lice: Would you tell me please, which way I ought to go from here?

The Cheshire Cat: That depends a good deal on where you want to get to.”

— Alice in Wonderland

A few days ago, a friend called from Islamabad. She was worried about her elderly mother-in-law, a widow who lives alone in Lahore. After a recent fall, she had broken her hip. She had a surgery and was sent home. A week later, in addition to the trauma of a major surgery, she now had a fever, and did not feel like eating. She was generally unwell. My friend and her husband, both professionals with high-pay jobs were frantic. They did not know who to contact in Lahore. In any case, the patient needed immediate as well as long-term care for her ongoing medical needs. Fortunately, I was able to introduce them to the right people in Lahore and a minor crisis was averted. But this is an affluent family with all the right connections as well as the financial resources to access whatever healthcare services are available. Millions of working families in Pakistan do not have the luxury of high incomes and have, in fact, been rapidly immiserated over the last few years with Pakistan’s economy taking a nose dive. With a semblance of political stability now in place, the news is dominated by a new financial rescue package from abroad. This time, we are told, it will be “long term” as if that were a cause to celebrate. The next few years promise more financial pain for the people of Pakistan and, as always, when people have to choose between groceries, household bills and healthcare, they will cut back as much as possible on healthcare. If a medical emergency arises it will invariably entail higher costs compared to preventive care.

April 7 was designated World Health Day in 1948 by the World Health Organisation’s World Health Assembly – the forum through which the WHO is governed by its 194 member states. World Health Day has been celebrated since 1950. The theme for this year is: My Health, My Right. The WHO sets forth various goals and objectives for improving global health. As of 2022, these include things like universal health coverage, emergency preparedness, health for all ages, prevention and treatment of non-communicable diseases and maternal and child health. Pakistan has made some progress over the recent decades in many of these areas but significant challenges remain in areas as diverse as control of infectious diseases such as polio, tuberculosis, hepatitis and HIV; and non-communicable diseases such as mental health conditions. Our maternal and child health indicators are still far below our neighbours, let alone advanced countries. We did a reasonably good job of responding to the biggest public health emergency of the 21^st Century in the shape of the Covid-19 pandemic but our healthcare system lacks the capacity to address future challenges. Our progress on promoting health for all ages is also patchy with high rates of child malnutrition and unacceptably high rates of mortality from many commonly preventable childhood illnesses such as measles.

As a practicing psychiatrist and mental health professional, stories about people, regardless of age, being unable to access quality mental health services in Pakistan are too numerous to recount: young people from smaller cities and towns who need mental health support and care to complete their school and college education but are unable to access such services; women with severe mental health issues compounded by lack of access to basic reproductive health services; families with vulnerable and ill elders who need help with eldercare (like my friend mentioned earlier), the list goes on. Interestingly, the legislative framework to build these services has been in place for more than 50 years. The 1973 constitution states unequivocally that the provision of “basic necessities” including healthcare, education and social security for all citizens is the responsibility of the state. Several articles of the constitution spell it out in more detail but the basic message is quite clear: the law of our land already mandates that the state must provide all basic health amenities to Pakistan’s citizens as spelled out by the WHO, of which Pakistan is a member. How to do this is a matter of debate and discussion but the government cannot abdicate its basic responsibility without repudiating the constitution and its global commitments.

Every country in the world is struggling with its own challenges regarding healthcare but one thing is clear: selling healthcare as a profit-making enterprise is a disaster as evidenced by America, which consistently spends more on healthcare per capita and has worse healthcare outcomes on things like life expectancy, infant mortality etc than many other countries. America’s neighbour to the south – much hated by successive American governments – Cuba, has shown that the opposite: a robust publicly funded healthcare system can outperform a private, for-profit healthcare on most measures while also being much more sustainable in the long-term.

Of course, Cuba managed to overthrow both feudalism and capitalism under their revolutionary leadership in the global turmoil after World War II and has managed to stay the course on socialist development despite intense pressure from its northern neighbour. It is also no accident that Pakistan’s 1973 constitution was formulated and passed by a democratically elected, nominally ‘socialist’ government following the trauma of a ‘second partition.’ Is that possible in our current budgetary and political straitjacket of international financial bondage enforced by repressive governments at home? Time will tell.

The writer, a psychiatrist, is a faculty member at King Edward Medical University. He is the author of Faiz Ahmed Faiz: A Biography, Sang-e Meel Publications, 2022. His X handle: @Ali_Madeeh