By Robert Balogh, Sarah Maraone, Kristin Parkinson and Joan Shaw
(parts of this profile were previously published in Synapse the Neuroscience Division newsletter of the Canadian Physiotherapy Association)
Introduction to the country and region
Pakistan is a country in South Asia with a population of 160 million. It is bordered by Afghanistan and Iran in the west, India in the east, China in the north and has a coastline with the Arabian Sea in the south. Its capital is Islamabad and official languages are Urdu and English. 96% of the population is Muslim. Pakistan declared independence from the United Kingdom in 1947. The people are avid cricket fans.
There is a long standing dispute between India and Pakistan as to the status of the Kashmir region located in the north of Pakistan and India.
Population Health
Life expectancy at birth is 62 years. There are approximately 350 maternal deaths per 100 000 live births. In contrast, there are 7 maternal deaths per 100 000 live births in Canada.
Close to one-third of the population live below the national poverty line despite the fast growing economy. Gross domestic product grew by 8.4% in 2004-05. The gross national income per capita is approximately 600 U.S. dollars.
Health Care System
According to the World Health Organization, health investment is low and more than 75% of health financing is out-of-pocket. The Pakistan Ministry of Health estimates that 80% of the population has access to local health services in rural areas and 100% in cities but reports significant regional differences.
Nursing is not considered a prestigious healthcare profession, which is reflected by lower number of nurses (48 000) compared to physicians (116 000). There are no specific statistics for rehabilitation professionals, but combined, there are approximately 19 000 occupational therapists, physical therapists, Speech Language Pathologists, psychologists, medical interns and dietitians (World Health Organization, 2004).
Personal Experience
In October 2005 an earthquake devastated the Kashmir region of Pakistan. As a result, an estimated 95,000 people were killed while another 100,000 people sustained injuries that were mostly orthopedic and neurological in nature. It was estimated that there were up to 1500 people living with a spinal cord injury as a result of the disaster. Most of the people injured were young adults, women, and children who were in their homes and schools at the time of the earthquake. Many of the injured were transported away from the devastation to hospitals in Pakistan’s major cities including Holy Family Hospital in Rawalpindi.
The health care system in Pakistan was overwhelmed by the needs of the injured people. The ongoing difficulties meeting basic, primary medical needs left very few resources to address rehabilitation issues. Recognizing the dire situation, Subh-E-Nau and other international NGO's made a request for foreign and Pakistani-trained rehab therapists to come and assist with the mounting rehab needs. Our team, made up of one Canadian physiotherapist and three occupational therapists, partnered with Subh-E-Nau to help initiate a structured spinal cord rehab program at Holy Family Hospital.
When our rehab team arrived at the hospital, we met 20 patients ranging in age from 3 ½ years to 75 years. All had spinal cord injuries with either paraplegia or paraparesis and were in one ward room with one besieged local physiotherapist assigned to provide care. The patients had received donated wheelchairs and cushions that were hardly being used. A team of local physiotherapists and rehab assistants had been assembled to help out at the 800 bed hospital, but this was still not enough. Aside from the immense emotional trauma, most patients had physical complications that included pressure sores, spinal deformities, contractures, surgical site infections and disuse atrophy. At three and a half months post-injury there was limited psychological counseling and bed mobility, transfer and strengthening exercises had just begun. There were no specialists in neurological or spinal cord injury (SCI) rehab providing intervention.
Our role was to start up a SCI rehab program for these patients, similar to a subacute rehab approach and to provide training in this particular area of rehab. We started by assessing all the patients using the ASIA scale and mobility skills progression forms provided by the Toronto Rehab Institute- Lyndhurst Spinal Cord Centre. We worked with patients on pre-functional training including bed mobility, mat skills, range of motion and strengthening. The program included transfer training and wheelchair skills. The occupational therapists also made wheelchair and cushion modifications and fabricated foot splints as needed.
Our efforts in Pakistan focused primarily on providing direct patient care and peer support to our Pakistani co-workers. In order to foster continuity of care, the Canadian rehab team also took time to organize education and clinical skills training sessions.
When we returned to Canada we realized that our work was not finished. We helped to organize follow up trips by fellow physical and occupational therapists. These teams provided continued rehabilitation to the same patients we saw and many more. Their efforts were coordinated by Subh-E-Nau. We have since formed the Pakistan Workgroup of the International Centre for Disability and Rehabilitation at the University of Toronto. This association helped us to raise funds for our ongoing work and provided a forum to share our experiences and bring attention to the project.
The head of Subh-E-Nau, Dr. Jawad Chishtie, has since visited Canada and was able to secure $100 000 of funding from the International Development and Relief Foundation for a community outreach program he has developed. This program is providing medical and rehabilitation care for persons with neurological conditions in the earthquake affected communities. In addition, the Subh-E-Nau team is training caregivers and local health care workers so that the community is able to continue providing support and care in the absence of health professionals.
Disability and Rehabilitation
As is the situation in many developing and in transition countries, rehabilitation consists of a mix of government and non-governmental organization initiatives. It is therefore difficult to give a summary of all rehabilitation activities. We focus on issues stemming from the earthquake affected area.
The mountainous terrain of the earthquake affected area has made community based approaches to rehabilitation challenging. Subh-E-Nau has provided actual hands on community based rehabilitation programming, with a rehabilitation worker, physiotherapist and physician making visits to the homes of people with a spinal cord injury.
Other community based rehabilitation initiatives have been funded to provide capacity building. The World Bank has partnered with the Pakistan Poverty Alleviation Fund on a project that will provide “capacity building of service providers for disability rehabilitation. This will be achieved by training mental health service providers and providing support to community-based organizations for proposal writing” (http://www.ppaf.org.pk/newspopups/News18.asp). Handicap International has also been funded by a World Bank-administered Japanese Grant to strengthen the capacity of community-based organizations to “ensure that persons with disabilities are satisfied and involved in the delivery of rehabilitation services and solutions” (http://go.worldbank.org/SO0YSS3TZ0).
Since the earthquake, at least two rehabilitation centres have been opened in Muzaffarabad. With funding from USAID and a consortium of Pakistan partners, a Spinal Rehabilitation Centre at the Abbas Institute for Medical Sciences was created (http://pakistan.usembassy.gov/pakistan/h06050301.html). In 2007, the International Committee of the Red Cross opened a Rehabilitation Centre focusing on the needs of persons with amputations.
The Government of Pakistan created the Earthquake Reconstruction & Rehabilitation Authority (http://www.erra.gov.pk/WebForms/Home.aspx) to help oversee rehabilitation initiatives. According to their website reconstruction and service provision is making progress. Considering it has been almost 3 years since the earthquake, this has been slow in coming.
The Pakistani physiotherapists we worked with were well educated university graduates; but depending on their work setting, some lacked the hands-on skills that are common in Canadian- trained physical and occupational therapists. In Pakistan, there is little opportunity for professional development and continuing education courses are almost unheard of.
There is very little university level training for Occupational Therapists in Pakistan. The World Federation of Occupational Therapists lists the Jinnah Post Graduate Medical Centre as offering a Bachelor of Science in Occupational Therapy. Some health professionals have taken week long sessions which focus on an aspect of Occupational Therapy.
Recommendations
Subh-E-Nau is a not for profit organization working in the areas of environmental conservation, medical rehabilitation, public health and sports promotion in Pakistan for the last 15 years. If you are interested in finding out more about Subh-E-Nau and its projects please visit their website http://www.greenpakistan.org/rehab/rehab.htm
