History Of Health And Medical Criminology

Vaccinations for travellers to Pakistan will depend on a number of factors, including but not limited to the amount of time spent in the country. Recommendations may differ for short-term and long-term visitors. It is advisable to consult with your travel health advisor to discuss your specific needs while in the country.

Travellers with existing medical conditions should pack an ample supply of prescription and routine medications in their original packaging. It is recommended to have a doctor's note in English and translated to Urdu when possible, that would explain the need for the prescription and non-prescription drugs.

Recommended Vaccinations

Vaccination for Hepatitis A, Hepatitis B and Typhoid fever is recommended for all travellers and expatriates to Karachi and Lasbela District. A booster shot is recommended for travellers who have never had the polio vaccine as an adult. Anti-Rabies vaccine should be considered by visitors who are likely to be in contact with potential rabies-carrying animals such as dogs during their stay. Yellow fever vaccine is required for everyone over 9 months old, especially for those arriving from a yellow-fever infected area in Africa or the Americas. This also covers people who were in transit for more than 12 hours in an airport located in an identified yellow-fever risk country. Foreign travellers who intend to stay for more than a year in Pakistan are required to submit an AIDS (Acquired Immune Deficiency Syndrome) free certificate.

Mosquito-Borne Diseases

Karachi is one of the identified areas affected by Japanese encephalitis (JE, inflammation of the brain) although there is limited data available on the peak periods of transmission. The disease is a serious viral illness which occurs mostly in rural agricultural areas in Asia and some parts of the Western Pacific. The virus spreads through the bite of infected mosquitoes and its symptoms include fever, neck stiffness, headaches and vomiting. Severe cases can develop weakness, confusion, drowsiness, seizures and comas. Data from the United States Centre for Disease Control and Prevention (CDC) indicated that 1 person out of 4 with encephalitis dies while half of those who survive may suffer permanent brain damage. There is some evidence to suggest that a pregnant woman infected by the virus is harmful for the unborn child.

A vaccine (Ixiaro) against JE is available and is highly recommended for long-term travellers to Karachi or those who are planning to stay for more than a month. It is not recommended for short-term travellers whose visits will be restricted to urban areas. The vaccine is approved for those who are 17 years old or older. Younger travellers in need of protection from JE should consult with a trusted medical doctor. The vaccine is given in two doses spaced 28 days apart. The second dose should be taken at least one week before travel. A booster JE vaccine may be given to anyone who was vaccinated more than one year ago and is still at risk of exposure.

There have also been reported cases of Malaria in Karachi, as well as in Lasbela District. The disease is transmitted by mosquitoes that usually bite from dawn till dusk and the risk is higher during the monsoon season from July till August. Symptoms can develop as early as six days or as late as several months after exposure. The early, flu-like symptoms include headaches, body aches, and a general feeling of malaise. If left undiagnosed and untreated, complications such as anaemia, seizures, mental confusion, kidney failure and coma can take place. The malarial strain in Pakistan (P. falciparum malaria) is resistant to the medication Chloroquine and as such the chemoprophylaxis options are Atovaquone plus Proguanil, Doxycycline, and Mefloquine.

Outbreaks of Dengue fever are reported annually from Karachi and the month of August to October is generally considered the peak season for the spread of the disease. Dengue is transmitted by the Aedes mosquito which bite primarily in the daytime and are found in densely populated areas. Symptoms include high fever, severe headaches, joint and muscle pain and often followed by a rash. The acute illness can last up to ten days, but complete recovery can take two to four weeks. There are no available vaccines against Dengue at this time. Last September, health experts warned the Sindh provincial government of a possible Dengue outbreak as the forecast weather and climatic conditions for October onwards are favourable for the breeding of the mosquito species that spreads the virus to humans. Local press reports indicate that as of October 2012 at least 15 to 20 cases of dengue are being reported on a daily basis from Karachi and this is likely to double in the coming weeks.

The best way to prevent mosquito-borne diseases is to remain in well-screened areas and wear clothes that cover most of your body. Travellers are advised to use as effective insect repellent such as those containing DEET. They should use mosquito nets (bed nets) when accommodations are not adequately screened or air-conditioned.

Food and Water

Traveller's Diarrhoea is probably the most common travel-related condition and there is a risk posed to travellers to Karachi and Lasbela District, and other parts of Pakistan. Most cases are mild and would not require either antibiotics or antidiarrheal drug, however it is advisable to keep a quinolone antibiotic or antidiarrheal drugs on hand and remain hydrated at all times. To prevent this ailment, travellers are advised to drink only bottled or boiled water and carbonated drinks as tap water and ice are not considered safe. Travellers should also choose food that has been thoroughly cooked and avoid food sold by street vendors as the standard of hygiene may be low and the food may not be fresh.

Recently in October 2012, the United Nations World Health Organisation (WHO) confirmed that at least ten people have died due to a brain-eating amoeba known as the Naegleria fowleri since May of this year in Karachi. The brain-eating amoeba is a water-borne organism and causes Primary Amoebic Meiningoencephalitis and enters the body when contaminated water is inhaled through the nose. The parasite then travels to the brain where it destroys the tissue. The disease cannot be passed from person to person but it has a fatality rate of 98 percent with death occurring five to seven days after being infected. Symptoms are judged as being initially mild, but include headache, stiff neck, fever, and stomach pain.

The disease was first reported in Karachi in 2006. Since then, there were no cases until May and July 2012 when the first few cases were recorded. After a nearly two-month respite, three deaths in September and October caused alarm among health officials and prompted the Karachi Water and Sewerage Board to increase chlorine concentration in reservoirs and supply stations as a precaution. An investigation is also underway to trace the water source of the amoeba outbreak.

Travellers are advised to be well-aware of the conditions and symptoms of the disease. It is highly recommended to avoid washing your face with water supplied through pipelines in the city that may be potentially contaminated. Instead one is advised to utilise bottled water, for drinking and cleaning one's face. Many of the victims have caught the disease by swimming in contaminated water, and as such it is advised to avoid swimming in any pools that may have the waterborne organism.

Karachi is considered among the most polluted cities in Asia and water and air quality are considered poor and pose a hazard to health. In July 2012, experts claimed that 60 percent of the garbage generated in the city is disposed at traditional garbage dumping sites while the remaining 40 percent are dumped in storm-water drains which leads to the pollution at the Malir and Lyari Rivers. The pollution generated by the city's unstructured economic growth and inadequate urban planning have raised the risk for asthma and other respiratory complications. In Lasbela District, Tuberculosis (TB) and other respiratory tract infections such as asthma were identified as the most commonly reported illnesses in a 2011 report from the United Nations Children's Fund (UNICEF).

Medical Facilities

The healthcare system in Pakistan is poorly developed and it is best to avoid public hospitals. The farther you go from the urban areas, the less likely will there be adequate medical facilities. Quality medical care in Karachi is available through the private major hospitals where majority of the doctors have been trained in Western countries. In Lasbela district, medical services are limited and it is recommended that travellers go to Karachi for treatment.

It should be noted that physicians and hospitals in Pakistan usually require cash payment or deposits prior to offering medical care, despite patients having health insurance policies. Ambulances services are not always reliable, and expatriates are known to fly to other countries for complicated medical emergencies.

The following facility is often recommended by embassies and/or used by expatriates:

The Aga Khan University Hospital

PO Box 3500 Stadium Road Karachi, NA 74800

Telephone: 92 21 3493 0051

References

http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/japanese-encephalitis.htm

http://wwwnc.cdc.gov/travel/destinations/pakistan.htm

http://www.antimicrobe.org/v43tabs.htm

http://www.dailytimes.com.pk/default.asp?page=2012%5C03%5C19%5Cstory_19-3-2012_pg12_6

http://www.nation.com.pk/pakistan-news-newspaper-daily-english-online/karachi/06-Aug-2012/experts-raise-alarm-against-dengue-outbreak

http://www.dailytimes.com.pk/default.asp?page=2011%5C09%5C26%5Cstory_26-9-2011_pg7_16

http://tribune.com.pk/story/449099/investigation-launched-after-brain-eating-amoeba-kills-10-in-karachi/

http://www.dailytimes.com.pk/default.asp?page=2011%5C09%5C30%5Cstory_30-9-2011_pg12_2

http://www.nation.com.pk/pakistan-news-newspaper-daily-english-online/karachi/17-Jul-2012/karachi-among-8-most-polluted-cities-in-asia

Environmental Hazards

As one of the fastest growing cities in Asia, there have been some legitimate concerns about Karachi's increased vulnerability towards natural disasters such as earthquakes, heavy rain, tsunami, tropical and non-tropical storms. Urban planning experts have said that the city's existing infrastructure, which include high-rise commercial and residential buildings, hospitals, schools, water supply and drainage networks are combined with unsustainable land-use patterns. Such an environment is likely to be significantly damaged should any disaster strike.

Overall, Pakistan has failed to sufficiently adapt its infrastructure or build up adequate emergency response mechanisms, especially in the less developed areas. Because of this, the country lacks Standard Operating Procedures (SOPs) to respond to flash floods, cyclones and earthquakes which are capable of causing deaths, health risks and infrastructural damage.

Flooding

Karachi is located along Pakistan's southern coast and it has a relatively mild arid climate. It has two distinct seasons, Summer which is usually from April to August, and Winter which is from November to March. Monsoon rains usually occurs from July to September. While the city typically receives low amounts of precipitation there have been recorded above-average amounts of rainfall in the last five years. Sudden heavy rainfall in Sindh province in 2011 caused widespread havoc and unprecedented devastation.

The areas identified to be most vulnerable to natural disasters such as cyclones and windstorms are those in the coastal belt including Korangi, Defence Housing Authority (DHA), Saddar and Lyari localities. Coastal communities, especially those on small islands and creeks, have no elevated ground and are more vulnerable to the risk of being inundated should there be a rise in sea levels of during a strong cyclone. The denudation of mangrove forests along the city's coastlines has also been cited as a factor that made Karachi less resilient to rising sea levels and storms. Weather experts have said that just 15 to 20 millimetres of rain is enough to cause flooding in Karachi which would lead to traffic and commercial disruptions.

The weather in Lasbela District is almost similar to that of Karachi. It is very hot from May to June and gets cold in December and January. Floods are also a primary concern in Lasbela District and the peak season for rain and floods to occur is usually from July to September.

Seismic Activity

Karachi and the southern coast of Baluchistan which is where Lasbela district is located are near four fault lines. The first is called the Allah Bund fault which passes through the coastal town of Shah Bundar and runs through eastern parts of the city ending near Cape Monz. Another fault lies in the Rann of Kutch near Sindh's southeast border with India. The third is called the Pubb fault which lies near the Mekran coast west of the city while a fourth is located in Dadu district on the northern boundary of Karachi. There are scientists who have said that the geographical location of Karachi is such that a natural curve is formed near the sea-shore, as a result, the possibility for a tsunami generated in Indian Ocean to hit the coastal areas is quite remote. Nonetheless, there are also experts who have said that earthquake with of over 8.0-magnitude on the Richter scale could generate a fatal tsunami in the area that would result in heavy casualties and massive infrastructural damages.

The last reported earthquake in the region was on 10 August 2011, when a 5.7-magnitude earthquake struck Baluchistan province with a depth of 54.1km (33.6 miles). The quake's epicentre was located about 147km (91 miles) south-southeast of the town of Dalbandin. Media reports indicated that tremors were felt across the province, although there were no immediate reports of casualties or damage. Earlier in January 2011, at least two people were killed and about 200 residences and government offices were damaged after a 7.4-magnitude quake struck Baluchistan.

Experts from the Pakistan Meteorological Department have said that current structures in Karachi, similar with the rest of the country, were constructed without regard for safety or building codes and as such, a strong earthquake could flatten the city. It is also worthy to note that the Pakistani government has yet to build its capacity to respond to earthquakes or tsunamis, which further heightens the risk posed for the safety of those who live and work in high-rise buildings and coastal communities.

References:

http://jang.com.pk/thenews/jun2012-weekly/nos-10-06-2012/kol.htm#2

http://jang.com.pk/thenews/jun2012-weekly/nos-10-06-2012/kol.htm#1

http://www.trust.org/alertnet/news/pakistans-cities-wake-up-to-climate-threats

http://www.nation.com.pk/pakistan-news-newspaper-daily-english-online/karachi/09-Aug-2012/moot-calls-for-meaningful-response-to-disasters

http://pakistanweatherportal.com/2011/07/30/history-of-earthquakes-in-pakistan-in-detail/

Crime

The security situation in Pakistan is marked with violence that stems from a variety of factors that interact and magnify each other's impacts. Jihadist networks, political, sectarian, ethnic and organised crime groups shape the security threat landscape. Criminal elements are believed to exploit state weaknesses and societal conflicts to their advantage and the proliferation of loose firearms raises the capabilities of such groups to engage in violence. To evaluate the state of crime on the basis of official statistics is inadequate as much criticism has been aired about the discrepancies and misrepresentations of such data to the on-the-ground situation. Official crime statistics are best seen as representative rather than comprehensive, as majority of criminal activities are largely unreported and there is a grey area between those perpetrated by criminals and terrorist elements.

The most commonly-reported crime against foreign personnel is petty street crimes which include pickpocketing and bag-snatching. Such crimes take place in crowded areas such as markets, shopping districts, transportation and commercial hubs. There have also been regular reports of burglaries and break-ins at residences as well as hotels.

Violent crimes such as armed robberies, kidnappings and carjackings have been reported in major cities such as Islamabad, Lahore and Karachi. However, such incidents purportedly pose more of a threat in rural areas and other high-risk regions such as along the country's border areas where criminals and militant groups maintain safe havens. Kidnappings, hijackings and highway robberies are also reported outside of the city centres and along major highways.

Police in Pakistan have limited capabilities to respond effectively and in a timely manner to crimes and other emergencies. There is a serious lack of resources and equipment for police personnel and corruption is pervasive as almost all police units are under-staffed and under-paid. It is nearly impossible for the police to curb crime and violence as criminals are equipped with better and more sophisticated weapons. In addition, bureaucracy and corruption are also prevalent in the justice system. The conviction rate of those arrested for crimes is very low and many are allegedly released after the payment of bribes to corrupt officials.

Karachi

Karachi has a long history of ethnic, religious and sectarian violence and recently, there are increasing concerns about the growing nexus of criminal and militant groups which are said to be behind the spate of robberies, targeted killings and other nefarious activities. The criminal environment in Karachi is populated by gangs, local mafia, extortionists, drug lords, weapons dealers and land-grabbers, some of whom are reportedly linked with political parties as well as ethnic and jihadist groups.

In 2009, it was reported that the city has become a major battleground for some 200 gangs involved in organised crime. Criminal syndicates have exploited the city's weak governance systems and growing commercial activities on order to gain a base for their operations. Much of these gangs' activities is politically-motivated and is either directly or indirectly linked to terrorism. These syndicates are involved in killings, kidnapping for ransom, robbery, theft, bhatta collection (extortion), gambling, narcotics and other forms of crime and violence. The same scenario still exists at some level today.

Crime Statistics

In September 2012, data compiled by news organisation Al Jazeera ranked Karachi as the most dangerous amongst the world's largest cities. Criminal statistics gathered from governments, police departments and the United Nations (UN) showed that the homicide rate is at 12.3 per 100,000 residents. Majority of the incidents are clustered around certain areas in Karachi's central and south zones which are key battlegrounds and stronghold for political parties and criminal gangs. One of the identified violent areas is Pirabad in Orangi Town, which is hotly contested between the ruling Muttahida Qaumi Movement (MQM) and the Awami National Party (ANP), as well an area where there is a high degree of activity in the informal land sector. Other districts with high incidents of violence were Orangi Town, Baldia Town, and Kala Kot. The Lyari area has notoriously become a "no-go" for law enforcement agencies. In May 2012, thousands of security officers raided Lyari area in an attempt to gain back control of the area from local gangs. However, they were ambushed by gunmen who laid siege to the area for several days and killed at least five policemen and 20 civilians.

The Citizens-Police Liaison Committee (CPLC) is a non-government organisation (NGO) which maintains a record of crime statistics in Karachi. Based on statistics available from their website, criminal activities are on the rise. Since January 2012, there have been 4,052 cases of stolen vehicles compared with 4,726 stolen vehicles for the whole of 2011. For the same period, there were 16,719 motorcycles/bicycles stolen, a significant number when compared to 18,906 reported stolen for the whole of 2011.

There were reportedly more than 100 kidnappings in Karachi last year and it is believed that the Taliban was involved in some of the incidents presumably to raise funds for their operations in Afghanistan. Some local gangs were also reportedly involved in kidnappings. Based on the CLPC statistics, from 1 January to 30 September 2012, there have already been 105 reported kidnappings, 93 of which have been solved. There were also ten kidnap gangs apprehended for the period. For 2011, there were a total of 113 kidnappings, 110 of which were solved and 23 gangs were neutralised. There was no available information on the identities of the victims, whether they were locals or foreigners.

Local press reports in October 2012 indicated that since the beginning of the year there have been a total of 18 armed bank robberies in Karachi and that the total money stolen amounted to Rs70 million (approximately USD730,000). The modus operandi in all of the robberies was reportedly similar- the suspects were armed with sophisticated weapons and were wearing the uniform of the banks' security personnel.

Police in Sindh Province also have comparative statistics for crimes against persons and property for 2011 and 1 January-30 September 2012 in Karachi. Based on their data, there has been a noted increase in rioting, assaults on police, armed robberies and kidnappings. As mentioned in an earlier section of this report, crime statistics, whether they are official data or gathered by NGOs, are best seen as representative rather than comprehensive as there is likelihood that a significant number of incidents have not been reported to the authorities. The overall assessment for crime in Karachi is that it is thriving and poses a significant threat to the safety and security of travellers to the city. It is important to maintain a heightened level of security awareness at all times due to the credible risk of incidental exposure to crime and other forms of violence.

Lasbela District

The overall security situation in Lasbela District is likely to be more stable than Karachi, although Hub Town, where the BYCO Petroleum Pakistan Ltd (BPPL) and Byco Oil Pakistan Ltd (BOPL) are located, is vulnerable to disturbance due to its large population and incidents of ethnic conflict. A report released in 2011 said that the crime rate in the district has been increasing slowly as a result of the increase in population and poverty.

It is difficult however to ascertain the real level of crime as there are not enough data available to assess the situation. The United Nations Children's Fund (UNICEF) said that the major cognizable crimes reported in Lasbela District from 2006 until 2010 were explosion incidents, rioting, kidnap for ransom, and illegal drug trade/smuggling. The data showed that for the aforementioned period, there were a total of 70 explosion incidents, 33 cases of rioting, one kidnap-for-ransom incident (2009) and 199 reported cases of illegal drug smuggling. There is likelihood that many criminal incidents are not reported to the authorities especially if it involves non-violent and financially-motivated crimes such as thefts, burglaries and scams.

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