Public Health (2006) 120, 132141

ORIGINAL RESEARCH

Health and road transport in Pakistan

A.A. Hydera,*, A.A. Ghaffarb, D.E. Sugermanc, T.I. Masooda, L. Alid
Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Suite E-8132, 615 North Wolfe Street, Baltimore, MD 21205, USA b Global Forum for Health Research, World Health Organization, Geneva, Switzerland c Department of Emergency Medicine. John Hopkins Hospital 10 N. Wolfe Street, Baltimore, MD 21205, USA d Independent Enviromental Consultant, Islamabad, Pakistan
Received 4 May 2004; received in revised form 6 December 2004; accepted 9 March 2005 Available online 2 November 2005
a

KEYWORDS
Pakistan; Road-based transport; Cars; Health

Summary Objective: The 1998 Global Burden of Disease Study estimated that road trafc injuries (RTIs) will become the third leading cause of lost disability-adjusted life years, with two-thirds of the deaths occurring in the least developed nations. Moreover, automobile-based transport systems are associated with air pollution (lead toxicity, asthma and greenhouse gas accumulation), noise disturbances, physical inactivity and obesity. Study design: This study (1) reviewed road transport literature in Pakistan and the impacts on health outcomes; (2) examined health policies to assess their focus on transport-related health problems; and (3) identied policy gaps for future research. Methods: A methodological review of the literature on direct and indirect effects of road transportation in Pakistan. This review includes government documents, memos, statements and draft policies as well as relevant articles indexed in MEDLINE. Results: A systematic review revealed no approved transport policy in Pakistan, despite three national health policy documents. The Health Chapter of the 9th Five Year Plan appreciates the grave threat of unchecked RTI, but fails to offer specic policy interventions. Despite ambitious plans by the Pakistan Environmental Protection Agency, actual projects and their implementation remain scarce, resulting in ever-increasing air pollution. The health impact of lead toxicity, noise pollution and RTIs remain high, while obesity is on the rise. Conclusion: The increasing health impact of road transport on 140 million people calls for immediate policy action. Government agencies must intervene effectively to establish monitoring and decentralised enforcement nationwide, while simultaneously supporting alternative modes of transportation. Q 2005 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.

Introduction
* Corresponding author. Tel.: C1 410 9553928; fax: C1 410 6141419. E-mail address: ahyder@jhsph.edu (A.A. Hyder).

The Global Burden of Disease Study estimated that 10% of global deaths are due to injuries,1 with road

0033-3506/$ - see front matter Q 2005 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2005.03.008

Health and road transport in Pakistan trafc injuries (RTIs) likely to be the third most common cause of lost disability-adjusted life years within two decades.2 Currently, two-thirds of injury deaths occur in low-income countries (85% of the worlds population)3 due to a wide array of risk factors that result in the lack of safety provisions at home, on the road and in the workplace. While developed countries have succeeded in decreasing the number of injuries, rates in developing countries continue to soar. In addition to injuries, road-based transport systems are associated with an array of poor health outcomes that are exacerbated in developing nations. The most closely related health problems are caused by the effects of air pollution, lead toxicity and sedentary lifestyles. Caused by emissions and tyre burning,4,5 air pollution can lead to childhood asthma,6 adult chronic obstructive pulmonary disease exacerbations, chronic bronchitis and increasing greenhouse gas emissions.7,8 Leaded petrol leads to lead toxicity and subsequent reductions in child intelligence quotient, behaviour and hearing. 9 Dependency on door-to-door motorised transport reduces walking and biking, thus contributing to obesity and its subsequent comorbid conditions (cardiovascular, musculoskeletal and endocrine).10,11 In urban centres, highvehicle density with loud engines and horn use can result in excessive noise pollution, which is associated with accelerated hearing loss and sleep degradation.12,13 Finally, rising rates of trafc congestion can lead to increased stress levels, resulting in cardiovascular morbidity14 and lost work productivity. Despite these associations, only a handful of low-income nations currently monitor the negative impacts of road-based transport systems, despite continued expansion of vehicle ownership and road construction. The aim of this study was to review the evidence (government and peer-reviewed) linking road transport and health in a developing country, using Pakistan as a case study. The specic objectives of this study were: (1) to review road transport policies in Pakistan and their documented impacts on health outcomes; (2) to review implemented road-transport-specic interventions; and (3) to identify gaps in policy and implementation for future research in the road transport sector.

133 reviewing government documents was to contact the relevant government organisations directly in Pakistan. A formal request was submitted to the Ministry of Communications, which deals with road transport policies, oversees the National Transport Research Centre, and administratively controls the Pakistan Motorway Police and National Highway Authority. The request was made for access to all related government documents (published reports, position papers submitted to policy makers and donors, and draft policies). Similar requests were also submitted to the Ministry of the Environment, Ministry of Health and the Federal Bureau of Statistics. The nalised National Highway Safety Ordinance,15 9th Five Year Plan16 and draft National Conservation Strategy17 were reviewed to extract relevant information. A search of peer-reviewed, indexed papers was done using MEDLINE for literature published either in English or with an English abstract (in a foreign language publication) for the years 19802003. Combinations of the following types of keywords were used: Pakistan; transport, automobiles, pedestrians; pollution, carbon monoxide; health, injury, morbidity, lead and stress. Further MEDLINE searches were conducted using the authors last name and the related articles link for key publications. Other publications were also identied from the reference lists of retrieved articles. Additional electronic databases, Embase and Cinahl were also reviewed. Abstracts identied using this process were reviewed for inclusion and full copies of these publications were obtained. Papers were included in this review if they included information from 1980 or later, referred to locations within Pakistan, and discussed an association between road transport and its health consequences. Papers were excluded if they referred to a specic health condition without association to road transport, did not specically refer to Pakistan or areas within its geographical boundaries, or only referred to theoretical constructs with no empirical data. Papers were reviewed and information was extracted for each health outcome from road transport and tabulated. The intent of the tabulation was to get an illustrative list of evidence available in Pakistan. The tables were analysed to assess the quantity and nature of transport to health linkages.

Methods Results
This study was based on a systematic review of government and peer-reviewed literature regarding the road transport sector in Pakistan. The strategy for A systematic review of documents from the Ministry of Transport, Ministry of Health and the Planning

134 Commission revealed that there has never been an approved transport policy in Pakistan. Three National Health Policy documents (1990, 1997, 2001) have been developed, but none of these identies the transportation sector, including RTIs, motor vehicle emissions or road safety issues, as a public health problem.17 The Health Chapter of the 9th Five Year Plan16 and the 1997 National Health Policy statement17 appreciate the grave threat of RTIs without urgent implementation of appropriate interventions, but fail to offer specic assessments or solutions. Research studies conducted by the National Transport Research Centre have emphasised the importance of the link between good transport policies and health in Pakistan in their discussion sections, but without suggested interventions.18,19 After 35 years of deliberations and redrafting from 1965 to 2000, the National Highway Safety Ordinance was approved in 2000 as a major breakthrough in road transport regulation.15 However, it is only applicable to vehicles on the national highway road network, with the 1965 Motor Vehicle Ordinance and provincial rules still governing all other roads in the country. The Constitution of Pakistan contains no statement or policy in relation to the rights and obligations of the state and its citizens with respect to the environment.20 Instead, it confers legislative power to the Federation and the Provinces to regulate environmental pollution and preserve ecology. The Government of Pakistan promulgated the Pakistan Environmental Protection Ordinance in 1983.21 It was later revised to make it more comprehensive; as a result, the Pakistan Environmental Protection Act of 1997 was passed. This Act extends to the whole of Pakistan, providing protection, conservation, rehabilitation and improvement of the environment for the prevention and control of pollution and promotion of sustainable development. One of the functions of the Pakistan Environmental Protection Agency is to establish National Environmental Quality Standards for municipal and liquid industrial efuents, industrial gaseous emissions, and motor vehicle exhaust and noise.22 Embase and Cinahl were reviewed but did not recover articles on the transportation sector in Pakistan; the following articles were recovered via Pubmed. Seven indexed studies were found to include RTIs in Pakistan (Table 1). The rst national injury survey in Pakistan revealed an RTI incidence of 15.1 per 1000 in 1997, with 34% (a majority) being public service vehicle occupants and only 12% involving pedestrians.23 In 1995, government data supported that there were 7377 deaths and 16,465

A.A. Hyder et al. injuries, reecting an injury to fatality ratio of 2.2:1, far lower than the 15:1 ratio reported in other countries.24 Data from Provincial Departments of Excise and Taxation indicated a 16-fold rise in registered vehicles between 1956 and 1996, and the Federal Police showed that during that same calendar year, the number of crashes increased 14-fold.25,26 More importantly, studies show that there may be substantial under-reporting in data.27 The impact of RTIs has also been documented in specic case reports, such as neurosurgical mortality, where 100% of the cause was RTI.28 A signicant percentage of these fatalities were less than 40 years old, with a male to female ratio of 7:1.28 In addition, RTIs impact on the lower socio-economic strata in Pakistan. A study of mortality patterns from verbal autopsies in the slums of Karachi from 1990 to 1993 cited RTIs as the second leading cause of death among men at 30 per 100,000, tied with tuberculosis.29 Pedestrians and motorcyclists accounted for the majority of all injuries and deaths from RTIs, with commercial vehicles being the most common striking vehicle even though they only represent 4% of the total vehicle distribution.30 Vehicles have been identied as important contributors of lead and nitrous oxide, and a major source of 10- mm particulate matter (PM-10), sulphur dioxide and carbon monoxide in Pakistan.31 The vehicle eet in Pakistan is increasing at the rate of 10% a year with the increase being concentrated in urban areas (8 per 1000). Carbon dioxide emissions from transport were estimated to increase from 7 to 18 million tonnes, while transitrelated sulphur dioxide increased from 52,000 to 105,000 tonnes between 1977 and 1997.32 In Lahore city, vehicles are the dominant emissions source, contributing about 96% of CO, 76% of NO2 and 28% of suspended particulate matter emissions (Table 2). The average Pakistani vehicle emits 20 times as much hydrocarbon, 25 times as much carbon monoxide, and 3.6 times as much nitrous oxide in grams per kilometre as the average vehicle in the USA.31 PM-10 levels in the range of 192 parts per billion (ppb) and 125 ppb have been recorded for Karachi and Lahore, respectively.31 Levels of all air pollutants (ozone, sulphur dioxide and nitrogen compounds) are highest along the roadside in three major cities compared with residential, suburban and even industrial settings (Table 2). In 1991, the Pakistani mean blood lead level of 1.52.0 g was the highest of all Asian countries and above the World Health Organisation (WHO) guidelines of 15 mg/dl.33 As shown in Table 3, a few national studies support a correlation with decits in stature, mental ability and class behaviour.34

Health and road transport in Pakistan

Table 1 Author Luby et al.30 (1997) nZ727 Road trafc injury (RTI). Title/source Road trafc injuries in Karachi: the disproportionate role of buses and trucks Studied health outcome Identied those people most likely to be injured in a road trafc accident and the vehicle types most involved Estimated the death and injury rates due to RTI in Karachi (comparing EMS log with police records) Highlighted the injury situation in Pakistan and suggested policy options Magnitude and impact of injuries from motor vehicle accidents Study type Cohort Final result

135

Pedestrians and motorcyclists accounted for majority of injuries and deaths. 4% of all vehicles are buses/trucks; they were the dominant striking vehicle Ofcial 1994 sources counted only 56% of deaths and 4% of serious injuries compared with capture recapture study results

Razzak and Luby25 (1998)

Ghaffar et al.26 (1999) Hyder et al.27 (2000)

Estimating deaths and injuries due to road trafc accidents in Karachi, Pakistan, through the capture recapture method Injuries in Pakistan: directions for future health policy Motor vehicle crashes in Pakistan: the emerging epidemic

Two sample capture recapture

Crosssectional

Injuries are a low priority for health policy planners as well as public health professionals in Pakistan Persistent increase in number of motor vehicle crashes, injuries and fatalities. Disproportionate contribution from commercial motor vehicles Leading causes of death among men were circulatory disorders (124), tuberculosis (30) and road trafc accidents (30) per 100,000 RTIs contributed to almost all deaths. A signicant number of patients died below the age of 40 years and the male to female ratio was nearly 7:1 RTI incidence of 15.1 per 1000, highest among men, those 1645 years old, vendors and labourers, and public service vehicle occupants

Marsh et al.29 (2000) Ghani et al.28 (2003)

Adult mortality in slums of Karachi, Pakistan Road trafc accidents as a major contributor to neurosurgical mortality in adults

Ghaffar et al.23 (2004) nZ28,926

The burden of road trafc injuries in developing countries: the 1st national injury survey of Pakistan

Mortality patterns from verbal autopsies under active surveillance from 1990 to 1993 The clinical records, including radiological records and death certicates, of patients who died due to RTIs were studied Household injury survey using 3-month recall period

Literature and government document review Cohort

Crosssectional

Crosssectional

According to a study by Khan et al., levels were four times higher in those exposed to trafc smoke compared with controls, and trafc-smoke-exposed people, such as trafc police staff, had even higher blood levels than those handling lead material.35 There was a negative correlation between blood lead levels and the distance from the main intersection, with those living in Karachi exhibiting much higher blood lead levels than those in rural environments.36 The most common result of sustained highaudible noise is hastening of presbycusis (hearing loss with increasing age), causing permanent reductions in sensorineural hearing.37 The reviewed studies reported that those who were exposed to noise also suffered from tinnitus, hypertension,

anxiety and poor-quality sleep. A study in Karachi recorded noise levels upwards of 180 db on hightrafc days, citing auto-rickshaws, public buses and trucks as the major culprits.38 A subsequent study, during a transportation strike, lent further support to this hypothesis with noise levels dropping by 90 db.39 Even more affected are rickshaw (threewheeled vehicles) drivers, shown to have a high prevalence of hearing loss and tinnitus.40 Exacerbating the impact of the nutrition transition in Pakistan (from low to high carbohydrate and fat intake) is an increased reliance on automotive transportation for work and travel. Data from a National Health Survey (19901994) showed that 9% of men and 14% of women aged 2544 years were obese, while these rates rose to 22 and 37% for

136
Table 2 Air pollution in Pakistan by residence. Site Lahore, June 1996 Road side Residential Industrial Suburban/ rural Road side Residential Industrial Suburban/ rural Road side Residential Suburban/ rural Ozone (ppb) 39.2 27.4 34.4 31.2 31.6 22.2 26.7 24.3 19.7 16.9 18.0 SO2 (ppb) 4.2 2.3 3.1 1.6 6.8 4.2 5.5 2.3 2.6 2.1 1.2 CO (ppm) 3.8 2.1 2.7 0.9 2.9 2.0 3.0 0.9 1.4 1.2 0.6 NO (ppb) 13.5 7.4 11.4 5.2 8.2 6.3 7.1 5.6 5.7 4.5 3.6 NOx (ppb) 43.5 21.3 24.5 8.9 38.9 17.3 30.2 8.1 14.5 12.6 7.1 Meth (ppm) 3.6 4.7 4.1 4.3 4.1 3.6 3.3 4.8 2.8 2.1 3.6 NMETH (ppm) 0.3 0.1 0.2 0.1 0.3 0.1 0.2 0.1 0.2 0.1 0.1

A.A. Hyder et al.

PM10 (mg/m3) 465 210 290 260 490 330 440 185 750 413 790

TSP (mg/m3) 780 470 585 440 870 560 685 290 1240 810 1350

Faisalabad, August 1996 Khan, December 1996

Sources. Federal Bureau of Statistics (1999)32 and Brandon (1995).31 ppb, parts per billion; ppm, parts per million.

Table 3 Author

Lead pollution. Title/source Studied health outcome Blood lead level, haemoglobin, and urinary ALA Study type Final result Policy recommendations/implications Reduce lead content of petrol and provide protection for those working in the transport sector Government lead regulations to limit childhood burden

Khan et al.35 (1995) nZ304

Lead poisoning a hazard of trafc and industries in Pakistan

Case-control

Transport jobs associated with higher lead haemoglobin, ALA and serum lead levels

Rahman et al.34 (2002) nZ138

Lead-associated decits in stature, mental ability and behaviour in children in Karachi

Rahbar et al.36 (2002) nZ400

Parekh et al.33 (2002)

Factors associated with elevated blood lead concentrations in children in Karachi, Pakistan Lead content of petrol and diesel and its assessment in an urban environment

Shed primary teeth and blood levels (Hbg, IQ, height, weight, head circumference, class behaviour) Mean blood lead

Crosssectional

Negative correlation with height, class behaviour and IQ

Crosssectional

Elevated blood lead associated with surma application (leaded cosmetic), fathers exposure to lead at workplace, and parents illiteracy Lead content of emissions reduced 2.7-fold since 1989

Reduce lead burden, especially leaded petrol

Lead content of fuel

Randomised sample

Continue lead regulations in Karachi

ALA, amino-levulinic acid; IQ, intelligence quotient.

Health and road transport in Pakistan urban men and women.41 Amongst those aged 4564 years, rates were similar to the younger stratum in rural areas, but increased to 23 and 40% amongst men and women in urban areas.41 Researchers point to higher energy density diets and reduced physical activity, linked with increased reliance on mechanised transport (Table 4). One study showed that obesity in Pakistan, as in other countries, is positively correlated with a higher prevalence of diabetes and hypertension.42 Other studies also showed higher than expected rates of obesityrelated diseases in the remote Northwest Frontier Province and the urban slums of Karachi,43,44 indicating the far-reaching inuence of modern
Table 4 Shera43 (1995) nZ96

137 diet and transport (Table 4). The prevalence of obesity and its comorbid risks remain highest for the afuent,45,46 demonstrating a possible association with more access to motorised transportation as well as energy-dense foods. Additional studies were not available to elucidate causal factors in addition to income and age. Publicprivate partnerships in Pakistan have recently resulted in positive sector-wide transportation developments. ENERCON (a private sector rm) is working to introduce energy-efcient technologies in Pakistan, including vehicle tuning and testing stations. Daewoo (Korean car manufacturer) introduced a super compact car without

Physical inactivity, obesity and associated morbidity. Pakistan National Diabetes Survey: prevalence of glucose intolerance and associated factors in Shikarpur, Sindh Province The frequency of known diabetes, hypertension, and ischaemic heart disease in afuent and poor urban populations of Karachi, Pakistan Socio-economic differences in height and body mass index of children and adults living in urban areas of Karachi, Pakistan The obesity pandemicimplications for Pakistan Prevalence of NIDDM Crossand IGT among those sectional O25 in a rural Pakistani town Diabetes prevalence: 16% in men, 12% in women, and 25% of total glucose intolerant Glucose intolerance no longer a problem conned to migrant communities and strongly correlated with obesity, suggesting modiable risk factors Obesity impact also seen in afuent communities, and not simply due to urbanisation

Hameed45 (1995) nZ4232

Comparison of prevalence

Crosssectional survey

Hakeem46 (2001) nZ2493

BMI calculated from household height and weight measurements

Crosssectional

Nanan41 (2002) nZ18,315

Data from National Health Survey of Pakistan, 199094 re-analysed using BMI cut-offs recommended for Asians to assess prevalence of overweight and obesity in adult Pakistani population

Crosssectional (re-analysed)

Afuent with three times the prevalence of ischaemic heart disease, 2.5 times higher rate of diabetes, higher rates of obesity, and equal rates of hypertension The inuence of increasing afuence is likely to be seen both in the form of increased obesity among older females and underweight among children Prevalence of obesity (BMIR25) in 2544year olds in rural areas was 9% for men and 14% for women; in urban areas, prevalence was 22 and 37% for men and women, respectively. For 4564-year olds, prevalence was 11% for men and 19% for women in rural areas, and 23 and 40% in urban areas for men and women, respectively

Further studies needed to demonstrate causal factors of obesity in Pakistan

More sedentary lifestyles (mechanised urban jobs and motorised transportation to and from work) along with poor diets and previous malnutrition result in obesity

NIDDM, non-insulin-dependent diabetes mellitus; IGT, impaired glucose tolerance; BMI, body mass index.

138 a catalytic converter to reduce fuel consumption. The Ministry of Petroleum and Natural Resources reduced subsidies for kerosene (to prevent mixing with diesel) and is also encouraging compressed natural and liquid petroleum gases as well as conversion from two- to four-stroke engines. Each of these projects is under the National Conservation Strategy, a privatepublic alliance to protect the environment. Mass transit systems are more premature in development. Lahore Development Authority (largest city in Punjab) is in the planning stages for developing a mass transit system in co-ordination with the private sector. Similar publicprivate collaborations are underway in Rawalpindi and Karachi. In Lahore, with assistance from the Punjab Government, bicycle lanes are being developed among major roads. Catalytic converters, nationwide pedestrian lanes and changes in the tax system to encourage fuel-efcient engines have yet to be implemented.

A.A. Hyder et al. Pakistan range between US $233 and 368 million per year.31 Factors contributing to increasing air pollution in Pakistan include an inefcient dieselbased private transport system and an institutional failure to implement national environmental quality standards. Despite clearly documented hazardous levels of emissions, there are no accessible scientic reports, beyond the effects of lead toxicity, in Pakistani literature between air pollution and its negative health impacts, such as asthma, chronic obstructive pulmonary disease exacerbations, coronary heart disease, lung cancer, stress and respiratory infections. This represents a gap in the national knowledge base and necessitates further research. Last year, the WHO pointed to automobile emissions as a major source of lead exposure among populations in busy urban centres within Pakistan.35 Worldwide, lead additives in gasoline currently cause 70% of total lead pollution.47 Children who used closed vehicles as their mode of transport had signicantly lower median blood lead levels than those using other means of transport, such as motorised rickshaws.36 The WHO strongly recommended lead removal from Pakistani petrol.36 Regulations appear to be working as lead concentrations in regular petrol dropped by a factor of ve over the last decade, halving the rate of lead emissions.33 A Government Directive in 2001 set the permissible limit of lead in petrol at 0.02 g/l, and all four major reneries in Pakistan (Pakistan Renery Limited, National Renery Limited, Attock Renery Limited and Pak-Arab Renery Limited) now produce lead-free petrol.48 This represents one arena of positive public policy implementation in the country. Noise pollution is an important health hazard seemingly neglected by health professional and policy planners in the health sector in Pakistan. There are hardly any research studies on this subject, and a few available studies reveal that high-volume horns in buses and the sound of rickshaws are affecting the health of the population. These studies support noise-reduction strategies, such as rickshaw silencers and horn-use regulations for the benet of drivers and the general public. The determinants of the global obesity pandemic are complex, extending from the genetics, physiology and behaviour of individuals to the inuence of their social and physical environment. Nevertheless, the rapid rise in obesity prevalence favours environmental factors changing behaviour rather than hereditary inuences. The obesity forecasts are more alarming in Asian nations as they exhibit the comorbidities of obesity at lower body mass index and because prior

Discussion
There is evidence from the global literature that air pollution, lead toxicity, sedentary lifestyles and RTIs are outcomes of road-based transport, thus contributing signicantly to the global burden of death and disability. The results of our study show that in Pakistan, there seems to be great need for a concerted effort on behalf of the government and civil society to emphasise this burden and implement appropriate actions. The quantity of work done in the country is limited, but includes evidence of the healthtransport linkages in both peer-reviewed and other national literature. The greatest measured impact from road transport in Pakistan is the loss of life and disability caused by vehicular crashes. The review revealed that the main victims of RTIs in Pakistan are men aged 1545 years. RTIs result in an estimated economic loss of between 1.5 and 2% of GDP or approximately 60 billion Pakistani Rupees ($1 billion) per year.31 One of the causes of RTI recognised in national documents is the lack of enforced regulations, including speed limit checks. An important barrier to enforcement is the restricted jurisdiction of the National Highway Safety Ordinance to only national highways in the country, leaving major road and provincial routes uncovered by federal law. The estimated cost of health impacts alone (morbidity, mortality and loss of intelligence quotient level) resulting from air pollution in

Health and road transport in Pakistan malnourishment places them at increased risk of gaining weight.42 Although the largest contributor is a nutrition transition from grains to high-density foods, the effects of the built physical environment cannot be ignored. Equivalent to the effect of quitting smoking, 30 min per day of cycling or walking cuts the chance of heart disease by half. The same amount of exercise only two to three times weekly also halves the risk of developing diabetes and lowers blood pressure to the same degree attained with antihypertensive medications.49 The engagement of the private sector has been a positive development for the road-transport-health linkage in Pakistan. As seen from Table 5, there are some limited interventions to reduce the specic negative health impacts of road transport. However, these are limited to a restricted geographical

139 area (city, state) or their cost and coverage are not clear. This reveals the need for effective policy efforts at the national level; a gap in need of wider attention. Beyond regulating the existing road transport system, transportation planning must incorporate other models of transportation associated with lower levels of air pollution, reduced obesity and far fewer injuries and deaths. Mass transportation systems as well as appropriate urban planning with cities built on a pedestrian scale with bicycle and walking lanes will facilitate great improvements.50 Literature from industrialised countries already argues for increased bicycle and pedestrian travel and greater reliance on public transport systems.51 There is a need for increased advocacy for such systems in developing countries like Pakistan.

Table 5 Implementation status of National Conservation Strategy. (The Pakistan National Conservation Strategy Islamabad Goverment of Pakistan; 1992.) Reduce urban air pollution Change import duties and adjust taxes to favour fuel-efcient engines Require new vehicles to meet the lowest possible emission levels achievable without catalytic converters Reduce subsidies for kerosene to prevent diesel dilution Reduce vehicle emissions Promote good maintenance of motor vehicles NO ACTION ENERCON is working to introduce energy-efcient technologies Daewoo Introduced a small vehicle in 2000 for short distance use (unknown efciency) Ministry of Petroleum and Natural Resources Reduced subsidies for kerosene to prevent mixing with diesel ENERCON Introduced vehicle tuning stations Pak-EPA (Urban Industrial Environmental Protection Programme) Vehicular Emissions Testing Stations (Peshawar & NWFP) Ministry of Petroleum and Natural Resources Policy to encourage use of compressed natural gas and liquid petroleum gas Converting two-stroke Rickshaw engines to compressed natural gas NO ACTION

Introduce four-stroke and/or alternative energy engines

Encourage the installation of catalytic converters in all vehicles Promote energy-efcient and environmentally benign transport systems Develop and upgrade economical mass transit systems Lahore Development Authority Planning development of mass transit in Lahore Upgrade public transit by providing comfortable Punjab Government bus/tram operations Introduced an urban transport system in Lahore with the private sector help (similar programmes underway in Rawalpindi and Karachi) Develop safe bicycle/pedestrian lanes Punjab Government Developed bicycle lanes along major urban roads in Lahore (particularly Gulberg area) Encourage a demand for small, highly fuel-efcient NO ACTION vehicles through duties and incentives ENERCON in planning stages
Source. National Conservation Society, Sector Paper on Energy.

140 In addition, Pakistan has no recognised protocols for collecting regular information about injuries, lead toxicity, air pollution and noise pollution. We would recommend an increasing role for the health sector, both in data collection and analysis, and also as a partner in a multisectoral effort for reduction in transport-related health impacts at national and local levels.

A.A. Hyder et al.

15. National Highway Safety Ordinance, Gazette of Pakistan. Islamabad: Government of Pakistan 1999. 16. 9th Five Year Plan. Islamabad: Planning Commission, Government of Pakistan 1998. 17. National Health Policy 2001. Islamabad: Ministry of Health, Government of Pakistan 2001. 18. Analytical Review of Road to Road Transport Statistics, National Transport Research Centre. Islamabad: Ministry of Communication, Government of Pakistan; 1987. 19. The Pakistan National Conservation Strategy. Islamabad: Government of Pakistan; 1992. 20. Constitution. Islamic Republic of Pakistan 1973. Islamabad: Feroz Sons; 1973. 21. Pakistan Environmental Protection Ordinance. Islamabad: Government of Pakistan; 1983. 22. Khan A. Haroon Working Paper Series #38, Implementing NEQS: Pakistans Experience in Industrial Efuent; 1998. 23. Ghaffar A, Hyder A, Masud T. The burden of road trafc injuries in developing countries: the 1st national injury survey of Pakistan. Public Health 2004;118:2117. 24. Bishai D, Hyder A, Ghaffar A, Morrow R, Kobusingye O. Rates of public investment for road safety in developing countries: case studies of Uganda and Pakistan. Health Policy Plan 2003;18:2325. 25. Razzak JA, Luby SP. Estimating deaths and injuries due to road trafc accidents in Karachi, Pakistan through the capturerecapture method. Int J Epidemiol 1998;27: 86670. 26. Ghaffar A, Hyder A, Mastoor M, Sheik I. Injuries in Pakistan: directions for future health policy. Health Policy Plan 1999; 14:1117. 27. Hyder AA, Ghaffar A, Masood T. Motor vehicle crashes in Pakistan: the emerging epidemic. Inj Prev 2000;6: 199202. 28. Ghani E, Nadeem M, Bano A, Irshad S, Zaidi GI, Khaleeq-uzZaman. Road trafc accidents as a major contributor to neurological mortality in adults. J Coll Phys Surg Pak 2003; 13:1435. 29. Marsh DR, Kadir MM, Husein K, Luby SP, Siddiqui R, Khalid SB. Adult mortality in slums of Karachi, Pakistan. J Pak Med Assoc 2000;50:3006. 30. Luby S, Hassan I, Jahangir N, Rizvi N, Farooqui M, Ubaid S, et al. Road trafc injuries in Karachi: the disproportionate role of buses and trucks. Southeast Asian J Trop Med Public Health 1997;28:3958. 31. Brandon C. Valuing environmental costs in Pakistan: the economy wide impacts of environmental degradation. Background paper for Pakistan 2010 report; 1995. 32. Compendium on Environmental Statistics of Pakistan 1998. Islamabad: Federal Bureau of Statistics; 1999. 33. Parekh PP, Khwaja HA, Khan AR, Navqui RR, Malik A, Khan K, et al. Lead content of petrol and diesel and its assessment in an urban environment. Environ Monit Assess 2002;74: 25562. 34. Rahman A, Maqbool E, Zuberi HS. Lead-associated decits in stature, mental ability and behaviour in children in Karachi. Ann Trop Paediatr 2002;22:30111. 35. Khan MH, Khan I, Shah SH, Rashid Q. Lead poisoninga hazard of trafc and industries in Pakistan. J Environ Pathol Toxicol Oncol 1995;14:11720. 36. Rahbar MH, White F, Agboatwalla M, Hozhabri, Luby S. Factors associated with elevated blood lead concentrations in children in Karachi, Pakistan. Bull World Health Organ 2002;80:76975. 37. Bogden JD. Detrimental health effects of noise pollution. J Med Soc N J 1974;71:84751.

Acknowledgements
This paper was partly funded by a grant from the World Health Organisation, Geneva to AAH. The authors thank all individuals in Pakistan who helped with accessing documents.

References
1. Murray CJL, Lopez AD. Mortality by cause for eight regions of the world: global burden of disease study. Lancet 1997;349: 126976. 2. Murray CJL, Lopez AD. Alternative projections of mortality and disability by cause 19902020: global burden of disease study. Lancet 1997;349:1498504. 3. Smith GS, Baarss P. Unintentional injuries in developing countries: the epidemiology of a neglected problem. Epidemiol Rev 1991;13:22866. 4. Horner JM. Tyre disposala burning environmental issue? J R Soc Health 1993;113:13841. 5. Ivanova-Chemishanska L, Khinkova L, Mikhailova A, Antov G, Khristeva V, Khalkova ZH, et al. The toxic hygiene problems of workers in the Dinamik automobile tire plant in Soa. Problemi na khigienata 1995;20:13845 [in Bulgarian]. 6. Guo YL, Lin YC, Sung FC, Huang SL, Ko YC, Lai JS, et al. Climate, trafc-related air pollutants, and asthma prevalence in middle-school children in Taiwan. Environ Health Perspect 1999;107:10016. 7. Stott R. Carsons syndrome: a major threat to the publics health in the twenty-rst century. Med Con Surviv 2000;16: 94103. 8. Patz JA, Engelberg D, Last J. The effects of changing weather on public health. Annu Rev Public Health 2000;21: 271307. 9. Kagawa J. Atmospheric pollution due to mobile sources and effects on human health in Japan. Environ Health Perspect 1994;102(Suppl. 4):939. 10. Swinburn B, Egger G. Preventive strategies against weight gain and obesity. Obes Rev 2002;3:289301. 11. Tudor-Locke C, Ainsworth BE, Adair LS, Popkin BM. Physical activity in Filipino youth: the Cebu longitudinal health and nutrition survey. Int J Obes Rel Metab Disord 2003;27: 18190. 12. Singh NM, Rao SN. A reconnaissance of trafc noise pollution in the city of Patna. Indian J Environ Health 2001;43:13843. 13. Wong CL, Chau W, Wong LW. Environmental noise and community in Hong Kong. Noise Health 2002;4:659. 14. Greenwood DC, Muir KR, Packham CJ, Madeley RJ. Coronary heart disease: a review of the role of psycho-social stress and social-support. J Public Health Med 1996;18:22131.

Health and road transport in Pakistan

38. Zaidi SH. Noise levels and the sources of noise pollution in Karachi. J Pak Med Assoc 1989;39:625. 39. Zaidi S. Noise levels in Karachi on a transporters strike day. J Pak Med Assoc 1990;40:299300. 40. Merchant AT, Lalani I, Afridi ZH, Latif N, Malik TA, Merchant SS. What is the effect of rickshaw noise on its driver? J Pak Med Assoc 2000;50:1248. 41. Nanan DJ. The obesity pandemicimplications for Pakistan. J Pak Med Assoc 2002;52:3426. 42. Basit A, Hydrie MZ, Ahmed K, Hakeem R. Prevalence of diabetes, impaired fasting glucose and associated risk factors in a rural area of Baluchistan province according to new ADA criteria. J Pak Med Assoc 2002;52:35760. 43. Shera AS. Pakistan National Diabetes Survey prevalence of glucose intolerance and associated factors in North West Frontier (NWFP) of Pakistan. J Pak Med Assoc 1999;49:20611. 44. Akatsu H, Aslam A. Prevalence of hypertension and obesity among women over age 25 in low income areas of Karachi, Pakistan. J Pak Med Assoc 1996;46:1913.

141
45. Hameed K. The frequency of known diabetes, hypertension, and ischemic heart disease in afuent and poor urban populations of Karachi, Pakistan. Diabet Med 1995; 12:5003. 46. Hakeem R. Original communication: socioeconomic differences in height and body mass index of children and adults living in urban areas of Karachi, Pakistan. Eur J Clin Nutr 2001;55:4006. 47. Settle DM, Patterson CC. Lead in albacore: guide to lead pollution in Americans. Science 1980;207:116776. 48. Paul R, White F, Luby S. Trends in lead content of petrol in Pakistan. Bull World Health Organ 2003;81:468. 49. Dora C. A different route to health: implications of transport policies. BMJ 1999;318:16869. 50. Frumkin H. Urban sprawl and public health. Public Health Rep 2002;117:20117. 51. Mason C. Transport and health: en route to a healthier Australia? Med J Aust 2000;172:2302.