Gender and Development

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Pakistan

Burn Care Project, Watan Welfare Society

Background to the project

The treatment of burns is arguably one of the most expensive and specialized of medical treatments. Burns care requires the combination of a number of surgical and general medical skills, such as pediatrics, plastic surgery, infection control, palliative care and labor intensive critical care nursing. On top of this, burn victims need intensive, one-on-one treatment from allied health professionals such as physiotherapists, psychiatrists and psychologists.

The irony is that countries with the greatest need often lack the facilities to treat and rehabilitate burn victims. Pakistan is one such country. For example, there is no publicly-funded specialized burn center or hospital burn unit in Pakistan. The only purpose-built burn unit in the country is the Army Burn Centre in Kharion, and this hospital only accepts civilian burn victims who can afford the high fee charged.

While there are no official statistics on the types and causes of burns, figures collected by non-government organizations suggest an increasing occurrence of burns. The majority of burns are accidental and result from contact with gas stoves, lamps, leaking gas pipes, exposed electrical wiring, boiling water, hot oil, etc. Most burns occur in the home, in or around the kitchen. As a result, women and children are most at risk of burns. According to data collated by the Watan Welfare Society, out of 306 burn victims treated at their Burns Care Centre between January 1999 and April 2000, women and children accounted for 82 percent of all victims. Of the total number, 62 percent of victims were burnt in or around the kitchen, with children most at risk here. Of the 41 cases of suicide treated by the Centre, 88 percent of suicide burn victims were women.

There is also disturbing evidence that increasing numbers of burn victims - particularly those described as suicide cases - are young women who have been set alight or had acid thrown on them by their husband or in-laws. Such extreme violence can be severely debilitating for women, who face ostracism because of their scarred appearance and loss of mobility. It is also a form of violence that is frequently covered up by the perpetrators as ‘accidental.’ The Human Rights Commission of Pakistan reported that between 1998 and 1999, more than 560 cases of women were burnt in the home in Punjab (Pakistan’s most populous state), and that while many of these cases where suspicious, there were only a handful of arrests. The Progressive Women’s Association tracked 3,560 women who were hospitalized after being attacked at home with fire, gasoline or acid between 1994 and 1995. Victims of such crimes face special problems in terms of their rehabilitation back into society. Even in the case of accidental burns, women and girls are often rejected by their husbands, in-laws or seen as unmarriageable due to scars and in some cases their limited mobility. For these reasons, programs designed to treat burns must incorporate a wide range of specialist services, including education and prevention campaigns, specialist surgeons, counseling and rehabilitation. In particular, there is a need for the professionals involved to structure support services to meet the special needs of female victims.

Alarmed by the lack of specialist burn care available in Pakistan, the Watan Welfare Society established a Burn Care Centre in Peshawar in January 1999. The Centre has treated over 300 burn victims since 1999, drawing on the skills of a dedicated team of volunteer medical specialists and allied health professionals. The Burn Care Centre has 15 volunteer specialists, including medical officers, an anesthetist, a pediatric surgeon, plastic surgeons, an orthopedic surgeon, general physicians, a cardiologist, an ophthalmologist, a physiotherapist, psychiatrist, psychologist and microbiologist. In its 15-bed Burn Care Centre, the Watan Welfare Society provides heavily subsidized or free medical, nursing and allied health care depending on the victim’s situation.

Lacking funds to fully outfit its laboratory and operating theater, as well the resources to promote awareness on the prevention and care of burn cases, Watan Welfare Society approached ADB for support under RETA 5889 for additional equipment and the conduct of an awareness program.

Project Components

The project’s main objectives are to prevent the occurrence, and improve the treatment, of burn cases amongst women and children. To achieve these objectives, the project sought to promote awareness on the prevention and treatment of burns cases, as well as upgrade the curative facilities at the Burn Care Centre. The project also hopes to make the Centre self sustaining. By funding new laboratory equipment, the Centre will be able to perform its own pathology tests and blood screenings, thus saving money and also providing an opportunity to make money by providing such services to private clinics, teaching hospital and other organizations in Peshawar for a fee.

Project components include:

1. A one-day seminar on burns issues in Peshawar designed to build the awareness and capacity of government institutions (notably the police, health department), NGOs, CBOs, the media, medical students and young doctors;
2. Upgrading of laboratory and curative facilities at the Burn Care Centre, including a micro laboratory machine, anesthesia machine, surgical instruments, monitor and pulse oxymeter; and,
3. Production of brochures and pamphlets on prevention and care of burns.

Outcomes of Project

The major outcome of the project has been the improved treatment and recovery rates experienced at the Centre after the purchase of the equipment. For example, the dermatones and mesher improve the rate of successful skin grafts as well as providing more sightly skin grafts. The cost of treatment has also decreased as procedures are more successful (thus avoiding the need to repeat surgery) and as the Burn Care Centre can meet its own pathology requirements.

In terms of prevention and education, the seminar held in Peshawar was a great success. Although it was envisaged that about 150 people would attend, closer to 400 participants attended. A number of papers and discussion panel were held, with major topics covering:

• Cause and treatment of burn patients at the Burn Care Centre
• Non-accidental burns in children, and
• Suicide and incidental burns amongst women.

The seminar was important in raising awareness of the need to fund and promote specialist burns care to government and non government sector. Apart from such formal occasions, the Centre relies on its patients to promote awareness of such issues. As the Centre’s Pediatrics Surgeon Dr Said Alam Mahasud commented- “we educate every patient”. This is certainly true in the case of Saadia, a young lady health worker and former patient at the Centre.

However, efforts to promote prevention and treatment require brochures and posters to enable the dissemination of important information. For this reason, the Centre is producing material not only for seminar participants but also for people working at the grassroots level, such as social workers and lady health workers. The Centre is currently considering how it might support a public campaign at the grassroots level by working cooperatively with such groups. One mechanism that has been trialed and found very successful is to run a Burns Camp. So far the Centre has held on burns camp in a rural area of the province. The idea here is that staff from the Centre visit villages to provide curative and preventive services. This camp also helped to raise the profile of the Centre and is helping to contribute to the increasing number of women patients brought by their families to the Centre. Not only that, but with knowledge, there is a greater number of acute cases coming to the Centre directly (rather than from referral) and thus more timely. Such changes dramatically improve the burn victim’s chances of survival and recovery.

Advocacy is also on the agenda and already members have met with government officials on the need for quality standards to regulate the manufacture of cooking equipment and consumer rights legislation to ensure such standards are respected. Other issues here include occupational health and safety regulations to protect and compensate workers burnt at work.

Finally, the project reached its objective in terms of sustainability. Currently, the Centre is able to meet its recurrent costs although it is largely reliant on the volunteer services of its specialists. Funds generated from patient fees or fees from use of their laboratory service cover the cost of treatment and the rent of the building. There are however financial constraints in terms of future expansion and further improvement. There are also limitations on the types of information and material that the Centre can fund. To assist here, the Centre has developed a Web site to provide data on the incidence and cause of burns treated in the Centre and other educational material. However, as the Burn Care Centre realizes, there is a need for a coordinated approach to burns care which will require some government commitment to burns as a public health issue.

The Story of a Burn Victim: Saadia

Saadia is a lady health worker who suffered third degree burns to her legs and arms as the result of a leaking gas cylinder in the kitchen. Her husband’s family brought her to the Burns Centre about two weeks after the accident. The delay was due to the family’s lack of knowledge about the Burn Centre. Finally, a doctor told her maternal uncle about the Centre and she was admitted. By the time Saadia was admitted, her wounds were infected, making treatment difficult. She spent over two months in the Centre undergoing several skin grafts as a result of the infection. During her stay, Saadia’s family had to pay only for her room (because they wanted her to have a private room) and medications.

Talking to Saadia six months after the accident, she expresses her gratitude to the Centre. As a lady health worker, she realizes just how fortunate she is. She often comes across other women burn victims. As she says, burns are part of women’s everyday experience, and yet she finds that the majority of women - like herself - are very ignorant of the risks and treatments available. She notes that many women who suffer serious burns are not taken to hospital because their families cannot afford the treatment or do not value the women in their family. Women who are taken to hospital often fare little better as there are no facilities for burn victims and low standards of sterility result in many infection-related deaths.

As a result of her experience, Saadia is committed to educating women on the prevention and treatment of burns. She says that women in her district have very limited knowledge of burn prevention measures and simple treatments, such as rolling victims in a blanket or putting the victim in cold water. They also do not realize the importance of seeking treatment as soon as possible. In her work, she discusses her own experience as a way of educating women on the dangers of burns and publicizing the work of the Burn Centre. She believes lady health care workers can play a special role as they mostly deal with women and children, the primary victims of burns. What is needed however are posters and information on the prevention and treatment of burns from the government, which she can distribute to the households and health centers in her district.

Future Direction

There is obvious scope to use this Burn Care Centre as a model for other potential burn centers in Pakistan. The close cooperation between different professionals in the treatment and prevention of burns is a useful demonstration of the team-based approach required in burn care. This cooperation between different professionals and burn patients also proved very useful in terms of education and prevention campaigns.

The experience of medical staff associated with the Centre also offers practical insights in the establishment of adequate burn care facilities within Pakistan. ADB should consider the following minimum requirements recommended by Dr Said Alam Mahasud on behalf of Watan Welfare Society in future public and women’s health projects:

• Financial allocation for a 10-15 bed burn unit for every one million of population in Pakistan;
• of a 5-10 bed burn intensive care unit for every twenty million of population in Pakistan;
• Establishment of one rehabilitation unit in each province;
• Establishment of at least one center of excellence for burn victims;
• A state-sponsored preventive campaign in print and electronic media to decrease the incidence of burns and crimes of violence against women;
• Legislation on quality control of public utilities (particularly gas and electricity supply) and the manufacture of domestic appliances; and,
• Penalty for negligence of public sector officials, public and private manufacturers who supply sub-standard services and goods.

The concern with women’s health, public health and violence against women integral to the prevention and treatment of burns is in line with ADB’s own priority areas of Human Development and Gender and Development as noted in the Country Strategy Program (2002-2004). ADB-financed loan projects in the areas of public health and women’s health can build on this project by including specific components on the treatment and prevention of burns, allocating funding for the establishment of specialized burns treatment centers in public hospitals; and incorporating burns awareness and prevention campaigns in all public health and women’s health projects. Lady health workers and other community-based health workers could be trained to deliver information on ways to reduce home-based accidental burns and first aid treatment of burn victims. Such information could be supported by mass awareness campaigns in the electronic and print media.

Technical assistance should also be provided to finance much needed research into the causes and extent of burn injuries in Pakistan. In particular, there is a need for research on the extent and nature of burn-related violence against women in order to design appropriate responses from the government and the community. This issue needs to be brought into the full glare of public scrutiny so that police and other government agencies are forced to address burn-related violence against women. ADB can assist here by including a component on burn-related violence in ADB-funded loan projects focusing on women’s rights, women’s health and violence against women in Pakistan. The National Commission on the Status of Women and the Ministry of Women’s Development could be considered as appropriate executing agencies here.

Finally, ADB-funded projects in the area of legal reform and governance could investigate the area of standards and consumer protection. Standards - supported by penalties and compensation in the case of negligence - need to be established to cover the supply and maintenance of public utilities, such as gas and electricity, as well as the manufacture of household equipment such as stoves, gas cylinders and lights. Such issues could be included in relevant technical assistance projects, such as the Strengthening of Institutional Capacity for Judicial and Legal Reform and the proposed ADF-funded Judicial and Legal Reform Program There is also a need for well-enforced workplace occupational health and safety regulations to protect workers from negligence.

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