Background

Those public health data available, place Pakistan 132nd on the human development index, (Human Development Report 1993). Twenty-five percent of babies born are of low birth weight. Maternal mortality is estimated at 500 per 100,000 live births. The use of contraceptives is also low (12%) with little rise over the past 20 years. The annual growth rate of 2.7 is one of the highest in the developing world. The budgetary allocation on health in Pakistan, though recently increased, nevertheless remains less than 1% of GNP. Medical education in Pakistan continues to emphasize curative care and neglect the study of public health and prevention.

In Pakistan, government and private sectors are not coping with health problems. The few preventive services that are offered, such as immunization, are run as vertical programs. Health professionals at the district and sub-district levels are not provided with adequate training to manage health services efficiently and competently. Currently, there are few institutions in Pakistan which cater to the training needs in public health skills. Lack of information is coupled with absence of a professional public health cadre and poor allocation of resources. Information, which, is the key to rational decision making is neither obtained nor adequately utilized when available. Informed decisions affect funding, efficiency, effectiveness and equity of health systems. Limitations in the availability, quality and use of information impede the evolution and progress of health care programs and systems. Furthermore lack of information promotes ineffective and wasteful allocation of funds. Lack of training for government health staff is only gradually and marginally being addressed mainly through in-service training. Currently dependence on clinicians with no training in public health skills, and no skill in the use of information leads to ineffective bureaucracy.

Epidemiology is the science at the core of public health. It is a discipline that teaches how to collect and interpret valid information. Trained epidemiologists are needed to analyze the major public health problems in Pakistan, assist in setting priorities, and developing and evaluating interventions. The epidemiologic training available in Pakistan, however, is currently limited. The Aga Khan University teaches epidemiology to the undergraduate medical students. There is a new university in Karachi offering a Masters in Public Health, but they do not have an epidemiologist on faculty. In short, there are currently no formal programs for training epidemiologists in the country. Graduates of a Masters of Science in Epidemiology could contribute to the country’s health through, for example, as district health officers, pursuing clinical or population research, teaching epidemiology in other medical and nursing schools, and assisting non-governmental organizations in their attempts to improve public health in Pakistan. The AKU is uniquely situated to develop a graduate program in Epidemiology. The Community Health Sciences Department has 11 years of experience in teaching undergraduate epidemiology. The Department’s faculty development efforts over the last 11 years has produced several junior faculty members who have recently completed or will be completing their doctoral work and would be qualified to teach masters level students. In addition to addressing the health needs of the people of Pakistan a Masters of Science in Epidemiology program at AKU would be an important regional resource that could provide relevant training to personnel from throughout the Asian subcontt, Central Asia, and East Africa at a fraction of the cost of similar training in North America or Europe, which is less focused on regional problems and needs. We believe the graduates of the program will be able to find opportunities within the country and the region to use their skills for three reasons. First, institutions addressing public health in the region recognize the need for appropriate training. As part of the evaluation of the role for graduates of these proposed programs we surveyed some key institutions within Pakistan and throughout the Aga Khan Network. On the government side, The Federal Institute of Health in Pakistan, the Director of Provincial Health Services in the Northern Areas, the Secretary of Health of the Province of Sindh, and the Director General of Health Services in Baluchistan all expressed interest both in sending current employees for training as well as employing graduates of the epidemiology program within their operations. We received responses of similar interest from Aga Khan network programs including the Aga Khan Health System Programs of Sindh province, Kenya, and India. Other organizations expressing interest either in sending personnel for training or employing graduates included The World Health Organization Pakistan Office, Save the Children Fund, the Dhaka Urban Community Health Program, and faculties from Iran and Kuwait.

A second way to measure the demand for this kind of training is to look at the number of applicants at institutions currently offering graduate degrees in public health disciplines. This provides a measure of how people in training see the value, including the market value of this training. The Masters in Public Health offered by the Health Services Academy in Islamabad had 546 applicants for 20 seats for their 1995 class. The Diplomate in Public Health offered by the Institute of Public Health in Lahore received over 2000 applications for 40 seats. Thus there is demand for this kind of training from potential students.

The third reason we believe there will be opportunities for epidemiologists is because of the marked need for this expertise outlined in the earlier paragraphs of this attachment. The core of the strategic plan of the Community Health Sciences Department is developing public health leadership to address these issues. It is difficult for persons without any background or exposure to epidemiology to envision how it fits into current institutional plans. As graduates go out and assume roles in institutions, the importance of an epidemiologic approach to problem solving will be increasingly clear, and will, we believe, create even more demand.

The masters of science program is also important for the ongoing development of the Aga Khan University. The Community Health Sciences Department currently has the expertise in study designs, biostatistics and teaching methodologies to teach a masters program in epidemiology. These core pieces are important for the growth and development of other post-graduate programs as well as developing research capacity within the university. Any other graduate programs that will require quantitative research will require expertise in these areas. Thus developing the program in CHS now will be an important step for future graduate programs which could ultimately link with the CHS expertise.

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MASTER’S PROGRAM IN EPIDEMIOLOGY CURRICULUM, 1996

* The Students will be allowed to take independent study in Epidemiology instead of the elective course upon mutual agreement between the program faculty and the students.

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ADMISSIONS PROCESS

Admission to the Master’s Program in Epidemiology is based on merit and potential for leadership. Merit will be evaluated through scholastic achievements of applicants. The course is open to anyone in the health field either public or private, regardless of nationality. Students throughout Pakistan as well as foreign students may apply. A high academic score in any discipline or any outstanding achievement alone will not be sufficient for selection.

Admission Requirement:

MBBS, BSCN or Master’s degree in a health related sciences with 3 years experience in the health field is the minimum qualification required.

Admission Procedure:

Application for admission to the Master’s Program in Epidemiology is made on a standard form attached herewith. Application should be submitted along with the supporting documents which includes:

1. A complete set of official transcripts of academic records at colleges, graduate schools, and/or professional schools, with certification of degrees conferred, courses taken and grades received.

2. The application should include a statement of objectives, summarizing past education, training and experience, as well as present interests and future aims. A curriculum vitae and list of publications, if any, should be included.

3. Letters of recommendation from at least three people who are well acquainted with your previous academic work and professional experience.

Evaluation of Applicants

Applicants are evaluated in two stages. Firstly, applications are reviewed and applicants are invited to write the Admission Test following which short-listed candidates are called for interviews.

Admission Test:

The Admission Test is designed to assess the basic knowledge of Mathematics which includes deduction and problem solving ability and critical reasoning ability. The English language component of this test is prepared to evaluate the knowledge of English and reading comprehension. All the course work and examinations are given in the English language. Good English is essential for success in a course of study or for doing research. Course essays, reports and other pieces of work require ability in written English. Students need to cope with reading and note-taking from lectures, books and journals and other material, and to speak English well in seminars, discussion groups and tutorials.

The duration of the test is 2 hours. The fee for Admission Test is Rs 500/-. The University has not authorized any publication or preparatory classes for the test.

OR

Candidates may be asked to take the Graduate Management Admission Test (GMAT), or the Graduate Record Examination (GRE). Application whose first language is not English must provide evidence that their ability in the various skills of English is sufficient by including with their applications details of any recognized experience in using English i.e. Test of English as a Foreign Language (TOEFL) or British Council’s International English Language Testing System (IELTS)

Interview Process:

Based on the scores in the admission test, a group of qualified applicants will be short-listed, who then will be interviewed by senior faculty of Community Health Sciences Department. The purpose of the interview is to assess a variety of attributes, including strengths and weaknesses, integrity, motivation for and interest in this program, maturity, social and cultural awareness, knowledge of health issues in developing nations, evidence of initiative and leadership potential. In exceptional circumstances, for instance foreign students, the interview may be waived by the chairman of the Department, on receiving two satisfactory recommendation letters describing candidate’s strength. Departmental recommendations for admissions will be forwarded to the Board of Graduate Studies for approval.

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COURSE DESCRIPTIONS

TERM I (Duration 3 Months)

Computer Skills

This course is designed to provide elementary computer skills. It covers personal computer software and its applications in public health research. Emphasis will be on concepts of research data processing. Topics will include microcomputers, operating systems, file management, appropriate data base structure, techniques for data verification, archiving, word processing, presentation graphics and introduction to spreadsheets. .

Instructor: Computer Teacher from Information Systems Unit of the CHS. Course will be supervised and developed in conjunction with Dr. Stephen Luby.

Epidemiology I - Introduction to Descriptive and Analytical Epidemiology

This course introduces principles and methods of epidemiological investigation of both infectious and noninfectious diseases. Students will be given the opportunity to acquire an understanding of these principles and concepts, the vocabulary of Epidemiology, methods of epidemiological investigation, and interpretation and evaluation of reports of epidemiological research. Some of the methods by which properly conducted studies of the distribution and dynamic behavior of disease in the population can contribute to an understanding of etiologic factors, modes of transmission and pathogenesis of disease are illustrated.

Study of disease from a population perspective as the interaction of host, agent, and environment. Fundamental concepts include case definition, measuring frequency of disease, mortality and morbidity data, and major study designs.

Text Book: Henneken’s Epidemiology in Medicine (Little Brown and Company) Instructor: Dr. Stephen Luby / Dr. Fariyal Fikree / Dr. Ashraf Lasee

Biostatistics I

Descriptive Statistics, measures of central tendency and dispersion, basic probability, Binomial random variable, normal distribution. Point and interval estimation of selected parameters including means and proportions in a population, T-tests for one-, two-, and paired sample, Chi-square test of independence and nonparametric tests.

Text Books: Basic Statistics for the Health Sciences, Jan W. Kuzma, Mayfield Publishing Company

Instructor: Dr. Hossein Rahbar or Dr S.M.T. Ayatollahi, from School of Public Health, Shiraz University, Iran, who has expressed his interest in teaching in our Master’s Program.

Teaching Skill

Faculty members from Institute of Education Development, The Aga Khan University will be invited to teach this course in order to equip the student with teaching skills.

TERM II (Duration 3 Months)

Epidemiology II - Epidemiological Methods: Intermediate Epidemiology

This course will present and illustrate some of the major methods used in epidemiological studies of chronic infectious and noninfectious diseases.

Topic presented include measures of disease effect: cohort analysis, screening; validity and reliability; sampling methods; interview design; analyses of longitudinal and case-control studies; bias; interaction and adjustment.

Texts Books: Modern Epidemiology By Rothman (Little Brown and Company) Statistical Methods in Epidemiology By Harold Kahn, Christopher Sempos,(Oxford)

Instructor: Dr. Fariyal Fikree / Dr. Stephen Luby

Biostatistics II

Simple linear regression and correlation, analysis of variance including 1-way and 2-way ANOVA models, goodness of fit and other non-parametric methods and selected topics in experimental designs.

Textbook: An introduction to statistical methods and data analysis - Third Edition By Lyman Ott

Instructor: Dr. Hossein Rahbar / Dr S.M.T. Ayatollahi

Seminars in Public Health

This seminar course is designed to provide students with a broad understanding of the major public health issues facing developing countries. Topics to be introduced include, modes of spread, effect on the individual and the population for the major communicable and non-communicable diseases of the region including tuberculosis, diarrheal diseases, hepatitis, HIV, vaccine preventable disease, malnutrition, maternal and prenatal mortality, issues in fertility control, tobacco’s effect on health in developing countries, and an introduction to problems of injuries, both intentional and non-intentional.

Reading Material: World Health Organization. The World Health Report 1996 World Bank Development Report 1993 Selected journal articles. List of topics/issues that can be discussed.

Instructors: Dr. Stephen Luby, Dr. Fariyal Fikree, with other faculty from CHS contributing in their area of expertise.

Journal Club

Seminars to present an issue in clinical/public health research, exemplified by assigned readings drawn from classical papers and contemporary literature. The students will be asked to present recent publications from different International Journals followed by a critical analysis and review of the paper. The CHS faculty will give their feed back to the presenter. Instructors: All CHS faculty will be invited to attend these sessions

TERM III (Duration 3 Months)

Epidemiology III (Case Control Studies)

This course will cover issues related to the design of cohort and case-control studies and the impact of design on the analysis and interpretation of data. Following a review of the basic strengths and problems of the case-control method, the course will examine the application of this most popular method of investigation.

At the end of this course students are expected to propose an appropriate epidemiological research design for the investigation of a chosen epidemiological problem; identify a population; choose and propose records for ascertainment and classification of diseases and risk factor; outline a plan of action for a record collection system, for data collection etc; and outline a plan of action for data editing, data processing, and data analysis.

Text Books: Case Control Studies By Schlesselman (Oxford University Press)

Instructor: Dr. Fariyal Fikree / Dr. Stephen Luby

Management Information Systems

With current faculty in CHS, this course could be developed along the lines of public health surveillance. Specifically it will address theoretical and practical issues in planning, organizing, analyzing, interpreting and communicating surveillance information in the context of a developing country. Topics will include public health surveillance system design and data interpretation, ethical and legal issues, computerized surveillance, and community involvement in surveillance.

Text Books: Principles and Practice of Public Health Surveillance By Teutsch SM and Churchill RE.

Instructor: Dr. Stephen Luby with assistance from other faculty members in CHS

Note: Alternatively, if a chief of Health Systems is successfully recruited for the department, then this individual could develop a course more along the lines of health systems/management information system with a text of his or her choosing.

Protocol Writing

This course will teach how to write a scientific protocol. Its focus will be the production of a document, that is scientifically sound, practical to implement in a developing country, and appealing to agencies that fund scientific work. Topics to be addressed will include structure of the research protocol, the issues raised by each of the sections and the whole practical process of how one actually implements a study. Students will be expected to develop their thesis proposal during their course.

Textbook: Designing and Conducting Health Surveys Jossey Bass Publishers By Aday LA.

Instructors: Dr. Fariyal Fikree / Dr. Stephen Luby

Journal Club..

Seminars to present an issue in clinical/public health research, exemplified by assigned readings drawn from classical papers and contemporary literature. The students will be asked to present recent publications from different International Journals followed by a critical analysis and review of the paper.

Instructors: All CHS faculty will be invited to attend these sessions

PREPARATION OF PROPOSAL AND DATA COLLECTION (Duration 3 Months)

It is expected that by this time students have selected their research advisor and are ready to start writing their research proposal, data collection and etc. By the end of this period the students should have completed their data entry and are ready for analysis of the data.

TERM IV (Duration 3 Months)

Advanced Statistics and Statistical Packages

General linear models including multiple regression and logistic regression will be introduced. The applications of these models will be taught along with the use of statistical packages (SPSS, SAS or Epi-Info).

Text Books: An introduction to statistical methods and data analysis - Third Edition By Lyman Ott Applied Statistics and the SAS Programming Language - Third Edition By Ronald P. Cody and Jeffrey K. Smith

Instructor: Dr. Hossein Rahbar or Dr S.M.T. Ayatollahi

Seminar in Public Health public health issues facing developing countries.

Topics to be introduced include, modes of This is a seminar course designed to provide students with a broad understanding of the major spread, effect on the individual and the population for the major communicable and non-communicable diseases of the region including tuberculosis, diarrheal diseases, hepatitis, HIV, vaccine preventable disease, malnutrition, maternal and prenatal mortality, issues in fertility control, tobacco’s effect on health in developing countries, and an introduction to problems of injuries, both intentional and non-intentional.

Reading Material: World Health Organization. The World Health Report 1996 World Bank Development Report 1993 Selected journal articles. List of topics/issues that can be discussed.

Instructors: Dr. Stephen Luby, Dr. Fariyal Fikree, with other faculty from CHS contributing in their area of expertise.

Elective - Epidemiology of Injury or Reproductive Health or Communicable Diseases

Injury Epidemiology This course will teach epidemiological methods for studying injuries and evaluating interventions to prevent them. Formation of appropriate research questions, choice of research methods, and sources for reliable, valid data will be explored. The particular challenges of applying principles of Epidemiology to injuries, including the difficulties in using rates and ratios and in applying epidemiological methods when evaluating programs, laws, medical care, and regulations will be evaluated. Finally, the application of economic concepts to injury policy analysis will be discussed.

Textbook: Robertson, L. Injury Epidemiology (Oxford, 1992).

Instructor : Dr. Stephen Luby

Reproductive & Prenatal Epidemiology Epidemiology of adverse health states in pregnancy and the puerperium. Impact of these health states on subsequent child development.

Textbook: Will be selected by Instructor

Instructor: Dr. Fariyal Fikree

Epidemiology of Communicable Diseases Application of principles of Epidemiology to research in communicable diseases relevant to public health in Pakistan and other developing countries. Topics will include framing an appropriate research question, use of efficient study designs, and analytical approaches of particular importance to communicable disease epidemiology. In addition techniques of communicable disease outbreak investigation and control, essential laboratory investigations, techniques to apply laboratory investigations to field conditions, molecular epidemiological methods, and modes of transmission, surveillance and strategies for prevention of zoonotic diseases will be discussed.

Textbook: Will be selected by Instructor

Instructor: Dr. Stephen Luby

Research Studies

During this course the students will be closely supervised for their progress in their research projects. The students will also be provided with various skills in order to maintain the natural progress. They will be required to present parts of their research work in the classroom.

Instructor: All program faculty

TERM V (Duration 3 Months)

Advanced Biostatistics Seminar

Selected topics in Biostatistics will be taught including survival analysis, modeling, etc.

Text Books: Survival Analysis - By Rupert G Miller

Teacher: Dr. Hossein Rahbar

Research Studies

During this course the students will be closely supervised for their progress in their research projects. The students will also be provided with various skills in order to maintain the normal progress. In their research they will be required to present parts of their research work in the classroom.

Instructor: All program faculty will be involved in this course

Cost Analysis and Cost Effectiveness

Methods and applications of cost-effectiveness and cost-benefit analysis for health program evaluation, medical technology assessment, and environmental risk analysis; theoretical foundations; "shadow" pricing; economic valuation of life saving; choice of discount rates; cost accounting applied to economic evaluation in institutional settings; methods for assessing costs of environmental controls; economic evaluation of biomedical research; health status indexes; ethical issues; and modern critiques.

Text Book: Cost-effectiveness in Health and Medicine By Gold MR, Siegel JE, Russel LB, and Weinstein MC.(Oxford, 1996) Meta-analysis, decision analysis, and cost-effectiveness analysis By Petitti DB. (Oxford, 1994)

Instructor: Dr. Hossein Rahbar or Dr S.M.T. Ayatollahi

Journal Club and Work in Progress

Seminars to present an issue in clinical/public health research, exemplified by assigned readings drawn from classical papers and contemporary literature. The students will be asked to present recent publications from different International Journals followed by a critical analysis and review of the paper. The students may choose to present their own research results.

Instructors: All CHS faculty will be invited to attend these sessions.

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Faculty Research Interests

Program Faculty

Joseph Benford McCormick, Professor and Chairman - CHS B.S. Florida; M.D. Duke Medical School; M.S. Harvard Research Interests: Infectious Diseases, HIV/AIDS

Mohammad Hossein Rahbar, Associate Professor - CHS Ph.D. Michigan; M.S., Shiraz, Iran Research Interests: Sequential Analysis, Censored Data, Survival Analysis, Modeling

Stephen Luby, Assistant Professor - CHS B.A. Creighton University; M.D. University of Texas Southern Medical School Research Interests: Epidemiologic Methods, HIV/AIDS, Communicable Diseases, Epidemiology of Injuries

Fariyal Fikree, Assistant Professor - CHS M.D. Shiraz; M.P.H. Johns Hopkins; DrPH Johns Hopkins Research Interests: Reproductive Health, Maternal and Infant Mortality, Pregnancy Outcomes and Child Survival

Ashraf Lasee, Senior Instructor - CHS M.B.,B.S. LMC, Jamshoro; M.P.H. Johns Hopkins; Dr.PH. Johns Hopkins Research Interests: Reproductive Health, Health Systems Research, Family Planning, Occupational Injury, Maternal and Infant Mortality

Farid Midhet, Senior Instructor - CHS M.B.,B.S. Baluchistan; M.P.H. Columbia Research Interests: Reproductive Health, Maternal and Infant Mortality, Pregnancy Outcomes and Child Survival Currently pursuing PhD studies and is expected to complete his studies by September 1996

Other CHS Faculty

Asma Fozia Qureshi, Professor - CHS M.B.,B.S. Karachi; D.C.H. Glasgow; F.C.P.S. Pakistan Research Interests: Nutrition, Child Health Paediatrics

Rukhsana Zuberi, Associate Professor - CHS M.B.,B.S. Punjab; F.C.P.S. Pakistan Research Interests: Medical Education

Kausar S. Khan, Assistant Professor - CHS M.A. Karachi & McMaster Research Interests: Women and Development, Gender Studies, Relationship between Nutrition and Schooling

Riaz Qureshi, Assistant Professor - CHS M.B.B.S. Karachi; D.C.H. London; DTM&H London; F.R.C.G.P. UK Research Interests: Audit and Quality Control, Prevalence of Common Diseases

Parvez Nayani, Senior Instructor - CHS M.B.,B.S. Karachi; M.P.H. Johns Hopkins Research Interests: Diseases of Transition, Accessibility of Health and Education Services

Masood Kadir, Senior Instructor - CHS M.B.,B.S. Karachi; M.C.P.S. (Fam. Med) Karachi; M.P.H. Hawaii Research Interests: Public/Private Mix in Health Care, Verbal Autopsies

Inaamul Haq, Senior Instructor - CHS M.B.,B.S. Rawalpindi; M.P.H. Harvard Research Interests: Various aspects of health systems research

Amyn B Lakhani, Senior Instructor - CHS M.B.,B.S. LMC, Jamshoro; M.P.H. Glasgow Research Interests: Health Systems Management

Fauzia Rabbani, Senior Instructor - CHS M.B.,B.S. Karachi; M.P.H. Alabama Research Interests: Maternal Health and Family Planning

Anwer Tajdin Merchant, Senior Instructor - CHS D.M.D. Shiraz; M.P.H. Harvard Research Interests: Chronic Diseases, Oral Cancer

Syed Mahboob Ali Shah, Instructor - CHS M.B.,B.S. Peshawar; M.P.H. Texas Research Interests: Hypertension in Northern Areas of Pakistan, Nutrition

Rozina Noorali, Instructor - CHS M.B.,B.S. Karachi; M.P.H. McGill Univ. Canada Research Interests: Reproductive Health, Accessibility of Health, Health System Research

Imtiaz Jehan, Instructor - CHS M.B.,B.S. Karachi; M.P.H. McGill Univ. Canada Research Interests: Reproductive Health, Family Planning, Infectious Diseases

Adjunct Faculty

Dr. S. M. T. Ayatollahi. Senior Biostatistician, School of Public Health, Shiraz University, Shiraz, Iran

Faculty on Study Leave

Rennie D'Souza, Senior Instructor - CHS M.B.,B.S. Karachi; M.P.H. Harvard Research Interests: Reproductive Health, Family Planning, Health System Research, childhood mortality Currently pursing Doctoral Study in Epidemiology at the Australian National Univ. Canberra. Expected to complete her PhD by June 1997

Rafat Hussain, Senior Instructor - CHS M.B.,B.S. Karachi; M.P.H. North Carolina Research Interests: Reproductive Health, Acute Respiratory Infection, Family Planning,Currently pursing Doctoral Study in Demography/Population Studies at Australian National Univ. Canberra. Expected to complete her PhD by June 1998.

Mohammad Afzal Mahmood, Senior Instructor - CHS M.B.,B.S. Punjab, M.P.H. Adelaide, Austrailia Research Interests: Health Systems Research Currently pursing Doctoral Study in Health Services Research at Adelaide University, Austrailia. Expected to complete his PhD by February 1998.

Amanullah Khan, Senior Instructor - CHS M.B.,B.S. Karachi; M.Sc. London School of Hygiene and Tropical Medicine Research Interests: Infectious Disease Epidemiology with major interest in Cholera. Currently on leave for Takemi Fellowship at the Harvard University. Will be proceeding for doctoral study in Epidemiology.

Ghazala Parveen, Senior Instructor - CHS M.B.,B.S. Karachi; M.P.H. Oklahoma Research Interests: Tuberculosis Management and General Practitioners. Currently pursing Doctoral Study in Epidemiology at Univ. of Oklahoma. Expected to complete her PhD by June 2000.

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