Planning your elective - Pakistan

Akil Fazal explains how to get around in the heart of southern Asia

Situated in the heart of southern Asia, Pakistan stands out as an interesting and enjoyable challenge for most visitors. Few Western people know much about Pakistan beyond media impressions of guns and drugs, communal violence and martial law, but it contains some of Asia's most mind blowing landscapes, a multitude of cultures, and very hospitable people. Pakistan was the site of one of the world's earliest human settlements, the great prehistoric Indus Valley civilisation, the crucible of ancient empires, religions, and cultures. The country is composed of towering peaks in the north, dry and scrubby mountains in the west, an inhospitable plateau in the south west, barren deserts in the south east, and alluvial plains everywhere else.

Culture and lifestyle

The pleasures of Pakistan are old: Islamic palaces, Hindu temples, Buddhist monuments, religious tombs, and widely spaced Anglo-Mogul Gothic mansions. Sculpture is dominated by ceramics, jewellery, silk goods, and engraved woodwork and metalwork.

Cricket is Pakistan's greatest sports obsession, and national players are afforded hero status. Pakistanis play cricket on open fields, roads, footpaths - almost any place they can get to. It is not uncommon to see roads deserted and shops closed whenever Pakistan is playing an important international cricket match.

Nearly all Pakistanis are Muslim, and Islam is the state religion. Minority religious groups include Hindus, Christians, and Parsees. Islamic dress code is strictly enforced. To avoid offence, invest in a shalwar qamiz - a long, loose garment worn by both men and women.

Pakistani food consists mainly of rice, meat curries, and chapatis. In the larger cities of Karachi and Lahore you will be able to find many Western fast food outlets, such as McDonald's and Pizza Hut, as well as culinary dishes from almost all over the world.

Health care in Pakistan

Pakistan's healthcare system is one of stark contrasts. Hospitals vary from the posh Aga Khan University Hospital in Karachi to badly stocked, makeshift health centres in rural areas. However, on the whole, Pakistan still has a lot of catching up to do, with a life expectancy of just 60 years¹ and a total fertility rate of 4.9. The World Health Organization's report 2000 ranks Pakistan's health system a grim 122nd in the world.

Goitre is endemic in northern Pakistan, with certain areas reporting a prevalence rate in excess of 70%.² This is due to a severe iodine deficiency in the soil. In order to try and solve the chronic iodine deficiency problems the government has set up an iodised oil campaign in conjunction with Unicef.³ Many patients in the developing world present with acute infectious diseases, such as cholera, gastroenteritis, typhoid, and tuberculosis.⁴ However, there is growing concern about the increasing prevalence of chronic diseases, such as cardiovascular illness and cancer, which are seen mainly in developed countries. In countries like Pakistan this is putting a greater strain on the already stretched healthcare system (see table).

The WHO describes this as an "epidemiological transition" that leads to a "double burden" of disease due to the "continued weight of endemic infectious diseases."⁴

Medical education and electives in Pakistan

Medical education in Pakistan began in 1860⁵ with the establishment of the King Edward Medical College in Lahore.⁵ Since then the number of government and private medical schools has increased to 19. Medical education takes five years and leads to the qualification of MB BS. Students don't have to do any compulsory internship on graduating, and the language of instruction everywhere is English.

Most of the medical schools have established elective programmes that are reasonably well organised. However, it would be better to seek clarification over what duties you'll have, what kind of accommodation they provide, and how far away local amenities like transport and the post office are before leaving. Please note that some of the people, especially in rural Pakistan, are very conservative about gender issues, so don't be surprised if you end up examining patients of your own gender only.

Visa and travel

Nationals from most European and English speaking countries require visas. A Pakistan visa allows you to enter the country for up to six months from the date you get it, and stay up to three months from the date you enter. However, if you stay longer than 30 days you must register at a foreigners' registration office; these are found in larger towns and cities. If you intend to stay for long, the Pakistani High Commission will be able to give you details of the registration office closest to where you'll be staying.

More than 25 airlines fly to Pakistan from over 40 countries. Most of the flights arrive at Karachi, but PIA and British Airways fly direct to the twin cities of Rawalpindi and Islamabad. PIA also flies direct to Lahore.

Health and safety

Despite an army coup and martial law being imposed, travel to Pakistan is generally considered safe. The British Foreign Office advises against travel to areas bordering Afghanistan and against travel to the Federally Administered Tribal Areas, most of which adjoin Afghanistan.

Travellers to areas adjoining India, or who plan to cross the international border, should be aware of the tension between Pakistan and India over Kashmir. Karachi also has a history of civil disorder problems. Please check the British Foreign Office website (www.fco.gov.uk/travel/) for the latest travel advice before embarking on your trip.

For a hassle-free journey it would be easier to tour Pakistan through an organised tour rather than your own initiative. The government tourism department - Pakistan Tourist Development Corporation (PTDC) will be able to give you information on the tours available. Try and avoid Pakistan during Ramadan, the Muslim month of fasting, which usually occurs sometime during December to early January. You may find yourself involuntarily joining in the fast because activity is kept to a minimum and food is hard to find during daylight hours. Food and waterborne diseases, especially traveller's diarrhoea, cholera, typhoid, and hepatitis A, are common, so be careful about what you eat and drink. Malaria is endemic in certain areas so prophylactic treatment is necessary. Dengue fever and Japanese encephalitis also occur in some rural areas.⁶

1. 1 World Health Organization. World Health Report 2000. Geneva: WHO, 2000. (www.who.int)
2. Stewart AG. Drifting continents and endemic goitre in northern Pakistan. BMJ 1990;300:1507-12.
3. Mull DS, Anderson JW, Mull JD. Cow dung, rock salt and medical innovation in the Hindu Kush of Pakistan: the cultural transformation of neonatal tetanus and iodine deficiency. Soc Sci Med 1990 30;6:675-91.
4. World Health Organization. World Health Report 1997. Geneva: WHO, 1997 (www.who.int)
5. World Health Organization. World Directory of Medical Schools, Geneva: WHO, 2000.
6. Lonely Planet. Destination Pakistan. www.lonelyplanet.com