Vulnerability to homicide in Karachi: political activity as a risk factor

A Miana,b, SF Mahmooda,c, H Chotania,d and S Lubya,e

a Department of Community Health Sciences, The Aga Khan University, Karachi, Pakistan.
b Current affiliation: Department of Molecular and Human genetics, Baylor College of Medicine, Houston, TX, USA.
c Current affiliation: Department of Internal Medicine, University of Illinois, Michael Reese Hospital, Chicago, IL, USA.
d Current affiliation: Department of Internal Medicine, University of Pennsylvania, McKeesport Hospital, McKeesport, PA, USA.
e Current affiliation: National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Dr S Luby, Mailstop A-38, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. E-mail: sxl2{at}cdc.gov


    Abstract
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Background Previous studies analysing Karachi ambulance data from 1993 to 1995 identified neighbourhoods in Karachi disproportionately affected by homicide. As a step toward developing intervention programmes to curb violence, we conducted a study to identify risk factors for becoming a homicide victim in a high violence area of Karachi.

Methods We interviewed families of 35 cases, individuals intentionally killed through acts of violence between January 1994 and January 1997, and 85 community-based controls frequency matched by sex, from Orangi, a high violence area of Karachi.

Results Most of our cases and controls were male (97% and 92%, respectively) and had similar socioeconomic and ethnic backgrounds. All the victims were killed by firearms; 4 (11%) had been tortured prior to death. Most of the victims were killed in the streets (n = 25, 71%). Of these, 7 (36%) had been killed by law-enforcement officers, while 6 (24%) died from indiscriminate firing. People who were killed were 34 times more likely to have attended all political processions (29% versus 1%, odds ratio [OR] = 34; 95% CI: 4–749, P < 0.001), 19 times more likely to have attended political meetings (31% versus 2%, OR = 19; 95% CI: 4–136, P < 0.001), and 17 times more likely to have held an important position in a political party (29% versus 2%, OR = 17; 95% CI: 3–120, P < 0.001) than controls.

Conclusions Homicide in Orangi was political. Efforts to improve trust between ethnic groups and to build legitimacy for non-violent forms of conflict resolution are important steps to limit future violence.

Keywords Political violence, homicide, Pakistan, risk factors for homicide, organized violence, ethnicity

Accepted 29 November 2001


    Introduction
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Homicide, defined as fatal injuries inflicted by another person with intent to injure or kill,1 causes over 500 000 deaths per year worldwide.2 According to ambulance service data in Karachi, Pakistan, between October 1993 and January 1996, 4091 people sustained violent injuries and were subsequently transported to a medical facility. Of these, 2400 (58%) died en route to a hospital emergency room, hence becoming homicide victims. Of these victims of violence, 95% were males under the age of 30 years, and 46% of the violent injuries were sustained in only 4 of the city's 41 neighbourhoods.3 These four neighbourhoods were dominated by a single ethnic group,3 Mohajirs, people and their descendents who had migrated to Pakistan at the time of partition from India in 1947.

Homicide is a common endpoint of many different behavioural pathways4 including arguments between acquaintances, escalating domestic violence between spouses, robberies perpetrated by strangers and organized political violence. Organized violence is violent behaviour that strives to achieve the specific political, economic, or social objectives of a social or political group.5

The different behavioural pathways of homicide call for different preventive strategies. As a step toward developing sound preventive strategies, we conducted a study to identify group characteristics of homicide victims, and to evaluate risk factors for homicide at the individual level in a high violence, low socioeconomic area of Karachi, Pakistan. We hypothesized that homicide in these neighbourhoods was a result of organized political violence and so people who were politically active would be at increased risk of homicide.


    Methods
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 Abstract
 Introduction
 Methods
 Results
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We conducted a case-control study in Orangi, the largest squatter settlement in Karachi with an estimated population of 1.2 million.6 While there are a number of ethnic groups settled in this area, Mohajirs, which literally means refugees, the Muslim immigrants from India who emigrated to Pakistan in 1947 at the time of the partition of Muslim Pakistan from India, are the predominant ethnic group. Ambulance records note that Orangi had the second highest number of individuals with intentional injuries from 1993 to 1995.3 These included 243 people who were either dead at the scene or died during transport to the hospital. Their mean age was 32 years (range 6–85); 97% were male and 93% were killed by a firearm (Habib Chotani, personal communication). We chose to study Orangi, rather than Korangi a similar squatter settlement, but with the highest number of violent injuries, because the Orangi Pilot Project, a trusted community-based organization, was willing to co-operate with the project. The Orangi Pilot Project is a non-governmental organization which has focused primarily on developing low cost sanitary latrines and sewer lines in Orangi using local financial and managerial resources.6 Their principle methodology involves identifying leaders in the community, providing them training in community organization and technical details, and then providing ongoing guidance and supervision. In addition to improved sanitation, community development efforts have been expanded to include a low cost housing programme, primary health care, family planning and a micro credit programme to support small family enterprises. Through its years of service in the community, the Orangi Pilot Project is generally trusted by the community, and this made the study team's access to people's homes and discussion of the sensitive subject of homicide possible. In some areas where the Orangi Pilot Project was not as active, Orangi Pilot Project representatives introduced the study team to other community-based organizations that identified a few additional cases.

We defined cases as individuals who lived in Orangi and were killed in Orangi between January 1994 and January 1997, due to intentional violence, by firearms, sharp or blunt trauma.

Karachi's municipal government divides Orangi into 103 neighbourhoods. We focused on identifying cases in the 15 neighbourhoods within Orangi, which Orangi Pilot Project workers identified as the highest violence neighbourhoods in the area. Field workers from the Orangi Pilot Project directly identified households within these neighbourhoods where they knew someone had been killed. In a few cases they also contacted other social organizations in the community to help identify homicide victims they were aware of in the community. The study team was introduced to each household which had suffered a homicide by members of the Orangi Pilot Project or other community-based organizations.

A prior study had already demonstrated that being a male aged 20–40 years was a risk factor for violent injury.3 We were interested in understanding specific behaviours that put this group at risk.

We recruited controls from a subset of households enrolled in a related study conducted at the same time in the same 15 neighbourhoods. The objective of this related study was to evaluate the health burden of violence in these communities. The Orangi Pilot Project provided maps and population estimates of the 15 neighbourhoods they characterized as ‘high violence'. The sample size for the Burden of Violence Study was 350 households. The Burden of Violence Study team calculated the number of households to be approached per neighbourhood proportional to the population in each neighbourhood. A point on each neighbourhood map was randomly chosen as the starting point for the neighbourhood. The study team approached the closest house to the identified starting point and if household participants consented, interviewers completed a burden of violence questionnaire. Next, the study team identified the fourth closest house, and requested their participation in the study. This process was repeated until the prescribed number of households in that neighbourhood had been approached. The control questionnaire for this risk factor case-control study was administered to the first household in each neighbourhood that participated in the burden of violence study, and then every fourth participating household from each neighbourhood.

The interview team designated any individual in the 18 to 60-year age group in the household as a control, provided there were no other family members that fitted the case definition. They enrolled one female control for every nine male controls, because previous studies suggested that males were nine times more likely to be victims of violence than females.3 When there was more than one potential control in the same family, the interview team chose the head of the family or the eldest child depending on who was in the 20 to 40-year-old age category. All the cases and controls were enrolled between November 1996 and January 1997.

We attempted to administer the questionnaire to the wife of the study subject; if she was inaccessible or unwilling to participate, we administered the questionnaire to the wife of the head of the household. Since the controls were not enrolled as pairs with the cases, though they came from the same general neighbourhoods as cases and were frequency matched assuming an age structure and sex ratio similar to ambulance data available at the initiation of the study, we conducted a non-pair matched analysis. We compared the prevalence of potential risk factors between cases and controls using odds ratios (OR), calculated CI using maximum likelihood estimates, and evaluated the probability of random sampling error using the {chi}2 test or the t-test as appropriate. To evaluate if the associations between political involvement and homicide were a result of confounding by age, we calculated an age-adjusted OR by stratifying the analysis for people above and below the median age of the study population (30 years), and calculating a maximum likelihood estimate summary OR and exact CI. We used Epi-Info7 software for all statistical calculations.


    Results
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
Of 37 cases identified by community organizations in high violence areas of Orangi, 35 (95%) agreed to participate in the study. Of the 350 households approached in the burden of violence study, 309 (88%) consented to participate. All 85 households who participated in the burden of violence study and who were asked, agreed to be interviewed as control households for the case-control study. Thirty-four (97%) of the cases and 78 controls (92%) were males. The mean age of the cases was 27 years (range 16–60 years) and they had completed an average 7 years of education. Most of the cases worked as tailors (18%), unskilled factory workers (18%) or had been unemployed (15%). Their mean personal income was 3000 rupees (US$65) per month. They came from households with an average of nine members and a median household income of 6000 rupees (US$ 129) per month. Within the family, the son of the head of the family was most often the victim (71%) followed by the head of the family (20%). Controls were a mean 5 years older than cases, but had a similar socioeconomic background (Table 1Go). Although family sizes of cases and controls were similar, case households had more sons (2 versus 1.5; P < 0.001). Most of the cases and controls were ethnically Mohajirs (94% and 93%, respectively).


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Table 1 Socioeconomic status of homicide victims versus controls in Orangi, Karachi, Pakistan, 1995–1997
 
All 35 victims were killed by firearms. Four (11%) were tortured prior to death. Methods of torture included beating with wires and ropes, breaking of limbs, cigarette burns and drilling of holes in the eyes and body. Most of the victims were killed in the street (n = 25, 71%), 7 (28%) reportedly by law-enforcement personnel, and 6 (24%), including the only female case, by indiscriminate firing (i.e. apparently random firing by unknown assailants). Twelve cases (31%) were arrested prior to the incident; 3 (25%) of whom were subsequently killed while in police custody. None of the cases had a previous history of being injured due to violence, nor did any come from households in which such injuries had occurred.

Individuals who were killed were 13 times more likely to be an active member of a political party (OR = 13; 95% CI: 2.9– 62.9; P < 0.001). By almost all measures of participation, cases were substantially more likely to be involved in political activities than were controls (Table 2Go). For example, people who were killed were 34 times more likely to have frequently attended political processions, 19 times more likely to have attended political meetings, and 17 times more likely to have held an important position in a political party. Adjusting the analysis for the age difference between cases and controls did not substantially affect these results (Table 2Go).


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Table 2 Involvement in political activities as a risk factor for homicide in Orangi, Karachi, Pakistan, 1995–1997
 
People who were killed in Orangi were six times more likely to have been previously arrested than controls (65% versus 35%; OR = 6.0; 95% CI: 1.8–21; P < 0.001). Similarly, cases were 12 times more likely to come from families in which another family member had been arrested (80% versus 20%; OR = 12; 95% CI: 2.2–91; P < 0.001).

Among people who were politically active, those who were killed were no more likely to be arrested than controls (45% versus 66%; OR = 0.42; 95% CI: 0.1–9.7; P = 0.52). However, among those who were not politically active, people who were killed were much more likely to have been arrested (25% versus 5%; OR = 6.5; 95% CI: 1.4–31.7; P = 0.003).


    Discussion
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 Abstract
 Introduction
 Methods
 Results
 Discussion
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The epidemiology of homicide in Orangi is most consistent with organized political violence. All of the risk factors significantly associated with becoming a homicide victim (attending a political procession, attending a political meeting, being considered a community leader and holding an important position in the local political party) were measures of political activity. Organized political violence is consistent with 46% of the violent injuries in the city being isolated to four of the city's 41 neighbourhoods that are Mohajir dominated enclaves.3 Cases and their families were much more likely to be arrested than controls. Amnesty International reports that unrecorded arrests and interrogation are commonly used in Karachi to intimidate political opponents.8

The competition for political power in Karachi is divided along ethnic lines, principally between the Mohajirs who emigrated in 1947 and the native Sindhis.9 Glazer and Moynihan suggest that the root of contemporary ethnic conflict typically lies in competition for control of the finite economic resources of the state.10 Gallagher notes the central role that political leaders play in fomenting ethnic conflict.11 Political leaders often distort or selectively interpret history to create an ethnic myth to mobilize their constituency. They appeal to this ethnic myth to legitimize what are basically personal, political or common material interests. In Karachi the conflict between Mohajir and the Sindhi ethnic group became more violent in the mid 1980s with the end of martial law and open competition for control of governmental power.8

Zwi and Ugalde describe a cycle of political violence where repressive violence is directed by the state at people living within it, usually when a government attempts to rule not in the interest of the nation as a whole, but in order to serve the political or economic objectives of a small ruling elite.5,12 Opposition groups, lacking the constitutional means of expressing their views, resort to terrorism. Although not a part of this study, terrorism by Mohajir groups against Sindhis and other government supporters is well documented.8 Governments launch repressive campaigns to reaffirm their authority, using state terror, disappearances, torture and indiscriminate killings, which in turn leads to an escalation of violence, and counter violence with spill-over effects on other communities and strains on the bonds that sustain civil society.5,12,13 Indeed, in this study, a minority of all homicide victims were politically active.

There are important limitations to this study. First, this study focused on a single area of Karachi and the dynamics of homicide in this area may not be representative of the causes of violence throughout the city. Indeed, there was not as much diversity in ethnicity and socioeconomic status as would be found if neighbourhoods throughout Karachi were studied. Thus, ethnicity as distinct from political activity, and poverty may be risk factors for homicide. However, there was substantial variation in socioeconomic status within Orangi, and we found no difference in income, occupation, or education among cases and controls.

A second limitation is that Orangi was a politically charged community. Some of the contacts who helped us identify homicide cases likely had strong political sentiments and may have been particularly aware of politically active people who were murdered, and so these may have been over-represented among cases. However, since the Orangi Pilot project and the other community-based organizations that identified homicide cases were not political organizations we would not expect them to disproportionately identify homicides of politically active people. Indeed, the parameters available for comparison—age, sex, and percentage of victims killed by firearms—were similar between homicide victims enrolled in the case series and those listed in ambulance data from Orangi. Moreover, there is no available objective method to identify all homicide victims in Karachi. Previous studies of road traffic injuries in Karachi, for example, demonstrated that police records identified only 56% of the deaths and 4% of serious injuries.14 We chose to have the organizations closest to the community identify the homicide victims.

A third limitation of the study is that all information for the case's homicide was collected from family members. Family members were often not eyewitnesses and the people supplying information to families may have been biased in reporting events, especially in the identification of the perpetrators of the homicide.

A fourth limitation is that the families who contained the individuals killed might have been less threatened by reporting political activity than families with living people. However, considering that both cases and controls lived in extended family households and had other sons alive, we believe that they were equally likely to be forthcoming in their accounts of the political affiliations of family members.

The political situation in Karachi has changed since this study. An election replaced the civilian government in February 1997, and a military coup removed the civilian government in October 1999. The number of homicides in Karachi, which peaked in 1998, has reportedly decreased 10-fold in 1999/2000.15 Nevertheless, this study demonstrates that ethnic and political tensions in Karachi represent an ongoing risk for violence. Efforts to improve trust between ethnic groups, and build legitimacy for non-violent forms of conflict resolution will be important steps to limit future violence.


KEY MESSAGES

  • Prior studies in Karachi, Pakistan demonstrated that males aged 20–40 years were at greatest risk of becoming homicide victims.
  • This study, conducted in a high violence neighbourhood in Karachi, found that homicide victims were much more likely to be politically active than controls of similar age and sex.
  • This suggests that organized political violence contributes importantly to homicide in Karachi.

 


    References
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 
1 World Health Organization. Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death. Vol. 1. Geneva, Switzerland: WHO, 1997.

2 Reza A, Mercy JA, Krug E. Epidemiology of violent deaths in the world. Injury Prevention 2001;7:104–11.[Abstract/Free Full Text]

3 Chotani H, Razzak J, Luby S. Patterns of violence in Karachi, Pakistan. Injury Prevention (In press).

4 Rosenberg ML, Mercy JA. Assaultive violence. In: Rosenberg ML, Fenley MA (eds). Violence in America, a Public Health Approach. New York/Oxford: Oxford University Press, 1991, pp. 14–50.

5 Zwi A, Ugalde A. Towards an epidemiology of political violence in the third world. Soc Sci Med 1989;28:633–42.[CrossRef][ISI][Medline]

6 NGO profile: Orangi Pilot Project. Environment and Urbanization 1995; 7:227–36.[ISI]

7 Dean A, Dean J, Coulombier D et al. Epi Info Version 6 [computer program]. Atlanta (GA): Centers for Disease Control and Prevention, 1995.

8 Amnesty International. Pakistan: Human Rights Crisis in Karachi. February 1996. Available from URL: http://library.amnesty.it/aidoc_everything.nsf/Index/ASA330011996

9 Malik I. State and Civil Society in Pakistan. London: Macmillan Press Ltd, 1997.

10 Glazer N, Moynihan DP. Why Ethnicity? In: Colburn DR, Pozzatta GE (eds). America and the New Ethnicity. Port Washington, NY/London: National University Publications, Keenikat Press, 1979, pp. 29–42.

11 Gallagher T. My neighbor, my enemy: The manipulation of ethnic identity and the origins and conduct of war in Yugoslavia. In: Turton D (ed.). War and Ethnicity. Rochester, NY: University of Rochester Press, 1997, pp. 47–76.

12 Zwi A, Ugalde A, Political violence in the third world: a public health issue. Health Policy Planning 1991;6:203–17.[ISI]

13 Horowitz D. Ethnic Groups in Conflict. New York: University of California Press, 1985.

14 Razzak J, Luby S. Estimating deaths and injuries due to road traffic accidents in Karachi, Pakistan through the capture-recapture method. Int J Epidemiol 1998;27:866–70.[Abstract]

15 Project Ploughshares, Armed Conflict Report 2000. Available from URL: http://www.ploughshares.ca/content/ACR/ACR00/ACR00-Pakistan.html