Can we stop the stroke epidemic in Pakistan?

Pakistan has the world’s 6th largest population with a growth rate of about 2% per year. Most recent national health survey conducted by Pakistan Medical and Research Council reported that 33% of Pakistani population above the age of 45 years is suffering from hypertension.4 About one-third of these hypertensives were unaware of their hypertension. A large proportion of Pakistani population is diabatic, 5.2 million in the year 2000 and projected to be 13.9 million by the year 2020.5 About 14-21% adolescents and adults are given to smoking tobacco, majority being male.6 Exact prevalence of smoking may be higher because a large number of smokers especially women do not report their smoking habits. There are no well-designed, population- based published studies related to stroke prevalence in Pakistan. The estimated annual incidence of stroke in Pakistan is 250/100,000, which is projected to an estimate of 350,000 new cases every year.7 Some of the potential stroke risk factors that are unique to our population and remain unstudied include huqqa (water-pipe) smoking, orally chewed tobacco (naswar, pan, mishri, ghutka, bajjar, and ghundi), different forms of clarified butter and hydrogenated oils, rheumatic heart disease, and high prevalence of hepatitis B and C.2 Younger age at first stroke particularly among women, higher prevalence of stroke among women, and higher proportion of haemorrhagic stroke are some alarming features in the available and known stroke epidemiology.1,2 About 85% of all stroke deaths are registered in low- and middle-income countries, which also account for 87% of total losses due to stroke in terms of disability-adjusted life years (DALYs).8 Although often neglected, informal care is of paramount relevance to maintain stroke survivors in the community, and a valuable economic resource for health care systems. Indirect and informal care costs are related to both the frequency, i.e. crude numbers expressed as incidence and prevalence, and the severity of the disease, in terms of mortality, morbidity and functional impairment. An effective resource optimization starts from primary prevention and treatment of vascular risk factors, admission of stroke patients to dedicated wards with a multidisciplinary approach, adherence to guidelines for the acute phase management, early rehabilitation and availability of acute phase treatments, such as thrombolysis, for selected patients.8 Assessing the direct cost in a retrospective analysis at a tertiary care teaching hospital in Pakistan, the authors concluded that the cost of acute stroke care was extremely high as compared to average national income and most important determinant of cost was the length of hospital stay.9 The economic burden related to cost of stroke