The people we are made of
I have an obsession with numbers. They epitomise knowledge in many ways and surveys give us a plethora of numbers and figures to handle and realize the reality of various beliefs and problems in our society. Although social science research remains limited in the country, the surveys conducted by the government do present us with some figures to assess. However, these are almost always never expounded upon and besides the obvious press release that states the executive summary of the reports, the entire news media and blogosphere never addresses them.
In that very spirit, I thought that I should highlight the worrisome state of health in our country. Numbers such as health indicators have never been a good sign in the land of the pure. They show where we have failed, where we continue to fail and wherein the perils just about to explode, lie.
Today the nation suffers a vast number of crises ranging from terrorism, rising inequality, health, education and population welfare to a myriad of others. While my aim is not to discuss the socio-politico reasons of the problems we are facing in these fields, I do realize that thinking about the reasons and addressing them is necessary as well.
I’ll try to compare Pakistan with different countries in the region when it comes to health. When I refer to neighbouring countries, I am excluding Afghanistan since a country ravaged by war for three decades is not one I want to compare ourselves to.
Firstly, let’s take a look at the state of child healthcare in Pakistan. According to the PDHS 2006-07, infant mortality stands at 78 per thousand births and under-five mortality stands at 94 per thousand births. That means that one out of every 13 children born in our country dies before their first birthday, and another 3 die before their fifth. The trouble is that these numbers have not decreased by much either. In 1990, these were 91 and 117 respectively, therefore roughly a 17 per cent decrease in both which is not remarkable keeping in mind the fact that we started the Lady Health Workers program during that time.
As expected, urban-rural differences, financial well-being and interval between child births have a direct correlation with infant and child mortality in the country. In short, if you’re born in a major urban area to a financially well-off family which practices family planning, you have a fairly higher chance of surviving childhood than your other counterparts who were born by the accident of their birth into not-so-lucky families. If you’re born into the lowest wealth quintile, you’re twice as likely to be dead by the first birthday compared to your rich counterparts. As socio-economic status is inexplicably tied to the state of child healthcare, children in Balochistan are eight times as likely as children in Punjab to never have received any immunisation.
Where do we stand
Comparing ourselves with other countries presents a horrible picture. The global averages are 46 and 67 respectively, meaning that on average eight out of every 1000 children born would have survived had they been born anywhere outside Pakistan and another 53 would have survived had they been born in Sri Lanka. We have by far the highest child and infant mortality rates in the whole region. Nepal had the same state of affairs in 1990. Today, the numbers are 41 and 51 respectively, identifying massive improvements. At the time of partition, Bangladesh fared far worse than us. Today, the numbers are 43 and 58 respectively and this is tied to improvements in the second problem I want to identify: fertility rate.
Fertility rate can be defined as “the average number of children a woman would have if she went through her entire reproductive period (15-49 years).” It therefore is an indicator of the state of family-sizes in the country and the success of family planning programs. This number today stands at 4.1 women per children and the horrifying fact is that it is not decreasing as rapidly as we’d like it to. In fact, the 4 is the “ideal number of children” according to 36.4 per cent of women, a far cry from “do bachay hi achay”.
Comparing ourselves with other countries demonstrates our failure at addressing our population problems. In 1968, Pakistan and Bangladesh had a near exact fertility rate of 6.9 children per women. Starting in the 1980s, Bangladesh’s population control measures have brought down this number to 2.34 - a remarkable achievement within forty years. In 1981, Pakistan and Iran had the near exact number of 6.6 children per women. Iran’s massive efforts have brought down this number to a remarkable 1.81 children per women, while ours is still above 4. This is of course tied to the fact that while the Islamic Republic of Iran promotes family planning at the state level like ours, the religious elites in their country (who are part of the state apparatus) promote and enforce population control measures unlike our case where the religious groups vilify population control measures.
Family-planning, a conspiracy against Islam
Deeming family-planning as haram and a Jewish conspiracy aimed at eliminating the growth of Islam, are mainstream views. I have myself heard a maulvi sahib of the “ummah ki kasrat” crowd telling people that Jews want to promote reduction in family sizes in order to control the burgeoning Muslim population and bearing a greater number of children is a praise worthy deed and he invoked the belief that “rizq Allah hi deta hai.” As I questioned him on the fact that schools, hospitals, sewerage systems and social welfare have to be supported by the state and that is dependent on the productivity and economic well-being of its populace which would be affected by the rising populations, he went on an anti-immunisation and anti-iodised salt rant as well. Maulana Fazlullah was not an isolated incident. Urban middle class often resonate the same views often about immunisation. In fact, I happen to have read a pamphlet stating that iodised salt and polio vaccines are conspiracies to sterilise Muslim males so as to reduce the population of the “ummah.” Although I reported the case to the Ministry of Health, it is beyond my understanding how such views can be spread openly.
Nutrition and the polio endemic
We are amongst the only four countries where polio is endemic and we were the last ones to eliminate small pox as well. Iodine deficiency is a massive problem in villages just twenty minutes from Islamabad. According to the last nutritional survey, carried out in 2001-02, 36.5 per cent of mothers and 23 per cent of pre-school children suffered from severe iodine deficiency. It would then be alarming that only 17 per cent of households use iodised salt in the country, especially since iodine deficiency is the single biggest cause of preventable mental retardation. The advertisements for iodized salt became eponymous with public health advertisements in the mid ‘90s. With the state of public health not improving, public health campaigns should have been a top priority. However, public health advertisement has steadily died down since '97 and reached the lowest point in the middle of the previous decade. There were no longer any lady health worker advertisements, iodine mila namak ads and the polio-vaccine ads were rare as well besides the near absence of family planning ads. The family planning ads have surfaced again since late 2008, but public health warnings and advice on television is still absent compared to what could be seen in the mid '90s. Moreover, I have heard my friends, and in one case a practising dentist, complain that advertisements for contraceptives make them feel “uncomfortable” when they’re sitting with their families. I guess that our exploding population and the coming economic problems owing to this are less important than the “comfort” factor for our urban elites.
Provincial demographics give us unique insight into the prevailing ideas and success of programs. The national level fertility has reduced by 24.1 per cent since 1990. However, it has only reduced by 15.7 per cent in Sindh. The greatest decrease in fertility has been in Balochistan (29.3 per cent) and the rural-urban divide has become massive with major city urban areas showing a 36.2 per cent decrease compared to 19.6 per cent for rural areas. As expected, education qualification of mothers and financial well-being is directly correlated to lower fertility. In fact, women from the highest income quintile have half the number of children compared to the lowest income ones. The economic value of children in rural areas can be understood. However, in urban areas people belonging to lower income groups should have smaller family sizes. Here, we have religious and social factors which influence decisions.
Education and population
Education, financial well-being and urban-rural divide have little or no correlation to birth intervals. However, it is astonishing that the average birth interval between child births is the highest in Balochistan and lowest in Punjab since it goes against the perception that the most under-developed province would have the most worrisome performance. Women in Balochistan are the oldest at marriage in the country and education qualification has a high correlation to delay in marriage throughout the country. Contraceptive use however, is lowest in Balochistan and the mean “ideal number of children” is a whopping 5.9. Across the nation, the wanted fertility rate is 3.1 compared to the actual 4.1. Elimination of unwanted births in the country would decrease fertility and control population growth by quite a bit then. Maternal Mortality presents one of the biggest challenges in our country. The number stands at an abysmal 297 deaths per 100,000 live births and women in Balochistan are three times as likely to die compared to women in Punjab during childbirth.
Even though contraceptive use has increased since the mid ‘80s, it is still abysmally low at 30 per cent and has in fact decreased since the previous survey by 2 per cent, even though 96 per cent know about at least one method of contraception. While this might be an anomaly, I personally cannot rule out the correlation between rising religiosity and decreased use of contraceptives. In Iran, 73 per cent of women use contraceptives and in Bangladesh the number is 58 per cent. Global statistics suggest that state programs aimed at promoting contraceptive when successful have massive effect even when the religious groups deem them unacceptable. This suggests that our programs have failed.
The most alarming indicator is that 28.4 per cent of the women who did not use contraceptives stated their reason to be the will of God and 10 per cent reported their husband’s opposition as the reason. Keeping in mind that the working classes have the lowest percentage of adoption of family planning methods, it would be obvious that they be the target of the population control programs. Surprisingly, only 14.6 per cent of women in the lowest quintile of income reported to have been visited by a lady health worker. Within the three years of the past surveys, unmet needs of family planning increased by 4 per cent and the survey itself states that “it is clear that urgent attention of policymakers is required to minimize unmet need by transforming it into met need.”
The diseases that plague us
Although the Ministry of Heath's National Programme for Prevention and Control of Hepatitis (NPCHV) states that the prevalence of Hepatitis B is between 3-4 per cent and that of Hepatitis C is between 5-6 per cent, this appears to be a grossly under-reported number. HCB prevalence according to most studies is now between 6-7 per cent and HCV prevalence is reaching 15 per cent nationally. Even more alarming is that HCV is more likely among women. It would then be difficult to imagine awhy only 44 per cent of the country’s population knows about HIV or AIDS and only 5.1 per cent have a comprehensive knowledge (ways to prevent, common misconceptions) about these issues.
Keeping all these horrifying numbers in mind, it would be no surprise that we have the highest population growth rate in the region as well. At an estimated 2.1 per cent, we continue to add 3.5 million people to the country’s population every year i.e. nearly ten thousand people every day. We simply have failed to control this population growth rate compared to all neighbouring countries that seem to have realised that controlling population growth is a primary task in riding the economic development train. Perhaps we can learn something from Iran or our former eastern wing that seem to have risen to the challenges.
Need for an efficient policy
The state of health in Pakistan is abysmal, horrifying and deeply worrying. Our population control measures have not lived up to the expectations we had and should have wished for. Countries in our neighbourhood seemed to have grasped the problem and tackled it very effectively. Population control is a primary task when it comes to healthcare since a developing country can address the needs of only a limited number of people. It is expected that within the next 35 years our population would double in size and urbanization is expected to increase as well. Where would be fit so many people? How would we feed so many people, especially since prime agricultural land is being doled out to gated elite communities (DHA Lahore being a prime example)? How will we be able to send so many children to school? How can the state support such an economic challenge?
This requires an efficient and socially acceptable population control policy and the Population Policy of Pakistan 2010, prepared by the Ministry of Population Welfare seems to have identified and addressed all major problems. Like most of our rosy legislations and programs, enforcement remains a distant dream. To address these challenges, social attitudes need to change and the public needs to understand the problems that we are likely to face in the future. Demographic momentum is not suggesting a very bright future for us. It would perhaps not to be a dictatorial move to enforce a ‘twochildren per family’ policy through tax credits, social welfare and any other measures. The problems lie before us, it’s time we start addressing them.
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