polio eradication staff and resources helped track and prevent the spread of communicable diseases such as cholera in affected areas. Polio teams also help prevent other diseases, communicating with families on why immunization can save their children's lives. As more children get immunized from diseases such as measles, hepatitis and pneumonia, thousands of lives are saved each year.
Globally, there is also quite a bit at stake. Fighting polio is like fighting a fire. If it is not completely put out, it can spread fast and reappear in places where it was previously eliminated. Afghanistan, which faces similar challenges to those in Pakistan, has made tremendous progress on eliminating polio, so we know it can be done even in the most challenging environments. Since December 2010, vaccinators in Afghanistan have reached 25,000 more children who were previously inaccessible. The number of polio cases country-wide is down to a near record low, and contained within just two provinces - Helmand and Kandahar.
Launching an aggressive effort to finally eliminate polio in Pakistan is a necessary precondition to a polio-free world. The tools and strategies are in place, now more than ever, and Pakistan has the opportunity to build on international support to eliminate polio once and for all.
Michael Galway is senior program officer at the Bill & Melinda Gates Foundation.
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This week, Pakistani President Asif Ali Zardari put the fight against polio at the forefront of his domestic agenda, announcing emergency measures to vaccinate 32 million children at risk of the disease. Pakistan is one of four countries in the world to continue to suffer serious incidences of the disease, and this new attention to polio eradication shows how far the world has come in battling the disease, while also showing the serious challenges standing in the way of eliminating it forever.
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The floods in Pakistan in 2010 were massive. The rains affected the length of Pakistan, maximally impacting the provinces of Khyber-Pakhtunkhwa (KPK), Punjab, and Sindh as well as parts of Baluchistan. Flooding displaced more than 20 million people and covered about one fifth of Pakistan's arable lands -- an area roughly equal to the U.S. eastern seaboard. This flood affected more people than the 2005 Kashmir earthquake, Hurricane Katrina (2005), Hurricane Nargis (2005), the Indian Ocean tsunami of 2004, and the 2010 Haiti earthquake combined. Irrigation systems were destroyed, crops ruined, and seed stockpiles devastated. More than six million heads of livestock (including poultry) were killed. Yet, amazingly, only 1,985 people perished while another 2,946 were injured.
Given the population density of the affected regions, the poor infrastructure, and the baseline level of poverty, these figures are astonishingly low. In spite of the physical destruction, the fact that fewer than 2,000 Pakistanis died suggests that the Pakistani government did something very well last summer. Amidst numerous ongoing internal security crisis, political challenges and shortfalls of international assistance, Pakistani agencies continue to manage this crisis well despite the serious challenges that remain.
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When the recent floods of Pakistan started rampaging through the northwestern parts of the country, they were initially overshadowed by Pakistan's worst airline disaster in history when a plane crashed into Margalla hills adjacent to Islamabad. Now again, the floods that took 1,600 lives; affected 20 million more; inundated 62,000 square miles (the size of England), including 3.2 million hectares of agricultural land; snatched a million heads of livestock; and damaged or destroyed 2 million homes, 7,000 schools, and 514 health facilities have again been forgotten, this time presumably by the goldfish-esque attention span of global stakeholders. However, while the floods may have receded from newspaper front pages and television headlines, the floods' actual impact seems to have much greater staying power.