When it comes to the health and welfare of the people of Pakistan, Pakistan has become a laboratory for the concepts of political economy put forward by Rev. Malthus almost two hundred years ago. Malthus believed that population growth will eventually outstrip supply of food and produce famine and death.

The crisis predicted by Malthus has not happened yet and all evidence suggests that at this time the amount of food being produced is more than enough to feed the existing population of the world. If any starvation exists, it is due to misdistribution.

Even Pakistan produces enough food to feed its population. That said, inadequate caloric intake is still a major problem for a majority of Pakistanis. The reason is not availability but rather the inability to buy food. Most Pakistanis subsist on two dollars or less a day. That in itself creates a serious problem when it comes to buying adequate amount of food for an average family living at or below the poverty line.

When Malthus presented his point of view, life was much simpler and of course much worse. Infant mortality even among the wealthy was high, infectious disease was prevalent and overall life expectancy was relatively short. But medical advances over the last two centuries have increased life expectancy considerably due to two major improvements. A decrease in child mortality and the decrease in mortality from infectious disease including things like small pox and tuberculosis.

So, in a strange way, even though we have the capability to feed most of our population in Pakistan, inadequate nourishment and inadequate healthcare have emerged as two major causes of death and disability. Recent studies done in the west suggest that inadequate nourishment, though not lethal leads to children that grow up into adulthood but have a lesser intellectual and physical capacity than they would have had if they were adequately fed while growing up.

Lack of appropriate healthcare is, however, an insidious and in its own way as bad a problem as inadequate caloric intake. Pakistan has one of the highest rates of maternal and child mortality in the world. But then even for the survivors, healthcare becomes a major issue.

For a family living under or around the poverty line, treatment for even the most basic medical problems can lead to further impoverishment. If we just take Diabetes, Hypertension (high blood pressure) and Hepatitis C -- three diseases of which we have an epidemic of sorts in Pakistan -- all three are either preventable or easily treatable in the early periods. But once established, the treatment is expensive.

The question then is why the government in Pakistan and its provinces don’t provide basic healthcare for its population. In 1971 when Pakistan broke up, what was then East Pakistan (now Bangladesh) had a population of ten million more than that of West Pakistan or what is Pakistan today. Today Pakistan has 30 million more people than Bangladesh (population of Karachi and Lahore). The second problem is the ‘priorities’ of successive governments in Pakistan.

The governments of Pakistan over the last 40 years have made little, if any, attempt to control population growth and at the same time have not devoted adequate financial resources towards public health. The problem in today’s world unlike that when Malthus presented his ideas is that now people do not just live on bread alone.

The concept of "The Social Contract" as originally presented by the philosophers of the enlightenment like Hobbes, Rousseau and Locke depended primarily on the concept of ‘security’. In the modern world the ‘contractual’ obligations now go beyond physical safety and include adequate supply of food, healthcare, and education for all.

The basic fact of life in Pakistan is that if our population keeps growing at its present rate, we will eventually reach a point where our production of food as well as our ability to keep our people healthy will become entirely inadequate and create a Malthusian nightmare.

The majority of Pakistanis are poor and are already threatened by lack of adequate nutrition and once you add on the burden of healthcare many of them will start dying from poverty made worse by the need to spend money on medical treatment. The choice between medicine to live and food to survive is a terrible choice.

Even if the malnourished and unhealthy children grow up into adulthood, they will not able to contribute as an effective labour force towards the economic development of the country and eventually will become a burden on society. No government in Pakistan has recently taken on the issue of population growth and at the same time has done anything significant to provide basic necessities for the poor people of this country. Increasing income inequality is aggravating this problem even further.

The recent suggestion by Prime Minister Nawaz Sharif to provide ‘health insurance cards’ and a previous similar suggestion by his younger brother, the chief minister of the Punjab, are both entirely bizarre. All citizens of Pakistan deserve adequate healthcare at least at the basic level. This includes food security, maternal and child health, immunisation, preventive care and treatment of common medical conditions that, if diagnosed early, can be controlled at a relatively low cost.

And yes, most Pakistanis already have a ‘health card’. It is called a Computerised National Identity Card (CNIC) for all adults and a children registration certificate (CRC) for minors. Creating another layer of identification is unnecessary. The real problem is whether any government of Pakistan with the resources available to it can provide the basic amenities mentioned above to all citizens. The answer is a qualified yes at least as far as healthcare is concerned.

Based upon a report published by the Health Department, Government of the Punjab, in 2007 and authored by the then minister for health, in the Punjab there exists a network of Basic Health Units (BHU) in every ‘union council’ (2456), Rural Health Centres (RHC-292), Tehsil HQ Hospitals (THQH-65), District Headquarter Hospitals (35) and the multiple tertiary care teaching hospitals in the major cities.

If we take the three basic primary care centres, the BHU, RHC and the THQH, these essentially provide care to a majority of the people of the Punjab. Sadly many of these facilities are under or inappropriately staffed, inadequately equipped and often rendered incapable of working effectively because of pervasive corruption (ghost RHCs and BHUs).

All the RHCs and the BHUs were ‘evidently’ built in the nineteen sixties with money provided by United States Agency for International Development (USAID). Since then no new RHC or BHU has been built. However, we have seen new medical colleges, heart centres, transplant centres and other facilities coming up but this network of basic health for the poor people has been ignored.

Politicians prefer to build edifices to immortality. But improving small little rural healthcare facilities that make the lives of ordinary and often poor people a little bit better clearly offers no such opportunity.

My advice to our national and provincial leaders is to take a few minutes to read Shelley’s poem, ‘Ozymandias’.