South Asia, a vast region stretching from Bangladesh to Afghanistan, has produced and exported respected medical professionals, research findings and innovations with universal reach. The poor record in domestic health care in almost every one of the seven countries in the region is a different story.
The British medical journal The Lancet reopened discussion this summer in an editorial, urging the new prime minister of Pakistan, Imran Khan, to prioritize the nation’s health in his inaugural address.
“Full immunization rates are below 50% in many areas and the prevalence of stunting in children younger than 5 years is over 40%,” the editorial said of Pakistan. “The country has the highest rate of neonatal mortality in the world, with one in 22 babies dying in the first 28 days of life. . . . In the past decade, Pakistan has spent only 0·3–0·8% of its gross domestic product per year on health (WHO’s benchmark is at least 6%).”
It isn’t only Pakistan troubling the region’s health care. South Asia recently made a poor showing in a survey of 195 counties and self-governing territories, judged on a scale of 0-to-195 (from great to awful). The rankings were measured by 32 causes of death that should be preventable with the right medical care.
It was mostly a race to the bottom by South Asians, despite improvements here and there, as they were ranked in the latest Global Burden of Disease Study 2018. The report was produced with funding by the Bill & Melinda Gates Foundation and published by The Lancet.
In the region, only Sri Lanka and the Maldives ranked with middle-income countries such as Thailand, Malaysia and numerous Latin American nations. The scores were 71 for Sri Lanka and 72 for the Maldives. (Among richer Southeast Asian and East Asian nations, by comparison, Japan, Singapore and South Korea ranked in the top 25. )
Bangladesh and Bhutan scored 133 and 134, respectively. From there it went downhill. India ranked at 145, Nepal at 149 and Pakistan, worst of all, at 154, just above a couple of dozen sub-Saharan African countries, small island states, plus Laos and Haiti, the poorest nation in the Americas. Afghanistan, an ungovernable nation trapped in unending civil war, fell near the bottom with a rank of 191.
In September, the Indian government of Prime Minister Narendra Modi announced its intention to provide free health insurance to 100 million poor families, up to the equivalent of $7,800 in expenses. The government, which faces a national election in 2019, also said it would spend $188 million to establish health and wellness centers. India’s population is more than 1.3 billion, and media commentators there have questioned whether the government can afford to keep these promises.
Analysts have offered many reasons why countries in the Indian subcontinent, several born in post-colonial optimism after World War II, have found economic, political and human development elusive. It is fashionable in the region to continue blaming the British seven decades after they left. But Malaysia and Singapore were British colonies, too.
Singaporeans regale visitors with tales of what a pestilential jungle their island nation was before Stamford Raffles in the 19th century and Lee Kuan Yew, a century later, took over. In Pakistan, people speak gloomily about how their country and South Korea were close to an economic par in the 1950s.
Cultural attitudes and the social policies that reflect them are often analyzed in South Asia, along with gaps in health care. This is especially relevant to women and girls. Child brides, honor killings and, in India, aborting female fetuses may all be against the law but continue in some regional countries. Girls lag in education and grow up ill equipped to contribute to national economic and social development. Women are missing out on screening for cervical and breast cancers and are often denied access to family-planning services and contraceptives.
Ironically, two of the most advanced thinkers in the world to promote women and girls have been Pakistanis. Nafis Sadik, a physician and executive director of the United Nations Population Fund (UNFPA) from 1987 to 2000, was a fierce defender of women’s rights. In 1994 in Cairo, she pushed the International Conference on Population and Development to redefine women’s roles in the family and society. She turned UNFPA from a family-planning organization into a force for a woman’s right to take control of her body, including the right to choose an abortion in countries where it is legal and medically safe.
Another Pakistani, Mahbub ul Haq, a founder of the UN’s human development reports, devised, with the Indian economist Amartya Sen, a new way to measure poverty, often focusing on women.
In November 2017, a conference held at the Aga Khan University in Karachi, Pakistan’s largest city, debated what is holding back Pakistani girls. A recurrent theme was that their lives were entrenched by male dominance. Dr. Zulfiqar Ahmed Bhutta, a founding director of the Center of Excellence in Women and Child Health at the university, called it a perpetual, feudal “patriarchal mindset.”