Health and Welfare
In 1992 some 35 million Pakistanis, or about 30 percent of the population, were unable to afford nutritionally adequate food or to afford any nonfood items at all. Of these, 24.3 million lived in rural areas, where they constituted 29 percent of the population. Urban areas, with one-third of the national population, had a poverty rate of 26 percent.
Between 1985 and 1991, about 85 percent of rural residents and 100 percent of urban dwellers had access to some kind of Western or biomedical health care; but 12.9 million people had no access to health services. Only 45 percent of rural people had safe water as compared with 80 percent of urbanites, leaving 55 million without potable water. Also in the same period, only 10 percent of rural residents had access to modern sanitation while 55 percent of city residents did; a total of 94.9 million people hence were without sanitary facilities.
In the early 1990s, the leading causes of death remained gastroenteritis, respiratory infections, congenital abnormalities, tuberculosis, malaria, and typhoid. Gastrointestinal, parasitic, and respiratory ailments, as well as malnutrition, contributed substantially to morbidity. The incidence of communicable childhood diseases was high; measles, diphtheria, and pertussis took a substantial toll among children under five. Although the urban poor also suffered from these diseases, those in rural areas were the principal victims.
Despite these discouraging facts, there has been significant improvement in some health indicators, even though the population grew by 130 percent between 1955 and 1960 and between 1985 and 1990, and increasing from 50.0 million in 1960 to 123.4 million in 1993. For example, in 1960 only 25 percent of the population had purportedly safe water (compared with 56 percent in 1992). In addition, average life expectancy at birth was 43.1 years in 1960; in 1992 it had reached 58.3 years.
Maternal and Child Health
The average age of marriage for women was 19.8 between 1980 and 1990, and, with the rate of contraception use reaching only 12 percent in 1992, many delivered their first child about one year later. Thus, nearly half of Pakistani women have at least one child before they complete their twentieth year. In 1988-90 only 70 percent of pregnant women received any prenatal care; the same proportion of births were attended by health workers. A study covering the years 1975 to 1990 found that 57 percent of pregnant women were anemic (1975 to 1990) and that many suffered from vitamin deficiencies. In 1988 some 600 of every 100,000 deliveries resulted in the death of the mother. Among women who die between ages fifteen and forty-five, a significant portion of deaths are related to childbearing.
The inadequate health care and the malnutrition suffered by women are reflected in infant and child health statistics. About 30 percent of babies born between 1985 and 1990 were of low birth weight. During 1992 ninety-nine of every 1,000 infants died in their first year of life. Mothers breast-feed for a median of twenty months, according to a 1986-90 survey, but generally withhold necessary supplementary foods until weaning. In 1990 approximately 42 percent of children under five years of age were underweight. In 1992 there were 3.7 million malnourished children, and 652,000 died. Poor nutrition contributes significantly to childhood morbidity and mortality.
Progress has been made despite these rather dismal data. The infant mortality rate dropped from 163 per 1,000 live births in 1960 to ninety-nine per 1,000 in 1992. Immunization has also expanded rapidly in the recent past; 81 percent of infants had received the recommended vaccines in 1992. A network of immunizations clinics--virtually free in most places--exists in urban areas and ensures that health workers are notified of a child's birth. Word of mouth and media attention, coupled with rural health clinics, seem to be responsible for the rapid increase in immunization rates in rural areas. By 1992 about 85 percent of the population had access to oral rehydration salts, and oral rehydration therapy was expected to lower the child mortality.
Health Care Policies and Developments
National public health is a recent innovation in Pakistan. In prepartition India, the British provided health care for government employees but rarely attended to the health needs of the population at large, except for establishing a few major hospitals, such as Mayo Hospital in Lahore, which has King Edward Medical College nearby. Improvements in health care have been hampered by scarce resources and are difficult to coordinate nationally because health care remains a provincial responsibility rather than a central government one. Until the early 1970s, local governing bodies were in charge of health services.
National health planning began with the Second Five-Year Plan (1960-65) and continued through the Eighth Five-Year Plan (1993- 98). Provision of health care for the rural populace has long been a stated priority, but efforts to provide such care continue to be hampered by administrative problems and difficulties in staffing rural clinics. In the early 1970s, a decentralized system was developed in which basic health units provided primary care for a surrounding population of 6,000 to 10,000 people, rural health centers offered support and more comprehensive services to local units, and both the basic units and the health centers could refer patients to larger urban hospitals.
In the early 1990s, the orientation of the country's medical system, including medical education, favored the elite. There has been a marked boom in private clinics and hospitals since the late 1980s and a corresponding, unfortunate deterioration in services provided by nationalized hospitals. In 1992 there was only one physician for every 2,127 persons, one nurse for every 6,626 persons, and only one hospital for every 131,274 persons. There was only one dentist for every 67,757 persons.
Medical schools have come under a great deal of criticism from women's groups for discriminating against females. In some cities, females seeking admission to medical school have even held demonstrations against separate gender quotas. Males can often gain admission to medical schools with lower test scores than females because the absolute number for males in the separate quotas is much greater than that for females. The quota exists despite the pressing need for more physicians available to treat women.
The government has embarked on a major health initiative with substantial donor assistance. The initial phase of an estimated US$140 million family health project, which would eventually aid all four provinces, was approved in July 1991 by the government of Pakistan and the World Bank, the latter's first such project in Pakistan. The program is aimed at improving maternal health care and controlling epidemic diseases in Sindh and the NorthWest Frontier Province. It will provide help for staff development, particularly in training female paramedics, and will also strengthen the management and organization of provincial health departments. The estimated completion date is 1999. The second stage of the project will include Punjab and Balochistan.
In addition to public- and private-sector biomedicine, there are indigenous forms of treatment. Unani Tibb (Arabic for Greek medicine), also called Islami-Tibb, is Galenic medicine resystematized and augmented by Muslim scholars. Herbal treatments are used to balance bodily humors. Practitioners, hakims, are trained in medical colleges or learn the skill from family members who pass it down the generations. Some manufactured remedies are also available in certain pharmacies. Homeopathy, thought by some to be "poor man's Western medicine," is also taught and practiced in Pakistan. Several forms of religious healing are common too. Prophetic healing is based largely on the hadith of the Prophet pertaining to hygiene and moral and physical health, and simple treatments are used, such as honey, a few herbs, and prayer. Some religious conservatives argue that reliance on anything but prayer suggests lack of faith, while others point out that the Prophet remarked that Allah had created medicines in order that humans should avail themselves of their benefits. Popular forms of religious healing, at least protection from malign influences, are common in most of the country. The use of tawiz, amulets containing Quranic verses, or the intervention of a pir, living or dead, is generally relied upon to direct the healing force of Allah's blessing to anyone confronted with uncertainty or distress.
Smoking, Drugs, and AIDS
Smoking is primarily a health threat for men. Nearly half of all men smoked in the 1970s and 1980s, whereas only 5 percent of women smoked. Twenty-five percent of all adults were estimated to be smokers in 1985, with a marked increase among women (who still generally smoke only at home). The national airline, Pakistan International Airlines (PIA), instituted a no-smoking policy on all its domestic flights in the late 1980s. In an unusual departure from global trends, PIA reversed this policy in mid1992 , claiming public pressure--despite no evident public outcry in newspapers or other media. Men also take neswar, a tobacco-based ground mixture including lime that is placed under the tongue. Both men and women chew pan, betel nut plus herbs and sometimes tobacco wrapped in betel leaf; the dark red juice damages teeth and gums. Both neswar and pan may engender mild dependency and may contribute to oral cancers or other serious problems.
Opium smuggling and cultivation, as well as heroin production, became major problems after the Soviet invasion of Afghanistan in 1979. The war interrupted the opium pipeline from Afghanistan to the West, and Ayatollah Ruhollah Khomeini's crackdown on drug smuggling made shipment through Iran difficult. Pakistan was an attractive route because corrupt officials could easily be bribed. Although the government cooperated with international agencies, most notably the United States Agency for International Development, in their opium poppy substitution programs, Pakistan became a major center for heroin production and a transshipment point for the international drug market.
Opium poppy cultivation, already established in remote highland areas of the North-West Frontier Province by the late nineteenth century, increased after World War II and expanded again to become the basis of some local economies in the mid1980s . Harvesting requires intensive labor, but profits are great and storage and marketing are easy. The annual yield from an entire village can be transported from an isolated area on a few donkeys. Opium poppy yields, estimated at 800 tons in 1979, dropped to between forty and forty-five tons by 1985, but dramatically rose to 130 tons in 1989 and then 180 tons in 1990. Yields then declined slowly to 175 tons in 1992 and 140 tons in 1993. The area under opium poppy cultivation followed the same pattern, from 5,850 hectares in 1989 to 8,215 hectares in 1990. It reached 9,147 hectares in 1992 but dropped to 6,280 the following year. The caretaker government of Moeen Qureshi (July to mid-October 1993) was responsible for the reductions in production and area under cultivation; the succeeding government of Benazir Bhutto has perpetuated his policies and declared its intent to augment them.
Use of heroin within Pakistan has expanded significantly. The Pakistan Narcotics Control Board estimates that although there were no known heroin addicts in Pakistan in 1980, the figure had reached 1.2 million by 1989; there were more than 2 million drug addicts of all types in the country in 1991. This dramatic increase is attributed the ready availability of drugs. There were only thirty drug treatment centers in Pakistan in 1991, with a reported cure rate of about 20 percent.
Acquired immune deficiency syndrome (AIDS) has not yet been much of a problem in Pakistan, probably as a result of cultural mores constricting premarital, extramarital, and openly homosexual relations. The effect of poor quality control on blood supplies and needle sharing among addicts is undetermined. The government has been slow to respond to the threat posed by AIDS. Cultural and religious restrictions prevent official policies encouraging "safe-sex" or other programs that would prevent the spread of the disease. State-run radio and television stations have made no attempt to educate the public about AIDS. In fact, the government has minimized the problem of AIDS in the same way that it has dealt with potentially widespread alcoholism by labeling it as a "foreigners' disease."
The Ministry of Health, however, has established the National AIDS Control Programme to monitor the disease and to try to prevent its spread. During 1993 twenty-five AIDS screening centers were established at various hospitals, including the Agha Khan University Hospital in Karachi, the National Institute of Health in Islamabad, and the Jinnah Postgraduate Medical Center. AIDS screening kits and materials are provided free at these facilities. By early 1994, approximately 300,000 people in Pakistan had been tested.
A center for AIDS testing has also been established at the Port Health Office in Keamari harbor in Karachi. Another is expected to open during 1994 at Karachi Airport. Beginning in 1994, all foreigners and sailors arriving in Pakistan will be required to have certificates stating that they are AIDS-free. Certificates of inspection are already required of Pakistani sailors. All imported blood, blood products, and vaccines must also be certified.
Zakat as a Welfare System
Social security plans were first introduced in the 1960s but have never achieved much success. Traditionally, the family and biradari have functioned as a welfare system that can be relied on in times of need based on reciprocal obligations.
In 1980, as a part of his Islamization program, Zia introduced a welfare system, known as the Zakat and Ushr Ordinance. Based on the Islamic notion of zakat, the aim was to forge a national system to help those without kin. The Zakat and Ushr Ordinance combined elements of the traditional Islamic welfare institution with those of a modern public welfare system. The ordinance's moral imperative and much of its institutional structure were directly based on the Quran and the sharia.
As a traditional religious institution, zakat involves both the payment and the distribution of an alms tax given by Muslims who enjoy some surplus to certain kinds of deserving poor Muslims (mustahaqeen). The traditional interpretation by the Hanafi school of religious law stipulates that zakat is to be paid once a year on wealth held more than a year. The rate varies, although it is generally 2.5 percent. Ushr is another form of almsgiving, a 5 percent tax paid on the produce of land, not on the value of the land itself. Both zakat and ushr are paid to groups as specified in the Quran, such as the poor, the needy, recent converts to Islam, people who do the good works of God, and those who collect and disburse zakat.
The Zakat and Ushr Ordinance set broad parameters for eligibility for zakat, which is determined by local zakat committees. Priority is given to widows, orphans, the disabled, and students of traditional religious schools. Eligibility is broad and flexible and presumes great trust in the integrity, fairness, and good sense of the local zakat committees. Although the program initially focused on providing cash payments, it gradually has moved into establishing training centers, especially sewing centers for women. By 1983 the zakat program had disbursed more than Rs2.5 billion to some 4 million people. The program, however, has come under a great deal of criticism for the uneven manner in which funds are disbursed.
Shia have vociferously criticized the program on the basis that its innate structure is built around Sunni jurisprudence. Shia leaders successfully have championed the right to collect zakat payments from members of their community and to distribute them only among Shia mustahaqeen.
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