I welcome the paper by Chotani et al on violence in Pakistan and the empirical nature of the exploration.[1] It is also encouraging to see Injury Prevention raise the issue of violence in developing countries, as it is a neglected health problem. However, from the Pakistani context, there are several contextual and explanatory points that are needed to clarify some of the issues raised in the paper and also to add to them.

Macro-economic changes have affected the Pakistani society for the past two decades with important impacts on the health and social sectors.[2] One of the impacts is on the levels of violence and unintentional injuries - trends that have not been appropriately studied in the developing world. The imapact of adjustment programs like the Social Action Program in Pakistan therefore merit discussion in a dialogue exploring the nature and patterns of violence.

I disagree with the claim made in the paper that there have been no comparisons of police data with other data sources in Pakistan. National burden of disease analysis for Pakistan included all types of injuries and used such a comparative analysis.[3] Moreover, innovative sources of data have also been compared to police data on violence, in the literature.[4] Indeed more work needs to be done in this area to enhance the internal consistency of data from Pakistan - a research agenda for the country.

I was surprised to note the lack of attention to the role of firearms in the discussion and prevention part of the paper. The influx of firearms since the eighties, the relationship with substance abuse, and the drug trade are important considerations for exploring violence in Pakistan. There are major economic relationships between these factors and all of them facilitate and potentiate the occurence and impact of violence in the country, including political and ethnic violence. Most importantly, the control of firearms and their use is a potential preventive strategy which needs to be explored in the Pakistani context.

Although not the intent of the study, it is worth reflecting that there are enormous costs to violence everywhere. In addition to the direct and indirect medical and treatment costs to those injured or dead, there are societal costs in the form of preventive, rehabilitative, structural, and quality of life factors. If such an assessment was to be done in Karachi, I am sure one could attribute a large cost amount to violence. We must begin to use economic arguments as well, to enhance the case for greater attention to violence in the developing world.

As suggested by the authors, it is time to analyze the causes and consequences of violence in Pakistan systematically. The use of evidence in doing such analysis is critical; the development of a framework to link the different causative and impact pathways is vital; and finally the ability to mobilize Pakistani society to reject such violence and develop their own capacity for preventing it, is probably the most important.

References

(1) Chotani HA, Razzak JA, Luby SP. Patterns of violence in Karachi, Pakistan. Injury Prevention 2002;8:57-59

(2) Bhutta Z. Structural adjustment and the impact on health and society: perpsective from Pakistan. Int J Epidemiol 2001;30:712-16

(3) Hyder AA, Morrow RH. Applying burden of disease methods in developing countries: a case study from Pakistan. Am J Public Health 2000;90:1235-40

(4) Ghaffar A, Hyder AA, Bishai D. Newspaper reports as a source for injury data in developing countries. Health Policy Planning 2001;16(3):322-325