Information About Pakistan Nation

Information About Pakistan Nation

CULTURE Statistics Population Patterns Total Population 166 million (2006) 14 or younger 39 percent Between 15 and 64 56.9 percent 65 or older 4.1 percent Population Growth Rate 2.1 percent Pakistan’s population rate has decreased by more than 3 percent per year since the 1980s. A further decrease, through family planning campaigns, is a government priority. The average Pakistani woman has four children. Although the overall population density is 186 people per square kilometer (482 per square mile), this statistic masks regional differences. Sixty-six percent of the population lives in rural areas; 34 percent is in urban settings. A population shift from rural to urban areas places pressure on the government to encourage job creation and economic growth in cities. Nearly 80 percent of the country’s population lives in either Punjab or Sindh; more than half live in Punjab. Eight major cities in Pakistan have a population of 1 million or more. The largest, estimated at 13 million, is Karachi. Second is Lahore, followed by Faisalabad, Rawalpindi, Multan, Hyderabad, Gujranwala, and Peshawar in descending order. Peshawar, in the KPP, is the only large city outside of Punjab and Sindh provinces.

Population Density Punjabis, Sindhis, Pashtuns, Muhajirs, and Balochs make up Pakistan’s five basic ethnic groups. The proportions are Punjabis, 55 percent; Sindhis, 20 percent; Pashtuns and Mujahirs, approximately 10 percent, each; and Balochs, about 5 percent. Subgroups exist within each of these ethnicities. Castes are occupational groupings within an ethnic group. Punjabi castes include Arains, Rajputs, and Jats; each group considers itself to be ethnically distinct. Sindhis are likewise fragmented into castes. In Balochistan, the Balochs are divided into eastern and western tribes. Other ethnolinguistic groups in Pakistan include Punjab’s Siraikis, Sindh’s Urdu-speaking Muhajirs, and Balochistan’s ethnic Brahuis.

Society
Family is the center of social life and support, and family honor is imperative. The family’s presiding male has significant influence over family members, and the elderly are highly respected. Social structure and individual identity in Pakistan are largely based on Arabian Sea Surab Jacobabad Hyderabad Nawabshaw Dadu Bela Pasni Ormara Jiwani Gwadar Nok Kundi Larkana Sukkur Rahimyar Khan Sibi Bahawalpur Multan Sahiwal Faisalabad Gujranwala Sialkot Rawalpindi Dera Ismail Khan Gilgit Chitral Badin Turbat Dera Ghazi Khan Bannu AFGHANISTAN IRAN INDIA CHINA TURKMENISTAN TAJIKISTAN 35˚ 30˚ 25˚ 70˚ 65˚ 75˚ 70˚ 75˚ Quetta Lahore Peshawar Karachi ISLAMABAD Pakistan Population Density Persons per kilometer Source data courtesy of LandScan2008 500 100 1 0 100 200 300 km 15010050 200 mi 0 0 Population Density 38 the extended family. The family is more private than in many cultures and family loyalty is primary. Traditionally, large extended families provided their members with socialization, sustenance, protection, and regulation. Even today, a family member living apart from relatives is uncommon. Men who have migrated to cities for jobs generally live with a relative or a relative’s friend. Children live with their parents until marriage. Except in very congested urban areas, sons (with their wives and children) tend to live with their parents. Living conditions range from inadequate to opulent. Wealthy landowners or industrialists tend to live in large, comfortable villas with an array of modern conveniences.

People in rural villages build homes out of mud or unbaked bricks. Many villages have no electricity. Villagers get water from wells and rivers, cook on small kerosene stoves, and wash clothes on river banks. The traditional economic and political hold that landlords enjoy in rural areas, particularly in Punjab and Sindh, ensures continued limited opportunities and mobility for agricultural workers. This limitation is an incentive for workers to migrate. Pakistan’s poorest slums are in Karachi, particularly in the working-class neighborhoods of Orangi and Korangi. Forty percent of Karachi’s population lives in katchi abadis (temporary settlements) or shantytowns. Many are often forcibly relocated either to combat the slum’s unsanitary conditions or to make way for city development. Karachi is also ravaged by violence and considered by some the most dangerous city in South Asia. Ethnic groups compete for local power and control, Sunni and Shi’a extremists battle each other, and crime and corruption is widespread. Drug use is the most common social problem in Pakistan. Opium smuggling and heroin production became major issues after the 39 Soviet invasion of Afghanistan in 1979. When the war interrupted the opium pipeline from Afghanistan to the West, Pakistan became an alternate route. Pakistan also became a major center for heroin production and a shipment point for the international market. Heroin use expanded significantly and, subsequently, drug addiction is a major problem.

People Most Pakistanis are devout Muslims and believe that the will of Allah is evident in all things. The saying Inshallah (God willing) expresses hope for success on a project, for a family’s protection and prosperity, and for a positive outcome to a planned event. Pashtuns and Balochs are more conservative and traditional than the other major groups; rural populations are more conservative than urban. Pakistanis, in general, are friendly, hospitable, and treat visitors with great respect. In traditional homes, however, there are strict customs governing the reception of guests. Men, for example, do not socialize with women they are not related to. In addition, homes have a front room for receiving guests and a separate, backroom, reserved only for close family members. Even the head of the household’s lifelong friends may never set foot into this room. Ethnic Groups Punjabi Punjab is the most populated province. Punjabis are heavily represented in the military and bureaucracy, which, leads to resentment and fear of the Punjabi majority in the smaller provinces, particularly Sindh. Two of the three most prominent national politicians in the 1980s and 1990s were Punjabis: President Mohammad 40 Zia-ul-Haq and Prime Minister Mohammed Nawaz Sharif. Even Pakistan’s capital was moved in the 1960s from Karachi, in southern Sindh, to Islamabad, in northern Punjab. Though they come from very diverse origins, Punjabis are united in an ethnic community of farmers. Tribal affiliation, based on descent and occupation, merges into an identity Punjabis call qaam (kinship). Qaam is an essential distinction and significant social marker in Punjab, particularly in rural areas. Many tribes have traditionally pursued a single occupation, which gave the group both its name and position in the social hierarchy. Kinship obligations are central to a Punjabi’s identity and concerns. Each person has free access to a kinsman’s income, political influence, and personal connections, and there is social pressure for an individual to share and pool these resources. Sindhi Ties among the Sindhi have traditionally revolved around a few large, dominant waderas (landholding families). The remaining people are tenant farmers who, as a result of contractual terms between themselves and the landowners, live in permanent poverty. Muhajir After Pakistan gained its independence in 1947, millions of Hindus and Sikhs left for India; they were replaced by roughly 7 million people who were called Muhajirs (Muslims who fled from India) and many settled in Karachi. The Muhajirs were generally better educated than native Sindhis and filled a void in the province’s commercial life. Over time, the Muhajirs provided the political basis for the Refugee People’s Movement, and Karachi became known as a Muhajir City. Other cities in Sindh, such as Hyderabad and Larkana, became the headquarters for Sindhi resistance. In the 1980s and 1990s, Sindh was a battlefield for ethnic strife between Muhajirs and Sindhis. Kidnappings were common by both sides; fear of dacoits (bandits) inhibited road and rail travel. Today, as a result of their higher educational status, Muhajirs are statistically overrepresented in public positions.

Pashtun Pashtuns are one of the largest tribal groups in the world. They are the majority group in southern Afghanistan and the dominant ethnic group in Pakistan’s KPP and FATA . The West has long been fascinated by the Pashtuns, whose fierce independence and fighting spirit made them one of the few peoples to withstand British colonialism. More is written about Pashtun norms, values, and social organization than any other ethnic group in Pakistan. Pashtun speakers in the FATA and KPP belong to different tribes and have no central governing authority. Officially, Pashtuns in the FATA are administratively governed by the executive branch (president of Pakistan) through the governor of the KPP in Peshawar. In reality, the federal troops and law enforcement entities do not have a significant influence in most of the FATA , particularly in the Waziritstans. Traditionally, Pashtuns have only acknowledged the authority their own maliks (tribal leaders). Gradually, however, this attitude has been changing. Since the 1979 Soviet invasion of Afghanistan, which ushered in a new era of Saudi-backed mullahs (Islamic religious leader), increasing numbers of Pashtuns have begun viewing mullahs as legitimate leaders. The Pashtun code of conduct, Pashtunwali, is central to their identity. Nang, the notion of honor, delineates right and wrong; a life without honor is not worth living. In order to maintain or increase Nang, a man needs to protect his lands, wealth, and family (particularly female relatives). Males are encouraged by peers to adhere to Badal and Melmastia; Badal requires revenge to defend one’s honor. Vendettas and feuds are, therefore, considered a basic part of social relations. Melmastia emphasizes hospitality is of utmost importance. 43 A complex etiquette surrounds the guest/host relationship. Because hospitality, particularly to strangers, is tied to one’s honor, it is insulting if a guest refuses what the host is offering. Men are also held responsible for ensuring female household members remain chaste until marriage. Accordingly, in much of the province, women are restricted to private family compounds. One consequence of the male-female dynamic among Pashtuns is that an accurate count of the population is not possible: census takers are not permitted to ask about women in another man’s home and the number of men in a household is often overstated because male family members are considered a source of strength. Baloch Balochs form a relatively small group but, like the Pashtuns, inhabit an area that extends beyond national borders. Seventy percent of Balochs live in Pakistan; the rest live in Iran and Afghanistan. Weather and topography in Balochistan make the region exceedingly inhospitable. Geologists have often compared its landscape to that of Mars. Baloch livelihoods rely on nomadic pastoralism, dryland and irrigated agriculture, and fishing. Sheep and goats are the main herd animals, providing dairy products, meat, and wool. Herders organize themselves around water sources; wells are the property of camps. In addition to pastoralism and animal husbandry, many Balochs support themselves by transporting goods and people across the borders. As with other ethnic groups in Pakistan, inheriting property and the family name is patriarchal; however lineage plays a minimal role to most Balochs. They are flexible in arrangements with family and friends. In families, the father or eldest male exerts absolute authority. Although young people may adopt Western clothing 44 styles and other habits, they continue to obey and respect their fathers and elders. Arranged marriages are the norm; in many cases the bride and groom meet for the first time on their wedding day. Marriage is viewed as the union of two families as well as the union of two people. Divorce is rare. Social life revolves around relatives. Families tend to be large because children are considered gifts from Allah. The family provides identity and protection; it is rare for an individual to live apart from his relatives. Children live with their parents until marriage. Except in very congested urban areas, sons live with their parents after marrying and having children of their own. Upon their father’s death, sons establish separate households.

Roles of Men and Women Pakistan’s society is male-dominated. Norms and traditions are established by men, and decisions about a woman’s involvement in society (e.g., education, marriage, work, and travel) are made by male family members. Because the activities of women directly affect family honor, restrictions are placed on their mobility, behavior, and activities. Women do not socialize with men to whom they are not related. The tradition of purdah (strict seclusion and veiling of women) is relaxing somewhat as Pakistani women become more educated and enter public life. In small towns and rural areas, however, some women still wear burqas (head-to-toe coverings) over their clothing when leaving home. The most extreme restraints are found in the KPP and Balochistan, where women almost never meet unrelated men or leave their homes, except to marry. Most Pakistani women are homemakers; men are the breadwinners. Only a small percentage of women work outside the home, mostly as nurses or teachers. A few women also work in government, serving as ministers in parliament and as ambassadors. The first female prime minister, Benazir Bhutto, served from 1988 to 1990. Women face serious social and legal discrimination. Domestic violence is occasionally tolerated, and the few laws that protect women are rarely enforced. Men do not discuss female relatives in public. Gender equality or women’s rights is seen as a Western effort to undermine Pakistani society. In legal cases dealing with financial matters, two women must testify for testimony to be introduced as evidence. In serious cases, women are not allowed to testify at all. If a woman files a charge of rape, she is required to produce four pious male witnesses; otherwise, she will be charged with adultery, an offense carrying a death sentence by stoning. In 46 some areas of Pakistan, it is socially acceptable for a man to kill his wife if he thinks she dishonored him with words or actions. Despite the government’s prohibition, such “honor killings” (karo kari) resulted in the deaths of more than 4,000 women between 1998 and 2003. Rites of Passage Most Pakistani marriages are arranged. It is believed that close family alliances have a greater chance of success than Westernstyle couplings. A match between cousins is preferred. The day before a couple marries the bride attends a mehndi (henna) ceremony in which her hands and feet are painted in intricate patterns to the accompaniment of raucous songs and dances. Mehndi leaves and tea water are mixed to form the paste. It is believed that the darker the mehndi the more a husband will love his wife. When a couple weds the quazi (religious leader) oversees the couple signing the nikah (marriage contract). Muslims view a new baby as a great blessing; consequently, there are many ceremonies at birth and throughout infancy. It is the paternal grandfather’s privilege to name a baby; one of the grandfather’s old shirts is even used to make the infant’s first garment. When a male is born, he is circumcised according to religious rites. Birth is celebrated by distributing sweets and sacrificing an animal, one goat for a girl and two for a boy; the meat is distributed among friends, relatives, and the poor. The family holds an aqeeqa (family feast) for a son when he is 7 days old. The boy’s hair is shaved off to ensure thick growth throughout life. The hair is then weighed and balanced against silver, which is given to the poor. When the baby is 6 or 7 months old, relatives use a silver spoon to place rice pudding and a drop 47 of chicken broth into the child’s mouth; afterwards there is an elaborate dinner for the adults. A turning point for a Muslim youth is the first fast, called Roza Kushai in Urdu. It is followed by a celebration, during which family members bring gifts and money. Muslim children are required to begin fasting at the age of 12; many, however, are eager to enter adulthood at an earlier age.

Education and Literacy Pakistan’s literacy rate is lower than that of many other developing nations. Less than half of all adults are literate; only about onethird of women can read. The educational system is based on the British colonial education system, which was used to educate a small portion of the population to run the government. Madrassas (conservative Islamic schools) are publicly supported and provide free religious education, boarding, and lodging. More than 1.5 million children attend madrassas, where they memorize the Qur’an and learn Islamic law, and in some philosophy, math, and geography. Supporters claim that these schools play a key role in countries where millions of Muslims live in poverty and state educational infrastructure is in decay. In 2005, 15 percent of schools had no buildings, 52 percent were without a boundary wall, 40 percent without water, and 71 percent without electricity; teachers were frequently absent. In 2005, Pakistan’s government pledged to reform and integrate madrassas into the formal education sector. It increased annual education budget, spending a total of US$1.3 billion on education between July 2004 and March 2005. However, the division between the Western-type private schools and the Islamic public 48 schools has caused significant social tensions and has motivated the better educated emigrate to the West. Higher education is available at vocational schools, technical schools, and colleges. The oldest university in Pakistan is the University of Punjab, established in 1882. The largest universities are Allama Iqbal Open University (in Islamabad), the University of Peshawar, and the University of Karachi. University classes are taught in Urdu and English. Language Language is a significant indicator of ethnic identity in Pakistan. Urdu, the national language, is spoken by only 8 percent of the population as a native tongue. It was chosen as Pakistan’s unifying language at the time of independence because it symbolized a shared identity for South Asian Muslims. Many people speak Urdu in addition to their own language. Urdu is a combination of the languages of early invaders and settlers, including Hindi, Arabic, Persian, and Turkish. Urdu’s spoken form is the same as Hindi; the written form uses a different script. English is also an official language; perceived by Pakistanis as providing access to the world community, it is the common language in scholarly, business, and government settings. Urdu and English are used in school instruction. About half the population speaks Punjabi, which is an old, literary language; early folk tales and romances were written in Punjabi. Punjabi has numerous dialects and Muslims have a history of speaking in a mix of Punjabi and Urdu, particularly in urban areas. Sindhi is the second most common native language. More than 20 other languages spoken in Pakistan belong to the Indo- 49 Aryan branch of the Indo-European language family. The remaining languages are related to early Dravidian. Islam has influenced the spoken language. It is common for Pakistanis to mention Allah in everyday conversation. Bismallah (I begin in the name of Allah) is a common phrase used before beginning an activity and inshaallah (if it is the will of Allah) is a common affirmative response to an invitation. Religion Pakistan was created as a homeland for Muslims. Islam is the state religion and 97 percent of the population is Muslim. Sunni Muslims make up 77 percent of the total population and Shi’a, 20 percent. Muslims adhere to the following five foundational tenets, called the five pillars of Islam:
■ Shahadah, the belief in the oneness of Allah and the belief in the Prophet Muhammad
■ Salat, the five daily prayers
■ Zakat, the giving of alms to the needy
■ Sawm, fasting during the month of Ramadan
■ Hajj, the pilgrimage to Mecca The remaining 3 percent of the population are Hindus, Christians, Ahmadis, Zikris, Parsis, Sikhs, Buddhists, and Baha’is. The leaders of the non-Muslim faiths claim that they actually make up 10 percent of the population. The constitution requires that laws be consistent with Islam, and that, “subject to law, public order, and morality, every citizen shall have the right to profess, practice, and propagate his religion.” In practice, the government limits freedom of religion. The government severely restricts, in law and in practice, public worship by minority Ahmadis. The constitution declares Ahmadis to be nonMuslims because they do not accept Muhammad as the last prophet of Islam. Ahmadis, however, consider themselves to be Muslims and observe Islamic practices. Society discriminates against and is sometimes violent toward religious minorities. The government discriminates against religious minorities through specific policies, such as the Hudood Ordinances and the blasphemy laws. The Hudood Ordinances impose the law of the Qur’an on Muslims and non-Muslims. The blasphemy laws require the death penalty for defiling Islam or its prophets, life imprisonment for defiling the Qur’an, and 10 years in prison for insulting the religious beliefs of any citizen. Recreation Pakistanis enjoy cricket and occasionally hosts polo competitions in the hills of northern Pakistan, the world’s highest polo grounds. Badshahi Masjid, Mosque in Lahore (Photo by Ali Imran) 51 Kabaddi is a traditional Pakistani sport. The 4,000-year-old game combines wrestling and rugby and was originally intended for developing self-defense skills. Each team has 12 players, seven of which are on the field and five are in reserve. There is mountain climbing, hiking, and skiing in the foothills of the Himalayas and deep sea fishing, sailing, and water sports in the Arabian Sea. Golfing is also popular; there are courses in Lahore, Rawalpindi, Islamabad, and other cities. Movies and television are popular entertainment. Many feature films are produced each year, mostly in Punjabi and Urdu. Pakistanis can easily find India-made DVDs and CDs, whose celebrities are household names. Poetry is integral to Pakistani culture. The qawwalis, a devotional song, is revered poetry set to music and a hand-clapping chorus. Also popular is the ghazal, which is lyrical rhythmic chanting set to music expressing love’s trials and tribulations. Customs and Courtesies Never enter a mosque without asking permission. When entering a mosque or a holy place, always remove your shoes. Never walk directly in front of someone who is praying. Do not eat, drink, chew gum, or smoke in the daylight hours during Ramadan in front of Muslims, who are not allowed to do so. Never be rude or discourteous; direct confrontation rarely brings positive results. Always obtain permission before photographing someone, particularly a woman.

Publicly consuming alcohol is banned. Non-Muslims can purchase alcohol and foreigners registered in international hotels can get a permit to be served alcoholic beverages. U.S. citizens may drink alcohol in their own homes, though alcohol should never be offered to a Muslim. Greetings The most common greeting for men is a handshake; close friends may embrace one another. Women greet each other with a handshake, hug, or kiss each other on each cheek. A man should not offer his hand to 53 a woman but may take hers if she offers it. A man may verbally greet another man’s wife but should not look directly at her. In a group, each person is greeted individually. Unless they are close friends or relatives, Pakistanis address each other by title and last name. Greetings often include lengthy inquiries about one’s health and family. A man may place his right hand over his heart during this conversation. The most common greeting is Assalaam alaikum (“may peace be unto you”). The reply is Waalaikum assalaam (“and peace also upon you”). A common response in conversation is Inshallah (“God willing”). Khuda hafiz means “goodbye.” Gestures Male friends commonly walk hand in hand or with their arms over each other’s shoulders, except in the more conservative Balochistan and KPP. Members of the opposite sex, however, do not touch in public. Staring is culturally acceptable, and even common; it is not considered rude or threatening. Never point the bottom of a foot or shoe toward another person; it is an insulting gesture indicating that the person is beneath you, on the same level as dirt. While sitting on the floor or crossing your legs, maintain awarness of the position your feet to ensure the soles are not pointed directly at anyone. Beckon someone by turning your palm face-down and waving the fingers up and down. It is impolite to use individual fingers to make gestures. Cultural Considerations Dress Standards Although some

Pakistanis wear conservative Western-style clothing, the shalwar kameez (Pakistan’s national dress) is more com- 54 mon throughout the country and worn by both men and women. The ensemble, traditionally made of cotton, consists of the shalwar (a pair of loose-fitting pants with a drawstring waist and tapered at the bottom) and the kameez (a long tunic). Men wear solid, subdued colors and add a vest or coat for formal occasions. A man also wears the headdress—a turban, pillbox hat, or karakuli (fez-type hat)—that symbolizes tribal identity. The woman’s shalwar kameez is made of brightly colored or printed fabrics (cotton, silk, chiffon, satin, and crepe) embroidered with sequins or beads. It is worn with a dupatta (long scarf) over the head and shoulders. Some women also wear a chaddar (long shawl). Women in more conservative areas wear a burqa (a headto-toe covering) over their clothing when they leave their homes. Visitors should dress modestly to show respect for Islamic values and to avoid offending Pakistanis. Women should adopt the shalwar kameez and dupatta or wear baggy, loose-fitting clothes exposing no more than head, hands, and feet. Tight-fitting or insufficient clothing causes great offense to Muslims. Eating Almost all Pakistanis follow three Muslim dietary customs: they do not eat pork, they do not drink alcohol, and they fast during the month of Ramadan. During Ramadan, Muslims fast from sunup to sundown in order to learn discipline and self-control. Islam does not require the elderly, pregnant women, or children who have not reached puberty to fast. Pakistani cuisine is diverse with Afghan-Iranian or Indian influences. Pakistanis sit on the floor and eat with the right hand. In Pakistani culture, the left hand is often used for unsanitary purposes so it should not be raised to the mouth, dipped in a com- 55 munal dish, or used to offer or accept anything. In some more Westernized households, Pakistanis sit at tables and use utensils. Seasonings are essential to Pakistani cuisine—they typically include bay leaf, black and red pepper, cardamom, chili powder, cinnamon, cloves, coriander, cumin, curry, garlic, ginger, nutmeg, paprika, poppy seeds, saffron, or tumeric. Roti (bread), chawal (rice), sabzi (vegetables), and gosht (meat) are the four main components of a Pakistani meal. Beef, chicken, lamb, and fish are curried or marinated. Plain rice is the standard side dish. Dals (lentils), split peas, and chickpeas are popular. Unleavened breads made with wheat or white flour are eaten with most meals. Naan and chapati are flat wheat breads baked in a tandoor (clay oven) and are often used to scoop up food. Ghee (clarified butter) is commonly used in recipes or for frying. Kheer is a rich rice pudding cooked with cardamom, cloves, and cinnamon. Mithai are sweets made with flour and cream and cooked in syrup. While fasting is imperative during Ramadan, feasting has its place on many other occasions, including Eid ul-Fitr, the holiday marking the end of Ramadan. The feast includes traditional fare such as shami kebabs (fried ground patties made from beef, split peas, onions, hot peppers, and spices), samosas (deep fried pastry triangles stuffed with spicy potatoes), cholay (chickpeas cooked in a spicy tomato sauce), and rasmalai (cheese soaked in sweet milk). Spicy dishes are often served with dahi (yogurt) to balance the spices. Chai (tea) is served at all meals and is offered as a welcome gesture. The tea is boiled with milk, cardamom, nutmeg, and sugar. Lassi (a yogurt drink) and sugar cane juice are popular during the summer. Non-Muslims can get permit to purchase alcohol from the Excise and Tax Department in major cities. There are about 120 licensed alcohol sellers across Pakistan, usually small places 56 at the back of upscale hotels. Much of what is purchased legally is sold to Muslims at a premium. Interpersonal Relations Pakistan was proclaimed an Islamic Republic in 1956. Islam is a significant part of Pakistan’s national identity and visitors should have some understanding of Islam and the accompanying social patterns. Women should cover themselves in public areas, since people are unaccustomed to seeing short sleeves and bare arms on a woman. It is inappropriate to discuss a man’s wife or female relative with him. A man should not extend his hand to a woman in greeting but can take her hand if it is offered. Any other physical contact between a man and woman must be avoided. Public displays of affection are not acceptable between a man and a woman, even between man and wife. It is considered rude for a man to have eye contact with women on the street. It is considered rude and unethical for a man to maintain constant eye contact when conversing with a woman. MEDICAL ASSESSMENT Disease Risks to Deployed Personnel National Center for Medical Intelligence (NC MI) assesses Pakistan as HIGH RISK for infectious diseases, with an overall disease risk that will adversely impact mission effectiveness unless force health protection measures are implemented. The following is a summary of the infectious disease risks in Pakistan. Risk varies greatly depending on location, individual exposures, and other factors. More detailed information is available at http://www.ncmi.detrick.army.mil. 57 Food- or Water-borne Diseases Sanitation is poor throughout the country, including major urban areas. Local food and water sources (including ice) are heavily contaminated with pathogenic bacteria, parasites, and viruses to which most U.S. service members have little or no natural immunity. Effective disease surveillance does not exist within the country. Only a small fraction of diseases are identified or reported. If local food, water, or ice is consumed, diarrheal diseases can be expected to temporarily incapacitate a very high percentage of personnel within days. Hepatitis A, typhoid fever, and hepatitis E can cause prolonged illness in a smaller percentage. In addition, viral gastroenteritis (e.g., norovirus) and food poisoning (e.g., Bacillus cereus, Clostridium perfringens, and Staphylococcus) may cause significant outbreaks. Vector-borne Diseases The climate and ecological habitat support large populations of arthropod vectors, including mosquitoes, ticks, and sand flies.

Disease transmission is sustained year-round at elevations below 2,000 meters, including urban areas. Serious diseases may not be recognized or reported because of the lack of surveillance and diagnostic capability. Malaria and dengue fever, the major vector-borne risks in Pakistan, are capable of debilitating a high percentage of personnel for up to a week or more. The highest numbers of malaria cases occur in the provinces along the Afghan and Iranian borders and west of the Indus River. One of Pakistan’s largest dengue fever outbreaks occurred from October through December 2006. 58 In addition, a variety of other vector-borne diseases occur at low or unknown levels; as a group, these diseases may constitute a potentially serious operational risk. Personnel exposed to mosquitoes, ticks, and sand flies are at high risk during day or night, in both urban and rural areas. Sexually Transmitted and/or Blood-borne Diseases Hepatitis B and HIV/AI DS are reported in Pakistan, particularly in prostitutes, a high-risk group for sexually transmitted disease worldwide. Parts of neighboring India have high HIV/AI DS rates, with likely spread into Pakistan. Men having sex with men, heterosexual contact, and intravenous drug use are the predominant modes of transmission. Carrier rates for hepatitis B are high. The long-term health impact of these diseases on individuals is substantial.

A variety of other sexually transmitted diseases (including chlamydia, gonorrhea, chancroid, herpes, syphilis, and venereal warts) may cause symptomatic infection in a high percentage of personnel who have sexual contact. Water-contact Diseases Operations or activities that involve extensive freshwater contact (lakes, rivers, streams, or other surface water) may result in personnel being temporarily debilitated with leptospirosis. In addition, bodies of surface water are likely to be contaminated with human and animal waste. Activities such as wading or swimming may result in exposures to enteric diseases such as diarrhea and hepatitis via incidental ingestion of water. Prolonged water contact also may lead to the development of a variety of potentially debilitating skin conditions such as bacterial or fungal dermatitis. 59 Respiratory Diseases Tuberculosis rates are high among the local population. Prolonged contact with the local population may result in high conversion tuberculosis skin test rates, well over the U.S. military baseline. In addition, U.S. personnel may be exposed to a wide variety of common respiratory infections in the local population. Animal-associated Diseases Rabies risk in Pakistan is among the highest in the world; dogs are the main rabies reservoir. Personnel bitten or scratched by animals are at high risk of developing rabies in the absence of appropriate treatment. Rare cases of anthrax could occur among personnel exposed to animals, animal products, or undercooked meat. Also, rare cases of Q fever could occur among personnel exposed to aerosols from infected animals. More cases are possible in situations where personnel have heavy exposure to barnyards or other areas where animals are housed. Medical Capabilities Pakistan has one of the least developed health and medical care systems in south Asia. In addition, the country has a few hospitals that approach Western standards of care. The health care system is inefficient, corrupt, and highly politicized. Disease surveillance and reporting are inadequate in large part because most seek health care in the private sector which does not report disease occurrences. Public awareness of mitigating disease risks, such as AI DS and tuberculosis, is poor. Some private specialty clinics and hospitals in major cities provide quality care approaching Western standards including the Aga Khan University Hospital, Karachi, the Doctors Hospital and Medical 60 Center in Lahore, and the Shifa International Hospital in Islamabad. Most facilities in Pakistan lack necessary supplies and equipment.

Military hospitals are better than comparable civilian facilities but still lack adequate staffing and medical materiel. The Pakistan Institute of Medical Science in Islamabad offers limited burn care capabilities. Many civilian and military physicians are well trained and qualified, but the quality of nursing care is far below Western standards. Military medics provide good basic lifesaving care but not to the same standard as U.S. combat medical personnel. Emergency medical services and trauma systems are extremely limited, even in major cities. Pakistan has some experience in disaster management, but lacks the resources to deal effectively with follow-on repercussions without international aid. Hospitals plan for emergencies by allocating beds for contingencies, keeping staff on call, and stockpiling supplies. These measures may not be possible, particularly in less accessible areas of the country, given existing medical staff and supply shortages. The military regularly assists civilian relief authorities in managing disasters. The blood supply is not considered safe for use by U.S. personnel. Hospitals and blood transfusion centers do not regularly test blood for HIV, hepatitis B and C, malaria, or syphilis in a quality assured manner and many unregulated private blood banks use unsafe paid donors. The quality of medical materiel depends on the product and source. Domestic pharmaceutical manufacturing is below Western standards; in addition, pharmaceuticals produced in Pakistan by Western pharmaceutical manufacturers do not meet Western standards. Imported medications are expensive and often in short supply, and quality varies based on country of origin. 61 English is widely used in the health care sector, primarily among physicians. However, most medical assistant personnel, including nurses, have little comprehension of English.

Information About Pakistan Nation