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Pakistani women are neglecting their lung health: World No Tobacco Day

Published: May 31, 2015


“I will break my children’s bones if they ever try to smoke,” says 27-years-old Sana (name changed). She tried her first cigarette at the age of 15 and was hooked onto the habit by the age of 17. Since then, except the one year where she quit, this young female journalist has been addicted. From regular to light, from non-menthol to menthol, from blue packs to green ones, and from cigarettes to sheesha and even electronic cigarettes, she has tried it all, but is unable to give up her reliance on one of the most addictive substances in the world.

Research shows that the gender gap between smokers is narrowing, and while smoking among females is on a decline in the developed world, it is on the rise in developing countries. A change in the traditionally defined gender roles has a correlation here, as do the marketing strategies. Use of coined terms like ‘light’ and ‘menthol’ make it more acceptable to women. Sheesha cafes have also made use of this psyche. Fruity smells and seemingly harmless flavours, such as green apple andpaan mint make the choice seem more aesthetic and less hardcore. Before one knows it, one is hooked.

Socio-economic reasons seem to have a definite influence. The study “Women and Smoking: A Report of the Surgeon General” states that women whose parents have been to college are more likely to have tried a hand at smoking. “The school one goes to has an impact for sure,” says Sana, adding that certain professions attract the habit, especially among females. The study also shows that women with stronger links with religion are more likely to avoid or discontinue smoking.

Globally, incidence of lung cancer and heart disease among women has gone up, and experts are searching its links back to an increase in use of tobacco. Smoking, in women, lowers their estrogen and their high-density lipoproteins that prevent arteries from blockage.

Getting it from the men

“We seem to have a unique tuberculosis (TB) epidemiology whereby young females appear to have the highest incidence of TB, and comprise more than a third of all our patients,” says Dr Asad Zaidi, who has been working on health initiatives to promote lung health and fight TB, and is associated with International Research and Development (IRD). The Sehatmand Zindagi Centre is the lunghealth and diabetes initiative established through Community Health Solutions (CHS), a social enterprise, in partnership with IRD, with which Zaidi is involved. Working in the peri-urban areas of Karachi, observation of these experts working for Sehatmand Zindagi reveals a definite trend of young women, aged between 15 and 22 years, having higher incidences of TB. “The exact causes for the high rates of TB amongst young women are poorly understood but we can speculate. We already know that nutritional deficiencies are much more common in girls, including widespread anemia and Vitamin D deficiency, often from a very young age. Stunting is more common in girls, they are less likely to be immunised during childhood or be treated once they fall ill. The high numbers of TB in young women, then, could just be another manifestation of the wider gender inequality plaguing this country,” adds Zaidi.

The connection between smoking and TB cannot be ignored, even though the young women being treated at these centres are from underprivileged backgrounds may not be smokers themselves. “We have a girl under treatment at Indus Hospital Karachi as part of our programme. She got married at the age of 20 to a man much older who already was a patient of TB, and smoked, and she acquired the disease from him. It is a complicated case of multi drug-resistant (MDR) TB, and she is expecting a baby. But she is better in the seventh month of her treatment,” says Sajida Qurban Khan who works as a manager in the Sehatmand Zindagi centres. In most cases, in Khan’s experience, these young girls have acquired the disease from fathers or brothers who were smokers and suffered from TB. “Women are actually more eager to come in for treatment and prove to be cooperative patients. But they also give up treatment midway more readily as they are less likely to be able to sustain the side effects of the medications.”

WHO confirms that TB is one of the major public health problems in Pakistan. Pakistan ranks fifth amongst TB high-burden countries worldwide. Pakistan is also estimated to have the fourth highest prevalence of multidrug-resistant TB (MDR-TB) globally.

Sheesha, social smoking and young ladies

“I don’t remember when I started smoking sheesha; I was very young, maybe 15 or 16. I started it because it was really in so I had to try it out. I thought it would make me look cool,” says Khizra Khan, 21-years-old, an undergrad student in Karachi. She says she now knows the health hazards of smoking sheesha or smoking, but defends the habit. “Everyone knows that sheesha and smoking are equally harmful. But you don’t get addicted to sheesha and you can never smoke sheeshaalone. I can go on for a month without smoking it. Plus it’s a good thing to hang out with friends over; it’s cheap and affordable compared to going out for lunch or dinner,” says Khizra, and shares that her parents hate the idea of sheesha smoking.

Waterpipe tobacco smoking, despite bans, has gained momentum among Pakistani youth. Women who hesitate smoking in public feel no hesitation smoking sheesha in public. “It is more socially acceptable compared to smoking. It’s the one fun thing I can do publicly,” says Sumera (name changed) who says she and her husband bond over sheesha smoking.

A research paper presented by Professor Javaid Khan, Aga Khan University, states that “Besides lung cancer, sheesha use is also linked with increased risk of mouth and urinary bladder cancer. There is also some evidence that sheesha use may also decrease the sperm count in men. Regular sheesha users have lung functions approximately 25 per cent lower than those who do not use this. One study has also shown that sheesha use increases the risk of pulmonary tuberculosis. Children are particularly vulnerable to the harmful effect of the sheesha use”.

According to the World Health Organization (WHO), sheesha, hookah, goza or hubbly bubbly, is indeed addictive and actually might end up being more harmful than smoking. WHO warns that a one-hour sheesha session can throw in as much nicotine in your system as smoking one hundred cigarettes. While a cigarette smoker typically takes between eight and 12 puffs, inhaling 0.5 to 0.6 litres of smoke, a sheesha smoker during an hour-long session may take up to 200 drags of between 0.15 to 1 litre of smoke each. “Reduced concentration of nicotine in the waterpipe smoke may result in smokers inhaling higher amounts of nicotine,” says the WHO report.

“There is already unequivocal evidence linking tobacco smoke, whether through cigarettes or shisha, to increased risk for TB. The rising trend in smoking then, is clearly a big problem. A lot young people out there don’t know that smoking could give them TB, and because smoking reduces our immunity, the infection is that much harder to cure.”

According to a study called “Prevalence of cigarette smoking among young adults in Pakistan” published in the Journal of Pakistan Medical Association, nicotine addiction and stress were the most common reasons given by students for why they smoked (53 per cent and 50 per cent, respectively). Most of the respondents shared that at least one of their five closest friends smoked cigarettes and more than half mentioned that at least one person in their home smoked cigarettes.

“I wish I had never acquired this habit,” says Sana with regret. For her, it might be too little too late. But creating awareness may potentially save lives of many young Pakistanis, especially women.

Tobacco kills up to half of its users

Tobacco kills nearly 6 million people each year, according to the World Heath Organisation. More than five million of those deaths are the result of direct tobacco use while more than 600 000 are the result of non-smokers being exposed to second-hand smoke. Unless urgent action is taken, the annual death toll could rise to more than eight million by 2030.

Nearly 80 per cent of the world’s one billion smokers live in low- and middle-income countries.

World Pneumonia Day: Saving lives with cell phones

By Farahnaz Zahidi / Creative: Munira Abbas
Published: November 12, 2013

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Pneumonia claims an innocent child’s life every 30 seconds, making it the number one cause of childhood mortality. DESIGN: MUNIRA ABBAS

KARACHI: As she steps out of a small grocery store in Korangi, she is carrying her nine-month-old baby in one hand and bags of grocery worth Rs300 in the other. Her baby is pneumonia free and she is one of the lucky mothers who have more than one incentive to ensure her baby gets regular vaccinations at Karachi’s Indus Hospital.

In this part of Pakistan, cell phone technology is being put to good use, often ending up saving precious lives. Under the “Save Life – Zindigi Mehfooz Hai” programme by Interactive Research and Development (IRD), a system has been set up to not just treat children with pneumonia, but track them and their progress by using Radio Frequency Identification (RFID) technology.

In a country where reportedly some 92,000 children under-five die annually of pneumonia, which contributes to 18 % of the total child deaths in Pakistan, this is good news indeed. It is also encouraging that there is no refusal by parents of children when it comes to the pneumonia vaccine. “We have immunised 15,000 children in the last one year in Korangi alone, and not had a single instance of refusal,” says a proud Dr Subhash Chandir, director of vaccines program at IRD. The Pneumococcal conjugate vaccine (PCV) was introduced in Pakistan’s Extended Programme on Immunization in October 2012. “What fundamentally changed the game in Pakistan was not medical advancement but the fact that the price of vaccines came down,” says Dr Aamir Khan, IRD’s executive director , adding that a big part of the solution lies in social business models.

This use of RFID technology started with small water-proof, rugged looking bracelets given to children, which were scanned by assigned health practitioners to get a medical history of the child. Now, a small chip is placed within a sticker on the child’s vaccination card. Through that the child’s progress is tracked and reminder texts are sent. “Apnay phool jaisay bachay ki hifazat karain. Jamal Khan ka agla hifazati teeka aaj lagna hai (Protect your flower-like child, Jamal Khan’s next vaccine is due today).” Standardised texts like these serve as reminders.

To incentivise it further, a “lottery” is set-up whereby one in five mothers with children under the vaccination program may win grocery.

Pneumonia claims an innocent child’s life every 30 seconds, making it the number one cause of childhood mortality in the world. In the 2010 World Health Assembly, a resolution on the prevention and control of childhood pneumonia was passed. The UN MDG 4 states that childhood mortality should be reduced by two-thirds from 1990 to 2015. However, even now, globally an estimated 22 million infants are not fully immunised with routine vaccines.

The PCV vaccine costs around Rs1500 for Pakistan, but people can get their children vaccinated for free. The Hib (Haemophilus influenzae type b) vaccine was introduced in Pakistan even earlier.

Unicef shared with The Express Tribune that “The World Pneumonia Day serves as a call to action for parents, caregivers, and healthcare providers to ensure that infants are fully immunised against all vaccine-preventable diseases. Immunisation prevents between 2 and 3 million deaths globally every year by protecting against the nine deadly diseases of the childhood including pneumonia under 5 years of age.”

While the vaccines are there, they don’t seem to be reaching all Pakistani children who deserve to be vaccinated. “We have a grudge. We are pumping vaccines into a broken system. What needs to be corrected is vaccine delivery,” says Dr Khan. He feels routine immunisation needs to be strengthened, and it is wasteful to introduce new expensive vaccines into a system which is unable to deliver them.

Dr Chandir goes on to explain that the reasons include issues with the “Cold Chain”. Vaccines have to be stored at certain temperatures, but by the time they reach children, they may have lost their effectiveness. “EPI may have a network of vaccinators but often doesn’t have its people in strong positions at district levels. The human resource may not be enough, or is, may be, not being used effectively.”

“It is a crime because it is a right of these children to be protected against these diseases. Usually media stories focus on the vaccines — and not on the system. We need a better system in the country,” says Dr Khan.

Facts about the disease

• More than 99% of deaths in children due to pneumonia occur in the developing world, with half occurring in five countries – India, Nigeria, Democratic Republic of Congo, Pakistan and Ethiopia.

• Only 61% of children with pneumonia are reportedly taken to a qualified health practitioner in developing countries.

• Globally, pneumonia kills more children under five than any other illness.

• Infants not breastfed are 15 times more likely to die due to pneumonia than those who are.

• Using a clean cook stove results in a 50% reduction in the risk of a child contracting pneumonia.

Source: World Pneumonia Day website

Published in The Express Tribune, November 12th, 2013.