Chronic Non-Cancer Pain Management Capacity in Karachi
Chronic Non-Cancer Pain Management Capacity in Karachi
S. Fatima Lakha . Peter Pennefather . Mubina Agboatwala . 0 1 2 3 4 5
Safia Zafar Siddique . Hanan E. Badr . Angela Mailis-Gagnon 0 1 2 3 4 5
0 S. F. Lakha A. Mailis-Gagnon Pain and Wellness Center , Toronto , Canada
1 S. F. Lakha P. Pennefather A. Mailis-Gagnon Centre for Study of Pain, University of Toronto , Toronto , Canada
2 S. F. Lakha (&) P. Pennefather A. Mailis-Gagnon University of Toronto , Toronto , Canada
3 H. E. Badr Kuwait University , Kuwait , Kuwait
4 S. Z. Siddique Civil Hospital , Karachi , Pakistan
5 M. Agboatwala HOPE , Karachi , Pakistan
Chronic non-cancer pain (CNCP) affects people everywhere in the world, but people in developing countries have far less access to therapies that provide relief. There are often missed opportunities to implement these therapies. Karachi shares many characteristics with megacities of the global south and represents Pakistan in the global city league. This review informs readers about the availability of health management and pain services for CNCP in Karachi, and their comparability to those found in other global cities. The literature about CNCP and its management in Karachi and Pakistan is scarce. Nevertheless, some conclusions can be made. In order to inform readers based in other global cities, a brief review of the current health system and pain services in Karachi and Pakistan are discussed together with barriers that impede pain service outputs. The present review employs vignettes to illustrate typical experiences of CNCP patients seeking pain management services in three sectors: public, charitable, and private institutions.
Barriers; Chronic non-cancer pain; Global cities; Pain management and services
Chronic non-cancer pain (CNCP) refers to pain
of nonmalignant etiology that lasts for more
than 3 months. It is widely regarded as a
biopsychosocial disorder  that requires
recognition of its multidimensional nature for
effective patient-centered clinical management
. The chronic disease model suggests that the
societal and personal burdens of such disorders
can be more effectively treated through
coordination of care where patients are actively
engaged in implementing personalized
multidimensional treatment strategies . The lack of
coordination and access to proven therapies
encountered in developing countries increases
the burdens of such problems. Indeed, a recent
study indicates that disabling CNCP is more
prevalent in developing countries , and that
this high prevalence seems to be attributed to
the limited treatment options and limited
access to chronic pain management services in
In a developing country such as Pakistan,
CNCP management services are not prioritized
as clinical services because of many other
competing concerns. As a result, even simple forms
of pain management are often absent .
Systematic information regarding the prevalence
and management of CNCP in Pakistan are not
available. Even when patients do access health
care services, pain relief remains elusive .
Several national and international associations
have recognized this situation as a global health
challenge and are collaborating to encourage
global solutions [6, 7].
Cities ranked as global or world cities are
recognized as important nodes in the global
economy. They share common attributes such
as access to the latest innovations and
worldclass human and technical resources. These
resources include high-quality health services
staffed with practitioners trained at highly
ranked educational centers. However, in a
rapidly urbanizing world, world cities of the
global south share a more pronounced burden
of noncommunicable diseases, including pain
. This review examines the case of CNCP
management in Karachi, Pakistan’s global city,
and explores how those services might be more
comparable to those found in other global
cities. Developing advanced clinical services
such as CNCP management facilities can be as
effective as building hospitals for promoting
health and wellbeing. Reducing the burden of
CNCP can be rationalized from both ethical and
economical perspectives. Documenting the
landscape of CNCP management services will
provide a useful lens for evaluating best
practices and barriers to health system
In order to understand the landscape of pain
management and services available in Karachi
with respect to global cities, there is a need to
first review the current federal health system in
which the city system functions. This review
then explores structural factors that act as
determinants of pain management service
availability in Karachi, as well as barriers that
impede the implementation of global best
practices. The present review also uses the lens
of three patient personas interacting with
different sectors of the Karachi health care system:
public, private, and charitable. A
comprehensive electronic literature search (1960–2015) was
performed using key words (‘‘chronic
non-cancer pain,’’ ‘‘chronic pain patient,’’
‘‘Pakistan,’’ ‘‘Karachi,’’ ‘‘developing countries,’’
‘‘musculoskeletal pain,’’ ‘‘neuropathic pain,’’
‘‘causes,’’ ‘‘prevalence,’’ ‘‘pain management,’’
‘‘pain therapies,’’ and ‘‘treatment for pain’’) in
multiple databases (Medline, Science Direct,
Scholars Portal, Sociological, CINAHL, and
Google Scholar). In addition, official reports
published in English were also reviewed.
Statistical data were obtained from the website of the
Federal Bureau of Statistics, Pakistan. Gray
literature and references cited in relevant articles
were also reviewed. This comprehensive
literature search provided evidence on pain
management services in Karachi, Pakistan and is
summarized in this manuscript. The purpose of
this review is to assess the current status of
CNCP management practices in Karachi (and
Pakistan in general) and to highlight
opportunities for ongoing development. The results of
this review are presented using a combination
of case study , illustrative vignettes , and
narrative review .
Compliance with Ethics Guidelines
This review article is based on previously
conducted studies and does not involve any new
studies of human or animal subjects performed
by any of the authors.
GENERAL BACKGROUND ABOUT
Pakistan is the world’s sixth most populous
country, with a population of over 180 million,
and it has one of the highest population growth
rates in the world . It is estimated that 24%
of the population lives below the poverty line
. About 2.8% of its gross domestic product
(GDP) is spent on health care, which is lower
than that of any other neighboring developing
country . The bulk of that expenditure is
directed towards supporting tertiary healthcare,
which is accessed by only about 15% of the
population. Only 15% of the total health care
budget (less than 0.4% of GDP) is spent on
primary health care . An increasing
proportion of Pakistan’s population (38%) lives in
an urban setting . Around 13% of its
population, or 24 million people, live in Karachi.
As Pakistan undergoes economic
development, changing lifestyles have resulted in a
growing burden of non-communicable diseases
(NCDs). Deaths due to NCDs now far
outnumber deaths due to communicable diseases .
This is relevant because the burden of many of
these NCDs is increased by CNCP symptoms
associated with them .
PAKISTAN’S NATIONAL HEALTH
Most provincial governments are primarily
responsible for health care management in
Pakistan. Every provincial government has a
department of health that serves to protect the
health of its population by providing basic
health care amenities. There is a divide in
spending on health care in the public sectors
across the provinces. The formulation of
national health policies falls under the
jurisdiction of the federal government . There is
a three-tiered system in which public, private,
and nongovernmental sectors participate in the
provision of health care in Pakistan.
Public health care is subsidized to make it
accessible to most residents by offering it at a
low cost. Patients that are treated in an
outpatient department (OPD) of a public hospital do
not have to pay for the consultations, but they
do when buying prescribed medicines or other
health products and services. In contrast,
private health care is primarily a fee-for-service
system and covers a range of health care
provisions . Despite considerable advances in
recent years, a lack of trained health care
professionals and basic health system
infrastructure, especially with regards to physical
medicine and rehabilitation, is recognized as an
important limiting factor for more effective
CNCP care in Pakistan . No
government-sponsored health insurance plan is
available in Karachi, but private health insurance is
available for the few who can afford it. Most of
the population cannot afford to access the
health care system directly. To meet this need,
several private charity hospitals have emerged
to provide free, high-quality health care,
including pain management services .
In Pakistan, 79% of the population utilizes
some aspects of the private health sector . In
the private sector, there are some accredited
facilities and hospitals, but also many
unregulated hospitals, nonmedical general
practitioners, hakeems, traditional/spiritual healers, Unani
(Greco-Arab) healers, herbalists, and bonesetters
. There are no formal watchdog bodies,
agencies, or audit commissions set up to
monitor the quality of health care delivered to
patients . A recent study revealed that
between 1990 and 2013, years lost to disability
from musculoskeletal disorders increased by
163% among women in Pakistan . Lack of
quality care is an issue for all chronic illnesses,
and CNCP is a significant health problem that is
commonly presented by patients suffering from
complex chronic conditions .
Currently, there are very few established
pain clinics, despite the introduction of pain
medicine as a specialty in the mid-1980s in
Pakistan. Recently, health experts have
expressed concern over the absence of acute, chronic,
cancer, and childbirth pain relief services in the
majority of public and private hospitals in all
Unrelieved pain remains a national health
problem; however, reliable data regarding the
prevalence and incidence of chronic pain are
limited. To illustrate the scale of the problem
from existing data, information from a WHO
collaborative study of pain in primary care 
revealed that chronic pain was present in
approximately 5–33% of individuals in any
global city. As Karachi is the major global city of
Pakistan, investment in pain management
facilities could have an important impact on its
citizens’ wellbeing while stimulating health
system development towards global standards.
Karachi is the capital of the province of Sindh; it
is the largest and most populous metropolitan
city of Pakistan as well as its main seaport and
the financial center of the country. The metro
region of Karachi had an estimated population
of over 23.5 million as of 2013 . It is also
ranked as a beta global city . There are
currently about 4700 Katchi abadis (squatter
settlements) which provide housing to 55% of the
residents of Karachi . The populations of
these Katch abadis experience poor living and
health conditions and very limited access to
healthcare services .
Health Care Services in Karachi
Healthcare in Karachi is administered by both
private and public health care providers
(integrated healthcare). The Sindh province
(including Karachi) ranks lowest for public sector
healthcare facilities; only 22% of its population
uses these facilities, in comparison to 29% in
the rest of Pakistan. Thus, 78% of the
population of Karachi use private practitioners,
whereas this figure is 71% for the rest of the
country . On average, there is one doctor to
every 1206 patients. There are 134 private and
public hospitals with total bed strength of
21,170 to cover the population of 20 million in
Karachi. Public sector hospital beds account for
11,550 while the private sector has 9520
hospital beds . According to a government
report, rural areas have well-designed district
health systems but they are functioning poorly,
while urban areas have ‘‘an almost nonexistent
primary and secondary health care tier.’’ Thus,
the few tertiary hospitals get utilized beyond
capacity. In Karachi, the three large government
hospitals are overwhelmed by the demands of
20 million people. Government statistics
indicate that the percentage of GDP allocated to
health care declined from 0.7% in the fiscal year
2000–01 to 0.3% in the fiscal year 2010–11
[29, 31]. As a result, the majority of the poor
population of the city must pay privately to get
access to any health service, including pain
Significance of Chronic Pain in Karachi
Chronic pain is an important health issue in the
adult population of Karachi and Pakistan [32, 33].
Recently, two studies conducted in public and
private academic teaching hospitals in Karachi
revealed a prevalence of chronic non-cancer pain
that did not discriminate between the sexes (the
female/male ratio was 1:0.9). Musculoskeletal
problems were the predominant cause of pain,
and the most common complaint was low back
pain. Two abstracts provide interesting
comparative information concerning a private  and a
public  hospital. The public teaching hospital
was visited by a younger demographic and its
patients ranked their pain higher on a numerical
rating scale (NRS) of pain than the patients at the
private academic teaching hospital, which tended
to have an older patient population. Another
survey revealed that most general practitioners
(GPs) (85%) lacked knowledge about modern
methods of relieving pain, especially
interventional pain techniques. Also, the survey indicated
that nearly half of the GPs were unaware of the
existence of pain clinics and pain physicians .
Despite the undisputed fact that there is a
high prevalence of chronic pain at the national
and international level, there remains a lack of
scientific evidence pertaining to the precise
prevalence of and the types of management
services offered for CNCP in Karachi and
Pain Services in Karachi
In Karachi, the idea of ‘‘pain management’’—
especially through the agency of a specialized
‘‘pain clinic’’—is an evolving concept, and
very few institutions offer these services. The
first multidisciplinary pain clinic to be
established has been run by Aga Khan University
Hospital, Karachi since 1998 . CNCP
management is primarily regarded as an
anesthesia subspecialty, though experts from
other disciplines are also involved. Currently,
there are only two government hospitals and
three private hospitals that have pain
management clinics in Karachi. The directors and
clinicians at those clinics are primarily
anesthesiologists (S. Zafar, personal
communication, Oct 2015).
The geographical distributions of the clinics
are unplanned and are not designed for
maximum benefit by the general population of
Karachi. There is a dearth of information
concerning how people who suffer from
chronic pain are gaining access to adequate
pain treatment. Also, there is a lack of
awareness, particularly among primary health care
physicians, about the presence of pain clinics in
Karachi. Therefore, the majority of these
general physicians provide CNCP management to
complex patients without having any
specialization in the subject and do not refer them to a
pain specialist. In comparison to private
hospitals, very few public hospitals have pain clinics
in Karachi . Private sector clinics are very
expensive. Therefore, many pain patients in
Karachi seek pain treatment from traditional
healers (hakims and ‘‘pehlwans’’) for pragmatic
as well as for cultural and economic reasons
In addition, many patients visit informal
healthcare practitioners (HCPs),
physiotherapists, and occupational therapists for their
ongoing pain. Hospitals in Karachi do not
follow the multidisciplinary approach for CNCP
and rehabilitation recommended by
international bodies . As a result, allied health
professionals are often unaware of pain clinics and
therefore deal with their patients’ pain
independently of those clinics. This is particularly
true of the pain management services provided
by physiotherapists working independently in
the private sector or running physiotherapy
departments in government hospitals.
Provisions must be made to transform the delivery of
chronic pain services into an integrated system
through improved coordination and
communication between various healthcare sectors and
At a recent conference, a Pakistani
anesthesiologist mentioned that while morphine and
other opioid analgesics had crucial roles to play
in all kinds of chronic pain management, they
were not available in hospitals. The reason for
this was said to be the time-consuming
procedure involved in procuring drugs for hospitals
and patients. A global study by the Global
Opioid Policy Initiative reveals a pandemic of
unbearable pain affecting billions, caused by the
overregulation of opioids and morphine .
However, there is no specific study relating to
opioid availability and accessibility for CNCP.
Patients are usually given injections in the
clinics to manage acute pain with opioids. This
is true even though morphine injection can be
substituted with oral dosages of morphine,
which are cost-effective, safer, and as effective
for pain relief. Indeed, the World Health
Organization recommends oral administration for
CNCP, if possible. There is a need to create
awareness among both clinicians and the
general public about the optimal use of these
Globally, Pakistan is one of the countries
with the highest rates of injection usage . In
comparison to the national level, the use of
injections in Karachi is 13% higher . Relief
from severe pain is an important reason for
injection therapy, as many patients are unable
to tolerate pain and consider injections to be
the only form of treatment that provides
immediate relief .
In 2014, the College of Physicians and
Surgeons Pakistan (FCPS) approved specialization
in pain management as a subspecialty of
anesthesia. This is a first step in the development of
this important field in Pakistan . Aga Khan
University Hospital offers a fellowship in pain
management to the anesthesiologist after their
successful completion of the anesthesia
residency program . A private medical
university in Islamabad offers a Master’s program in
pain management for anesthesiologists only,
and many anesthesiologists from Karachi enroll
themselves in it (S. Zafar, personal
communication, Oct 2015). Key informants acknowledge
that pain management training remains
inadequate in medical schools across Karachi. In
particular, graduates entering clinical practices
are inadequately trained in interprofessional
collaboration for pain management.
Recently, a group of anesthesiologists, with
IASP support, delivered courses on ‘‘pain
education and services’’ to family physicians in
several cities [40, 41]. The researchers who
organized these educational activities in
Pakistan are from Karachi. CNCP education and
delivery of management services seems to be
better in Karachi than in the rest of Pakistan.
However, there are no available reports on the
impact of those workshops. Many private and
public hospitals conduct pain awareness
programs and workshops for patients, general
practitioners, and residents throughout the year
(S. Zafar, personal communication, Oct 2015).
However, those pain management programs are
delivered in an ad hoc manner and are not
staged strategically to reach a wider population.
Given the complex nature of the healthcare
delivery system in Karachi and the limited
resources available for the management of
CNCP, it is instructive to illustrate how existing
CNCP services are offered by different health
sectors in Karachi using hypothetical vignettes
based on our review.
The interactions of health professional with
patients are complex, and occur in an ad hoc
manner. There is likely to be a lack of coordination
in the interaction between patient, health
professional, and institution. This contributes to
undertreatment of chronic pain and missed
opportunities to reduce the CNCP burden. The
present review uses a clinical vignette approach to
illustrate expectations of how the care received by
CNCP patients within the three main health
sectors (private, public, and charitable organizations)
could impact the outputs of services provided by
pain clinics. Vignettes are standardized case
studies that are not fully realistic but are
comparable across clinicians and can be used for most
outpatient conditions. The goal of the use of
vignettes in our review is to illustrate how
common conditions are likely to be dealt with in a
setting that is typical of the sector, while allowing
comparison across sectors. The following
vignettes are adapted with input from key informants
from Pakistan, from treatment program cases,
which provide a glimpse into patients’
experiences (Table 1) (at http://www.kktpakistan.com/
As noted in the vignettes, all
patients—regardless of the health sector—are likely to be
treated at a single-modality pain clinic.
Long-lasting pain results in profound changes
in pain perception, pain threshold, coping
mechanism, mood, and enjoyment of social
and professional life . Due to the complexity
of chronic pain, no single discipline has the
expertise to assess and manage it
independently. A multidisciplinary team approach is
considered to be the optimal therapeutic model
for CNCP patients . To ensure that care is
delivered in a coordinated manner, clinicians
should familiarize themselves with
evidence-based treatment guidelines. In order to
improve pain management and maximize their
patients’ quality of life, clinicians should use
treatment and clinical activities that suit the
needs of the patient . However, existing
literature supports the perspective provided by
the vignettes: that most clinics offer only a
monotherapeutic rather than a comprehensive
multidisciplinary approach in Karachi .
Vignettes make an important contribution
to knowledge because they allow some
understanding of the distribution of proficiency in
the different health sectors. When developing
strategies and management skills for chronic
pain, the barriers that hinder progress in CNCP
management in Karachi must be taken into
There are many systemic factors related to the
healthcare system, healthcare professionals,
and healthcare users that contribute to the
burden of unrelieved pain. Many of those
factors are the same as those that were considered
to require urgent attention 20 years ago in
developed countries . Also, the lack of
chronic pain management options for
Table 1 Patient vignettes
Mr. X, 29 years
Present complaint: Suffered low back
pain 6 years previously after slipping
at work as a manager; unable to work
since. Gradually developed an
antalgic gait and spreading pain to his
upper thigh, knees, wrists, and ankles
Associated complaints: Fragmented
sleep, weight gain, depression, very
Assessment: O/E looks , sweaty,
disheveled, sleepy, and asked to lie
down. Displayed multiple verbal and
nonverbal pain behaviors, with hand
shaking and a very limited range of
lumbosacral spine movements. Rated
Mr. Y, 29 years
Associated complaints : Fragmented
sleep, weight gain, very high disability
Medical and psychosocial history: three
back surgeries, but the last two failed
to provide him with any pain relief.
On medication for at least 7.5 years,
with intermittent epidural injections
for the last year. Has stopped
working full-time, but continues to
perform irregular part-time work. Is
currently managing the pain with
Mr. Z, 29 years
Present complaint: Suffered low back
pain 6 years previously after slipping
at work as a painter; unable to work
since. Gradually developed spreading
pain to his upper back and knees
Associated complaints: Fragmented
sleep, mood with periods of
irritability, and very high disability
Table 1 continued
Expected outcome: Prescribed
long-term pharmacotherapy without
any benefit. Despite being treated at a
private hospital with full access to
health care, pain ratings remain high
and still exhibits extreme disability.
Morbidly depressed, which is not well
addressed, and pain is not being
marginalized and special populations (children
and the elderly) within countries raises
significant health equity concerns. These factors
continue to limit access to CNCP management
in both developed and developing heath
systems [45–47]. After reviewing the literature on
rehabilitation and pain management services in
Karachi and Pakistan, various important barriers
to pain assessment and the recommended
adherence to treatment regimens [5, 24, 48]
were identified, as shown in Table 2.
Thus, the pain management crisis that results
from these systematic barriers must be resolved
to improve CNCP management. Identifying and
acknowledging these barriers is a first step to
overcoming them. Successful initiatives to
overcome patient, physician, and institutional
barriers need to be multidimensional and integrative.
Key informants suggest that the need and the
opportunity to invest in pain management
services in Pakistan are starting to be recognized (S.
Zafar, personal communication, Oct 2015).
OPPORTUNITIES FOR CHRONIC
PAIN MANAGEMENT IN KARACHI
The expression of chronic pain in different
individuals in different locations and its impact on
their quality of life varies greatly in type, intensity,
frequency, and prognosis. The goal of pain
treatment is not to cure disease but to improve quality
of life and allow the CNCP patient to function as
effectively as possible. However, resources and
patient demands vary throughout the world, and
international guidelines need to be adapted to
local realities. The strategies and information
presented in this review are offered as a guide for
clinicians, educators, administrators, and
governmental or professional organizations involved
in the establishment and maintenance of
standards for pain treatment services in urban settings
in Pakistan (Fig. 1). However, they may have
relevance to other global city settings. The suggested
recommendations are the synthesis of the current
literature, and are presented here to aid attempts
to improve pain management services and
facilities, including those in resource-limited settings
[1, 2, 24, 49–52]. These recommendations are not
intended to represent required standards. Rather,
it is recognized that these idealized practices will
need to be adapted to the needs and constraints of
the health system in Karachi and Pakistan (Fig. 1).
Summary of Recommendations
(1) Increasing availability and accessibility of
chronic pain management services across
the city of Karachi, based on the guideline
provided by the WHO policy for pain
management, should be considered a
strategic investment in urban
(2) There is a need to invest in infrastructure
and access to systematized services such as
rehabilitative services, behavioral
medicine, and medications so as to enhance
Table 2 Barriers to effective chronic non-cancer pain
Healthcare professional barriers
Healthcare user barriers
Healthcare system barriers
treatment of CNCP at a primary care
provider level, as per patient needs.
(3) For more complex cases, if primary services
prove inadequate, more specialized
assessment services that apply a coordinated
multidisciplinary approach need to be
accessed, and ongoing care needs to be
integrated and coordinated in a
comprehensive manner. All healthcare
professionals could benefit from professional
development around providing
comprehensive CNCP services at all levels of the
health care system.
Inadequate knowledge of treatment options
Inaccurate evaluation of pain
Legal issues regarding substances
Concerns about addiction
Fear of respiratory depression
Pain management is a low priority
Cultural or social barriers
Inadequate reimbursement for physicians
Fear that the disease is worsening
Shifting focus from the disease
Fear of addiction
Fear of being identified as an addict
Reliance on traditional medicine
Limited specialist or treatment access
Lack of or limited availability of opioids (quantity)
Restrictions on inventory systems
Pain management is a low priority
Regulatory requirements/restrictive regulations
A rigorous curriculum focusing on pain
education should be introduced at the
undergraduate level in medical schools,
and interfaculty and interprofessional
short courses should be encouraged.
Chronic pain patients also need to be
viewed as part of the solution; they also
require education about pain, including
instruction in self-management strategies.
The quality of care delivery and outcomes
associated with chronic pain management
services should be analyzed systematically.
These data can then be used to raise
Fig. 1 Schematic presentation of recommendations
awareness in public and primary care
providers about the importance of seeking
CNCP healthcare services.
(6) Barriers that hinder people with special
needs (e.g., children, older adults, the
developmentally challenged, the
cognitively impaired) from receiving CNCP
assessment and management need to be
The challenges facing CNCP management in
Karachi are numerous and multifaceted. The
health system consists of charitable, public, and
private sectors, with most of health services
provided by a loosely coordinated private
sector. Planning for the future in relation to pain
management in Karachi is becoming extremely
difficult due to the large number of patients,
insufficient data, the lack of infrastructure, the
scarcity of trained professionals, and the lack of
a venue for coordinating efforts to improve the
quality of care across the system and for sharing
data pertaining to such efforts. Although a
culture of ongoing research, reflection, and
improvement is developing slowly, this progress
could be accelerated by embracing better CNCP
management as a civic goal. This review has
demonstrated that there is a need for and an
opportunity to improve the education of health
care providers and patients regarding CNCP
management and to enhance the involvement
of government, educational, and professional
society institutional actors in advancing
internationally recognized CNCP practice standards
[1, 2]. The first step in that regard would be to
explore mechanisms for improving access to
and the appropriate use of pain management
drugs as well as to create dedicated facilities for
chronic pain management services at all public
and private sector hospitals. As the first item of
business, such facilities could be charged with
evaluating the need for pain management drugs
and ensuring that these drugs are used
appropriately within the framework of a
comprehensive CNCP management plan. Adapting
international standards for dealing with the
universal problem of CNCP management to the
complex but localized context of the global city
of Karachi could trigger innovative thinking
concerning health services with potentially
No funding or sponsorship was received for this
study or the publication of this article. All
named authors meet the International
Committee of Medical Journal Editors (ICMJE)
criteria for authorship for this manuscript, take
responsibility for the integrity of the work as a
whole, and have given final approval for the
version to be published. I would like to thank
Sunita Kak (who was not provided with any
financial assistance) for her editorial assistance
with this manuscript.
Disclosures. S. Fatima Lakha, Peter
Pennefather, Mubina Agboatwala, Safia Zafar
Siddique, Hanan E. Badr, and Angela
Mailis-Gagnon have nothing to disclose.
Compliance with Ethics Guidelines. This
review article is based on previously conducted
studies and does not involve any new studies of
human or animal subjects performed by any of
Open Access. This article is distributed
under the terms of the Creative Commons
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