 "In Pakistan, health is not a top priority, people have other things to worry about."
- Osman Yusuf RESPONSES BY SUBJECT
 Are there any special problems in diagnosing asthma in children? Do they vary by age?
What do you think are the special issues and challenges in treating children with asthma? Do they vary by age?
What questions do parents/carers and patients ask of you?
Which educational strategies work?
Which in your opinion are the top three problems children and parents/carers face in managing asthma in daily life?
RESPONSES BY COUNTRY
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Responses by countryOsman Yusuf (Pakistan):
Are there any special problems in diagnosing asthma in children? Do they vary by age?That's something tough. If I were to speak from the perspective of a primary care physician, sitting in the community, where he's seeing children with all sorts of diseases, asthma would probably be one of the back benches on the diagnosis profile. He will most likely be looking first for any sort of acute viral exacerbation, viral pneumonia, bacterial pneumonias, very common here, a lot of chest infections. Asthma really takes the back seat to that. Then of course tuberculosis even in children is something to worry about; especially since they normally come in with a chronic cough. Primary care physicians don't have the facilities to diagnose the asthma very well; they don't normally use peak flow meters or spirometers, or any such tools. So the asthma patients usually end up being misdiagnosed and mismanaged. Only when they really exacerbate do they end up getting to someone who knows how to diagnose asthma. So that's why I would see that as the biggest problem in diagnosis: the lack of awareness on the part of the primary care physician. And that's what we're aiming through the IPCRG to change.What do you think are the special issues and challenges in treating children with asthma? Do they vary by age?Primary care physicians are not adequately or properly trained or qualified in managing asthma, with the result that you have underdiagnosis, overtreatment, and maltreatment of asthma. Number two, easy accessibility of medications in Pakistan at all levels actually reduces the number of visits of patients to qualified practitioners for asthma. The third issue is the patient factor: patients are not very happy going to qualified medical practitioners, because of the long-term treatment, the supposed side effects of treatment, the cost of medication; and by this I'm talking about the western system of medication. I'm not referring to the local healers or traditional medicine. A major issue is the economics of it: the cost of medicine, therefore the ability of patients to pay, the accessibility to health-care facilities, all these come into play. The next common issue in several developing countries is that of gender. If it is a son who's unwell, the family would like to spend lots of money getting the son treated because he's going to carry the name of the family forward. While if it's a daughter, in the more illiterate and less educated parts of Pakistan, they wouldn't worry about her so much. Another big issue is the actual stigma associated with the word 'asthma,' so 'allergy' is conveniently used as a cover-up for that. The biggest need is government commitment to asthma care and education-we need that a lot, and we're working on it. Ramadan, the Muslim month of fasting, entails the abstinence from food, drink, and all worldly desires from before sunrise till sunset, for one lunar month. Muslim children may feel uncomfortable taking even inhaled medications while fasting in Ramadan. However, in fact, if taken properly through a spacer, inhaled medication can be taken even while fasting.What questions do parents/carers and patients ask of you?Are you sure it's asthma? That's a very common question. And the second is, is it going to remain all his life? Everyone is looking for a cure. And if you go on to mention inhalers as part of the treatment, then automatically the conversation changes to inhalers: Are they addictive? The patients come in with a lot of fallacies that they've heard about inhalers. Misconceptions include that they're addictive, they're the last mode of treatment and nothing else works after that, they're damaging to the lungs, etc. etc. We've put a lot of material to counteract these misconceptions on our website, in the press, and through other fora. Patients here in Pakistan have several misconceptions about diet and asthma; the four foods that people blame as causing asthma are milk, yoghurt, banana, and rice. We've done multiple allergy tests and never found a histamine reaction to those. However, banana actually contains serotonin, which can trigger an allergy attack and increase production of mucus as it's related to histamine. So there could be some weight in the anecdotal evidence. Basically patients are concerned about when will the asthma finish? When will the medicines stop? That's the bottom line of all the questioning.Which educational strategies work?Everything, any educational strategy which is going to target the parents and children. What we are doing includes cartoon books in schools, leaflets in public for increasing the awareness of parents about children's asthma. Increasing the level of education for doctors to be able to diagnose it more. The biggest impact I would say is from television. Because every time I'm on television, I receive at least 20 to 30 telephone calls the same day or the day after. The biggest impact we've had is with television talk shows, television interviews, talking to people about asthma. That's what we're doing for World Asthma Day this year: a massive media show in one of the hospitals here where patients are going to come and listen to other patients. It's going to be televised as well as on the radio for people to call in and discuss, as well as for other patients to say, "Look, we are taking inhalers and this is how our lives have improved." I have done two or three programs, not televised, however, for an organization called Mothers' Network of Asthmatic Children in Dubai, where we invite mothers at random to come and ask all the questions they want about asthma and allergy for their children, about management of asthma. And that seems to work well: they feel they're getting free advice, they come with prepared questions, they're open and relaxed, they cross-question. Also I've done a couple of programs about children with allergy and asthma as part of an English-speaking talk show on ARY digital channel, which is televised from Dubai and broadcast all over the world for Pakistani and Indian populations; it's a Hindi-English channel. And on that mothers can call in live and ask questions and get a reply. It's widely watched; I get calls from all over the world. People ask, "Where do we go for advice?" That's a common question.Which in your opinion are the top three problems children and parents/careers face in managing asthma in daily life?
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