What is on your Plate?

There was a time when the greek men had the longest life expectancy... but with the fast food industry growing , things have changed for the worse. I was reading a very interesting article on the NPR : ' few Americans finish their vegetables. '

Recent report by the Centers for Disease Control and Prevention says two-thirds of Americans don't get the recommended two servings of fruit a day; three-quarters miss the target for vegetables. But how do you convince all these people, everybody, all of us, to trade in their fries for a carrot salad or pack an apple with lunch? Obviously, knowledge is not enough. USA has that national dietary guideline. And we are reminded of the food pyramid? How many of the Americans actually consult this before every meal?

NPR article discusses further: So maybe we need some new ideas. Remember home ec classes? Maybe we should bring it back. We should teach kids, all kids, boys and girls, the joys of veggies. Or how about vending machines for baby carrots instead of chips and soda? Some schools are trying this. And there's always the pocketbook approach. Should we tax doughnuts, give credits - tax credits for your broccoli? (On a lighter note: My economics Prof would be happy to see econ being applied here ).

Quoting Dr. Walter Willett's interview. He's chairman of the Nutrition Department at Harvard School of Public Health in Boston . "First of all, you have to look and see what's being promoted. For example, the Kaiser Family Foundation did a study a few years ago looking at the ads that children would see on television, and it's amazing. The average child sees about five or 6,000 ads per year. And in an evaluation of these ads, out of five or 6,000, there was not a single one that was promoting fruits and vegetables. It was almost all junk food ."

The article talks about Michael Bloomberg proposing a two-year trial where people on food stamps will not be able to buy sugary sodas, and, in fact, may get extra dollars if they spend their food stamps on fruits and vegetables. Dr Willett feels, "I think that's a very sensible idea. It's something we've been suggesting for several years. It just doesn't make any sense at all, what we're doing. The cost of the food stamp program is over $80 billion a year, and I think that's important money. People really do need that as a safety net. But we're writing checks for - paying for Cokes with one hand, and on the other hand, we're writing checks to pay for treating diabetes caused by the Coke. That just doesn't make any sense. So sugary beverages have many adverse effects, and it just doesn't make sense that we're essentially contributing to their consumption through federal food programs."

Eating habits are very different in Pakistan. Poverty and inflation has increased the poverty burden. Many live below the poverty line and are under nourished. For middle and upper classes ...however, people do have access to fresh vegetables , lentils. The trend is to over fry every food item, which renders the caloric value high and compromises the nutritional value. The way a normal every day meat/chicken or fish curry is cooked - it is soaking in oil or ghee.

An article published in Am J Public Health. in 2001 compared the health profiles of Pakistani population and American! Yes and the study was: "Health status of the Pakistani population: a health profile and comparison with the United States." Results from the National Health Survey of Pakistan (n = 18,315) and the US National Health and Nutrition Examination Survey (n = 31,311) were compared. Standardized and comparable methods were used in both surveys.
Indicators of undernutrition among children were high throughout Pakistan. Among adults, there were urban-rural differences and economic gradients in indicators of undernutrition and risk factors for heart disease and cancer. In comparison with the US population, the Pakistani population has a higher rate of undernutrition, a lower rate of high cholesterol, and an approximately equal rate of high blood pressure.

Overweight and obesity are a global pandemic. According to a WHO report, there are 1 billion overweight people in the world, of whom 300 million are obese. Findings of the National Health Survey, Pakistan, 1990–1994, found that the prevalence of obesity for adults aged 25–64 from low, middle to high socioeconomic status (SES) was 9%, 15% and 27% for rural areas and 21%, 27% and 42% for urban areas respectively.

In another study PLoS One. 2009. "Prevalence of obesity in school-going children of Karachi" . Obesity and undernutrition co-exist in Pakistani school-children. The study showed that socio-economic factors are important since obesity and overweight increase with SES. Higher SES groups should be targeted for overweight while underweight is a problem of lower SES. Meat intake and lack of physical activity are some of the other factors that have been highlighted .

Concerns:

WHO ranks Pakistan 7th on diabetes prevalence list. In Pakistan, 6.9 million people are affected by diabetes with the International Diabetes Federation estimating that this number will grow to 11.5 million by 2025 unless measures are taken to control the disease. USA is at number 3rd on the same diabetes prevalence list with 19.2 million people being affected by diabetes. Studies have shown that Central obesity or apple shape of the body and insulin resistance is the main reason for diabetes increase in Indians.

So watch what is on your plate.

Photo Essay- Flood Relief Medical Camp in Thatta.

Thatta- the historic town of the province os Sindh in Pakistan. Between 1592-1739, it was governed in the name of the Moghul Emperors of Dehli. In August 2010 floods , Thatta was one of the worst affected areas of Pakistan. By August 28, 175,000 had left their homes and were camping along side roads , under the open sky. These are pictures from the medical camp conducted by the Pakistan Navy and Aga Khan University Hospital Doctors. This camp site has 1000 tents; generator provides light at night; school for childree, vocational training for women , medical camp and free medicines; three free meals a day and drinking water.


The Pharmacy section of the camp, providing free medicines.

A child getting nebulized.

A patient being referred to the Tertiary care hospital several Km away - the Civil hospital. Navy ambulance takes the patients free of cost.

Peads consultation.

A PCM- failure to thrive case. Maina , one and a half year old baby girl.

Elderly woman with hirsutism .



Peads consultation.

Elderly woman being nebulized.

Patient feeling better after nebulization.

Elderly patient at the camp.

GP consultation.

The view of the tents.. children playing outside. A blue water container seen on the right hand side of the photo.

We're no. 122......Curable or not?!

Pakistan's healthy life expectancy ( HALE) is 55 years for males and 56.8 years for females ( WHO) , making us 125th . According to our health performance , we are ranked 85th ; where as the over all health system performance , bestows us a rank of 122 nd ! Pakistan has one of the largest populations ( within top 10) within the developing world. Hence, the population has a greater prediposition to certain diseases and hence, health systems may find limitations along several issues.
In order to achieve better quality outcomes we will need a improved quality of access to a better quality system. In order to measure quality accurately we will need access to accurate data.
So safe to say: we need a health sector reform. The overall goals of Health Sector reform are to enhance efficiency of the health care system, both technical and allocative; to improve the quality of services; and/or to generate new resources for the system. Pakistan has so far introduced little fundamental change in its health care system.
The extremely precarious and deteriorating economic reality in Pakistan alone demands such restructuring and reorganization of its health care system. Basic performance indicators of the health system also point to this need.
The goals of health sector reform are to improve the technical and/or allocative efficiency of the health care system, enhance the quality of services, and make the system more equitable. It has numerous dimensions - from financing to organization of services to the package of services to be delivered.A policy, legislative, regulatory and institutional overhaul in health has been long overdue.
(According to Dr Sania Nishter's published comment 2008) , it is important to recognise that the health status of populations has a direct correlation with the level of public spending on health. However, it is not just the aggregate level of spending, but the percentage of GDP allocated for health adjusted for inflation and population growth, and its translation into per-capita public expenditures relative to private expenditures that gives a somewhat truer picture of the state’s investments in health. Here, it is acknowledged that Pakistan’s aggregate level of allocation for health has increased considerably over the last decade, with further increases in this budget representing a positive trend. However, changes in health allocations as a percentage of the GDP have remained unremarkable; over the last 10 years this has ranged from 0.67 percent to 0.8 percent. The internationally recommended number is 4 percent of the GDP.
In 2008 , the public sector spends $4 per capita on health annually, as opposed to the internationally recommended $34 per capita, the minimum required to provide essential health services in developing countries. Clearly, this huge gap needs to be bridged.
Approximately 70 percent ( in 2008) of healthcare in the country is financed through out-of-pocket payments made to health providers at the point of care. This is the most inefficient and inequitable way of financing healthcare. Ideally, health should be funded through public sources, which include revenues, social health insurance or other means of pooling, such as social protection.
The classical budgetary disparity evidenced in priorities for allocating resources for preventive healthcare is obvious. According to the Federal Bureau of Statistics’ Pakistan Demographic Survey, it is documented that more than 50 percent of deaths are due to non-communicable diseases (NCDs). However, as opposed to this, only 0.66 percent of the total healthcare budget has been allocated for the prevention of these diseases. NCDs, a collective name given to the diseases of the heart, diabetes and some lung conditions and cancer, incur significant costs in healthcare, undermine income-generating capacities of the productive workforce and have the potential to perpetuate acute poverty crises.
Hence, as we see ,there's many factors well beyond the quality of the health care system that contribute to these lagging rank: persistent poverty in the country ; chronic un- and underemployment; high levels of income and status inequality; and high levels of social stress and insecurity.

The Plight of the Uninsured- my dear health care , is very elementary.

From Boston to Karachi , people struggle to perfect a model of health care formula for the uninsured , to create a sustainable access to clinical care. At my school in boston , I learned from my Professor, that the number of uninsured in America has increased from 40.6 million in 1995 to 45.7 million in 2007. The rate of uninsurance also varied from across states ( 2006-2007) : MA being the lowest at 8% and TX being the highest at 25%. The number of uninsured is increasing because of structural changes in the economy as the trend is moving from manufacturing jobs to service jobs. There is also an increase in part-time or contract jobs. There is a decrease in the family 's median income. Health insurance is becoming expensive. The are employer cut backs in insurance coverage. People who are generally found to be uninsured are: low income groups; unemployed, part time and new jobs ; less educated ; non documented immigrants; more recent legal immigrants.
There is ofcourse compelling evidence of being uninsured and ill health. People either post pone seeking health care because of cost ; did not fill out a precription because of cost; had problems paying medical bills. As the professor mentioned in one of the lectures: Ideas are many about what could be done: Expand medicaid progams for the low income groups ; expand medicare to young age groups ;Expand employer based coverage; expand individual coverage and introduce a single payer system. Majority of the public health opinion is in favour of the goal: " health care should be provided equally to every one just as public education is " ( 2000) . However, coming to a consensus regarding the best solution is challenging. According to a survey 2003: 85% favour Tax credit for businesses , 72% favour the tax credits for individual , 64% favoured exonading medicare to less than 65 years of age , and 47% favour a national single payer plan. What is more interesting is the result of the survey of Kaiser / HSPH regarding willingness to pay to help the uninsured, either in higher health insurance premiums or higher taxes so that there can be an increased number of insured in America.....51% said "no, not willing to pay" and and 45% said " yes willing to pay."
Spanning across continents, my Professor in Pakistan designed the first ever health insurance for the poor as a pilot project. The project is now launched in 16 districts and we await to see how effective is the implementation of the program and how much is the utilization of the services.
Pakistan’s population is more than 170 Million; in 2008 with an annual growth rate of almost 2.4%. Literacy rate is about 54% according to government estimates .Inflation rate is more than 25% in 2009: the cost of living is becoming out of control for majority of the people. Monthly minimum wage is Rs. 6,000 (US $ 73) per month. Afert designing an inclusion criterion , It is proposed that eligible family units be enrollment with the entitlement of the family being up to Rs.25, 000 year.The premium for each family is anticipated at Rs.500 per annum .
This health insurance scheme would be operated through insurance companies selected by competitive bidding of premium for provision of service in a block of Districts designated bythe central fund providing/management authority , at the start up but eventually in each Administrative Division of the country. The envisaged insurance scheme for the poor would require involvement of the central fund providing authority, the participating insurance companies, the Federal and Provincial Health authorities, the health care providers and the beneficiaries linked by an information technology backbone with a chip-enabled card as its central features.
What we would need in Pakistan is a strong political will and proper administerative capacity.
Waiting and hoping that this would be an effective beginning to adressing the issue of the uninsured that spans form the developed world to the developing world.

Notes:
(a) Lecture presentation by Prof Nancy Turnbull- HSPH
(b) Lecture presentation by Prof Rasheed Jooma- Director General Pakistan