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Health Deliver y

Diabetes in Pakistan
` Fatema Jawad

Pakistan is a South-Asian country with a population of Institutions specializing in diabetes


care are limited in number and are
approximately 150 million. Diabetes prevalence Pakistan concentrated in the big cities.There
are no support personnel and very
is high: 12% of people above 25 years of age suffer from
few dietitians. Family physicians have
the condition and 10% have impaired glucose tolerance little time for counselling: a survey of
GPs working in both rural and urban
(IGT).1 When one considers the associated risk factors areas of Pakistan,2 showed the
average time spent with a person
present in Pakistani society, the large number of people with diabetes was 8.5 minutes.
with diabetes is no surprise. Obesity tops the list. Recent Culture and demographics
figures based on body mass index (BMI) show 37% of All these factors have been
compounded by cultural practices in
men with diabetes and 79% of women were obese. the country. The gender bias is very
strong. Pakistan is a male-dominated
According to the waist-to-hip ratio (WHR), 79% of men society and prejudice against women
is reflected in the higher female
with diabetes and 96% of women had central obesity. mortality rate and low literacy rate
According to a Diabetic Association of Pakistan study into (32% for 15 yr and above). The
combination of factors is giving rise
chronic complications (recently submitted for to strong negative repercussions on
health.
publication), involving 500 people with diabetes, eye
Women suffer most.They perform all
damage (retinopathy) affected 43% of the people, kidney the domestic chores and take care of
the large extended families while
disease (nephropathy) 20%, and nerve damage
gender discrimination means they
(neuropathy) 40%. enjoy only secondary status in the
home and in society in general. Male
children receive better nourishment
>> and better opportunities for
education. Women in the rural areas
are doubly oppressed. Child
marriages and lack of mobility
confine the women to their homes.
While they perform physical labour
without remuneration, they are very
often not allowed to set foot outside
the home, even for medical

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July 2003 Volume 48 Issue 2
Health Deliver y

treatment. A woman's hospital visit


is often considered some kind of
stigma by husbands and many
women continue to die due to
complications arising during
childbirth.

Any recommendations for the care


of people with diabetes in Pakistan
must be made in the wider context
of the health-care system in the
country. Certain key features have a
direct bearing on the health-delivery
system of Pakistan: the population
size and distribution; the country's
geography; the gender ratio, and the
socio-economic development of the
people.The government faces a
major challenge to provide
healthcare for everyone – 69% of
the population is rural, spread over
an area of 800 000 km2.

Limited resources
This difficult situation is aggravated © Mauritius
by economic factors. Poverty is
widespread – 31% of people in
Pakistan are subsisting on 1 USD per the health sector), the private sector measures has led to a growing
day and 85% are earning less than is playing an increasingly important incidence of the condition, with the
2 USD per day. With only 22% of role. However, this has made health rural areas being the worst affected.
the population economically active, care expensive and beyond the reach
the proportion of people officially of most people. The problem is A call for united action
unemployed is currently 20%. compounded by the scarcity of Policy makers in Pakistan have failed
health-care services: a total of to adequately focus on primary

( )
The scarcity of health- 91 823 doctors gives a ratio of 57 health care and preventive medicine.
care services means per 100 000 people; there are This is a priority matter which needs
that people with 37 623 nurses with none trained immediate attention. Since the rural
diabetes in Pakistan specifically in the field of diabetes. areas have been most neglected,
cannot be provided The 4632 Basic Health Units (BHU) their need for attention is greater.
with the care they located in the rural areas supposedly Effective campaigns for health
require. care for nearly 100 million people. education are essential and the low
Each unit is responsible for the literacy rates mean that if diabetes
Health facilities are concentrated in health of over 21 000 people, many awareness campaigns are to be
the urban areas and the major of whom are physically unable to successful, they must be transmitted
services are provided by the private attend. As a result, the people with via television and radio. Educational
sector. Given the failure of the diabetes in the country cannot be television programmes on health
government to invest in health care provided with the care they require. issues, promoting a healthy lifestyle,
(it spends only 0.7% of the GDP on Failure to implement preventive and focussing on sound dietary >>

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July 2003 Volume 48 Issue 2
Health Deliver y

There is also a need for subsidized


insulin and syringes – presently out
of the reach of poor people.

In order to prevent the development


of chronic diabetic complications, it
is important that GPs, often the first
healthcare contact for people with
diabetes, are trained in screening and
treatment. Stemming the diabetes
epidemic in Pakistan is a major
challenge. It calls for all to join
hands – people affected by
diabetes, health-care professionals,
and health-care policy makers.
© Mauritius

` Fatema Jawad
Fatema Jawad is a Consultant
habits and exercise are urgently First steps Diabetologist and Research Fellow. She
needed. Warnings about the hazards Some extraordinary measures is Editor of Diabetes Digest, bulletin of
of diabetic complications should also should be taken urgently in the case the Diabetic Association of Pakistan,
be emphasized. In the past, such of diabetes. Due to the multifaceted Karachi, Pakistan.
programmes have been effective in nature of the condition, tackling
promoting awareness about family diabetes leads to the potential References
planning and AIDS. Producing well- solution of a number of other 1. Shera AS, Rafique G, Khwaja IA, et
pitched awareness-raising health problems related to the al. Pakistan National Diabetes Survey:
programmes would be a cost- complications. The first goal should prevalence of glucose intolerance and
effective method of promoting be to screen people with diabetes associated factors in Shikarpur, Sindh
diabetes knowledge in Pakistan. for complications. In rural areas, Province. Diabetic Medicine 1995; 12:
where the infrastructure simply 1116-1121.
The diabetic community lacks the does not exist, ad hoc measures
facilities for screening and should be implemented. All BHUs 2. Shera AS, Jawad F, Basit A. Diabetes
monitoring, and the drugs which can should be provided with related Knowledge, Attitude and
ensure a healthy, 'normal' life for glucometers to test blood sugar, and Practices of Family Physicians in
people with diabetes.The 1995 training to ensure that they are Pakistan. J Pak Med Assoc 2002; 52:
National Action Plan for health used correctly. If these measures are 465-470.
placed special emphasis on diabetes to be effective, they must be backed
and was designed to ensure the up by a vigorous public health
provision this care. However, the Plan education campaign.
was not fully implemented.
For remote areas, beyond the reach

( )
Health-care measures
must be backed up by
a public health
education campaign.
of the BHUs, mobile camps should
be set up periodically. If these are
subsidized, the private sector could
also be welcomed into this
programme.

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July 2003 Volume 48 Issue 2