Daily Times

We live in an unfair world. Nothing seems fair or equitable right from the time we are born. The great English writer Charles Dickens summed up this sentiment well in one of his novels. “In the little world in which children have their existence whosoever brings them up, there is nothing so finely perceived and so finely felt, as injustice. It may be only small injustice that the child can be exposed to; but the child is small, and its world is small —.” Dickens would also say: “The sum of the whole is this: walk and be happy; walk and be healthy. The best way to lengthen out our days is to walk steadily and with a purpose.” In saying so, he was telescoping what physicians and public health practitioners would be saying a century and a half after his death. In one of his most famous speeches the legendary human rights activist Martin Luther King Jr. remarked, “Injustice anywhere is a threat to justice everywhere.” A couple of years before his assassination, he had remarked, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” King was, in effect, eloquently reminding the world of the raison d’etre for the creation of the World Health Organization on April 7, 1948 with a strong affirmation that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.

Winston Churchill was a war time Prime Minister of Britain. At the height of the World War II when bombardment of London was the norm and his aides were painting a doomsday scenario, Churchill asked, “Are the courts functioning?” and when informed in the affirmative he said, “then nothing can go wrong.” At another point he would remark,“Healthy citizens are the greatest asset any country can have.” Here was a man whose country was facing an existential threat, yet the considerations of justice and health apparently weighed more on his mind than the might of his arsenals. Dickens, King and Churchill were three very different stalwarts with hardly any shared interests, yet they were saying the same things.

Scores of years later, both Health and Justice figure prominently among the 17 Sustainable Development Goals to be achieved by 2030 by all the United Nations’ member states. What is more, public health and human rights are mutually reinforcing forces, inextricably linked to each other. Global Health and Public Health aim to bridge the differences or inequities in the health status of men, women and children due to considerations of race, religion, political belief, economic or social condition.

The implementation of human rights also necessitates a cross-sectoral approach that increases synergy amongst the various sectors relevant to promote health and development and avoid fragmented interventions

As we observe World Health Day today with the theme – ‘Building a fairer, healthier world’, we are all the more conscious than ever of the health inequities confronted globally. And no, not even the major world powers, can claim to be devoid of them as some of them have been the hardest hit by the COVID-19 pandemic, which has thoroughly exposed their lack of preparedness and overwhelming their relatively strong health systems in relation to the developing world. What is more disparaging, however, is the scramble for vaccines against the pandemic by the rich nations at the cost of the poorer ones.

In Pakistan that has quite sub-optimal health and demographic indicators with a growing disparity between the privileged and under-privileged classes, a shrinking middle class and millions more on the brink of falling down the poverty line due to catastrophic health expenditures, it is all the more important to emphasize the health and human rights nexus. When we examine some of the causes of health inequities the foremost among them are social determinants of health such as income poverty, unemployment, lack of basic education, particularly in rural females, gender and human rights issues, an almost unchecked population growth, lack of road safety, low coverage of essential services such as safe water and sanitation, rapid urbanization with urban slums, inadequate though expanding measures for social protection, and a high prevalence of natural and manmade disasters.

The COVID-19 pandemic has had a devastating impact on certain priority health problems such as the silent pandemic of tuberculosis, maternal and child health, nutrition and immunization. Some time ago, a seminar was held in Islamabad with the support of the Stop TB Partnership advocating the accessing of TB care services as an inalienable human right. Celebrities were engaged at Stop TB ambassadors to promote civil society engagement

There is also a growing realization that implementing a Tuberculosis control program involves all tiers of the health system including the community level and can strongly complement efforts toward attaining universal health care. Meanwhile, WHO was asked by the United Nation’s high level meeting held in 2018 to assist countries in developing a multi-sectoral accountability framework involving all sectors as a prerequisite to better End-TB outcomes.

It is therefore imperative to conduct intersectoral planning and action involving the government and other stakeholders to proactively address social determinants and health inequities. Intersectoral action needs to be promoted as an integral and vital component of the national health planning process. Without intersectoral action as a fully integrated component embedded in the national health planning process, health inequities are likely to persist, imperiling the health of Pakistan’s population.

It is also important to sensitize policymakers on the concepts of inequality and inequity in health, measuring equity, and development of the strategies designed to effectively address health inequities. Incidentally it was the celebrated economist and Finance Minister of Pakistan the late Dr Mahbubul Haq who is said to have given the world the concept of Human Development Index by merging three critical measure of well-being namely per capita income, longevity, and literacy. Equity is often considered as synonymous with social justice or fairness, and is an ethical concept grounded in the principles of distributive justice. It also denotes the absence of socially unjust or unfair health disparities.

Underlying social deprivation can be in relation to wealth, power or prestige – attributes that define how people are grouped in social hierarchies. A disproportionate number of poor citizens in Pakistan do not have adequate access to health care. Health inequities can also result from geographical, gender, ethnic, social, political, cultural or linguistic disparities.

Rapid urbanization in Pakistan also has grave implications for health warranting the need for meticulous planning. Even the hitherto fore planned capital city of Islamabad, with an annual population growth of 5%, is beginning to suffer from unplanned growth with the quality of life in its urban slums being miserable and much worse than those living in peripheral rural areas. Increasing urbanization gives rise to a unique set of health challenges, including non-communicable and infectious diseases, air pollution, access to water and sanitation, the need to improve nutrition, increased physical activity, and building resilience to health emergencies.

The implementation of human rights also necessitates a cross-sectoral approach that increases synergy amongst the various sectors relevant to promote health and development and avoid fragmented interventions. This is also necessary to fulfil an internationally agreed set of principles and norms that are contained in treaties, conventions, declarations, resolutions, guidelines, and recommendations at the international and regional levels.

Pakistan has to be very proactive in ending gender discrimination, such as denying girls and women access to education, information, and various forms of economic, social and political participation, as this can significantly increase health risks. Attention to human rights also brings into focus less popular vulnerable groups like prisoners, miners, migrants, refugees and substance abusers where some interventions have been carried out by the TB and HIV/AIDS control mechanisms.

Education and information can promote understanding, respect, tolerance and non-discrimination in relation to persons with Tuberculosis and other communicable and non-communicable diseases with which some stigma is attached. Public programming explicitly designed to reduce the stigma by challenging beliefs based on ignorance and prejudice has been shown to help create a more tolerant and understanding supportive environment.

Within the Health Sector, the negligible efforts demonstrated to prevent and control noncommunicable diseases is intriguing as it has been an integral part of public policy in Pakistan ever since 2004. We can start by establishing population based cancer registries to inform the establishment of cancer control programs, while taking effective measures for diabetes control, institutionalizing preventive cardiology in health programs while containing chronic respiratory diseases. All these diseases make up the larger part of the disease burden spectrum and are responsible for a lot of excess and premature mortality across the country, disproportionately affecting women and marginalized population segments.

While the current drive of the government to provide health cards to the people in certain pilot districts is highly laudable as an interim poverty reduction measure, it can be sustained and institutionalized by implementing mandatory health insurance in the country through premiums or co-payments in which the rich can cross-subsidize the poor, while those in good health can cross-subsidize those in ill health. Other social safety nets such as Zakat, Baitul Maal and other interventions under the Ehsaas program need to be enhanced in an effort to strengthen the middle class to promote food security and avoid catastrophic health costs till such time as the economy can stand on a firm footing. Good governance is of essence to the whole exercise encompassing affirmative action in enhancing health allocations to a respectable level in keeping with government policy and must be regarded as an investment in the future.

Everything said and done, the need for maintaining peace and tolerance cannot be over-emphasized if the social sectors including Health have to prosper in Pakistan to the immense benefit of not only our country but the region as a whole. Emotive rhetoric has distracted us from our main goals for too long, let us now be guided by Mr. Jinnah who stated in unequivocal terms: “Our object should be peace within and peace without. We want to live peacefully and maintain cordial friendly relations with our immediate neighbours and with the world at large.” No advice can serve us better in building a fairer and healthier country with justice for all.

The author is a senior public health and public policy specialist of Pakistan and can be reached at gnkaziumkc @gmail.com