Health is not just the absence of disease. As I started studying medicine, our purpose was thought to be to prevent and then treat different diseases. But the one thing few of us ever considered as a part of the medical domain was the general condition that people lived in.

Yes we read how overcrowding facilitated the passage of infections from one person to another. We learned that a poor diet with absence of vitamins could lead to specific medical conditions and that absence of Iodine in food caused ‘cretinism’. And that poor sanitation led to cholera and dysentery epidemics. Yet no attempt was made to put it all together by our teachers.

But then as I went into practice and actually started thinking about disease in a more general fashion especially after I started writing for this newspaper, I realised the obvious that all the conditions that I mentioned above that lead to disease and many others like them were connected to each other. And the connection is poverty.

Even the rich get sick. And indeed we all will die one day. However, in medicine we also work on the assumption that some deaths can be delayed. Or that what we refer to as ‘premature’ deaths can be prevented. In the case of the relatively well-off one thing that helps them out in medical terms is education with which comes knowledge and information.

I am almost inclined to call poverty a disease that needs to be treated just like high blood pressure or diabetes. As medical planners we concentrate on providing the poor with medical help when they get sick. Nothing wrong with that but what happens after we cure them and then send them home?

Poverty alleviation is and must be the primary aim of all governments. How it can be done depends on different types of government systems. And no I am not going to go into that. But two simple measures can tell us what is happening. Population growth compared with the growth of the national GDP (gross domestic product).

Simply put, if the GDP is significantly higher than the rate of population growth then we can presume that the people in a developing country are probably getting less poor (richer?). Sadly that does not seem to be happening in Pakistan. And the relatively recent loud claims and plans to control population growth have, as expected, died down without much notice.

The point I am trying to make today is that even if we keep trying to provide better healthcare for the poor, in the larger scheme of things the overall improvement in how the poor live is not going to be very apparent. That of course does not mean that we should not even try and make better healthcare available to all those that need it.

Let me just summarise some of the areas of medical interventions that make people live longer. The beginning is of course when a woman becomes pregnant with a child. She for starters needs to be physically mature enough to carry and deliver a child. Then she needs adequate nutrition and medical care including tests and diagnosis for possible problems and complications that can occur during pregnancy.

The next step is the birth of a child. Here I am all for child birth at home but only after it has been determined that the delivery is expected to be normal. Even so, medical assistance must be available in case of problems like difficult delivery and post-delivery bleeding.

Childbirth has historically been the most dangerous time in a woman’s life as well as that for the newborn, and human life expectancy started improving a century ago when women and children dying at this time became less frequent.

For the child the first month and then the next few years are vital for long term survival. Breastfeeding over the first two years of a child’s life has been shown to improve growth and decrease the chance of ‘stunting’. Here modern interventions like ‘immunisation’ (vaccination) against many childhood diseases are important.

However, most important is availability of nutrition that not only provides adequate calorie intake for a child but also a varied diet that includes all the vital ‘micronutrients’ (vitamins and minerals). At this tender age children are most vulnerable to diseases transmitted primarily through contaminated drinking water.

So, clean drinking water and ‘sanitation’ become important needs. The conditions that can be transmitted through contaminated drinking water include intestinal worms, typhoid, Hepatitis A, dysentery, and cholera. Even adults are not immune to these problems but it is children that are most susceptible to severe problems if infected or infested.

Once children start going to school or intermingling with other children, communicable diseases become important and here the childhood immunisation plays an important role in preventing diseases like measles.

Also overcrowding and multiple family members living and sleeping in the same area can cause transmission of other diseases like tuberculosis (TB). Fortunately, it is not a problem in Pakistan but in the West, during the early part of the last century, overcrowding and living in ‘tenements’ was a medical problem due, amongst other things, to lack of access to sunshine leading to a disease like ‘rickets’.

So now the child has grown into a teenager and eventually an adult. It is education, employment and ability to feed adequately that becomes the next vital need.

I presume that most poor people that work for a living or work at home are active enough and not well fed enough to develop the major problem of the rich and the well to do, and that is ‘obesity’.

But even without obesity, the poor can still develop many chronic problems like high blood pressure, diabetes and if they were unfortunate enough to get treated with injections by village or small town ‘quacks’, the major scourge in Pakistan of Hepatitis C.

Having escaped into adulthood, even the poor need regular medical checkups to diagnose problems early enough while they are still easily treatable. But this treatment does require lifelong medicines and medicines cost money. During my medical practice in Pakistan I have seen poor patients that essentially had to make a choice between taking medicines regularly or else feeding their children.

Another problem that poverty breeds is the need to have many children. For the poor, children especially boys, are like an old age pension. And girls being a ‘burden’ are therefore married off as early as possible leading to child marriages and child pregnancies with its inherent medical problems.

Besides these common problems, it is the poor that smoke cigarettes and tobacco products most often leading to severe lung problems as they get older. In short being poor is an overall problem and all the medical interventions I have mentioned above can and should be provided to all those that need them but that costs a lot of money and needs a lot of manpower.

If Pakistan can afford all these services including jobs that provide a living wage for all, then Pakistan will have become a developed country. Until then poverty will remain Pakistan’s major healthcare problem.