Posts Tagged ‘Bangladesh’

Healthcare: Dubious Distinctions

March 20, 2018

By Samia Altaf

Two recent reports about Pakistan’s health system tell of deficiencies of far reaching significance.

The first, from UNICEF, confers on Pakistan the dubious distinction of registering the highest number of deaths in newborns (neonatal mortality) in the past decade. It is now number one in the world, climbing from number three, and ahead of Afghanistan and the Central African Republic. The second, a National Nutrition Survey, informs that 45% of Pakistan’s children are stunted, suffering from chronic, extreme, and irreversible malnourishment that causes permanent physical and cognitive deficiencies. What would this half of future generations be capable of with its severely limited capacity to learn even if the opportunity for education is available? It would fall sick much quicker and get better a lot slower creating a permanent burden on the already constrained health service delivery system.

The situation in other areas of healthcare, though not part of these reports, is equally grim. Measles continues to be endemic with 6,494 cases last year in Pakistan compared to 1,511 in poor Afghanistan and 513 in war-torn Syria. This is a stinging indictment of the national Expanded Program on Immunization, underway since 1988, which provides 50% coverage when 90% is minimum needed for herd immunity. Maternal mortality, deaths in women due to pregnancy related events, continues to be unacceptably high — 286 per 100,000 nationally and 786 in Balochistan. Deficiencies in large city hospitals with patients dying in hospital corridors or refused treatment have forced the CJP to step in the mess that should be cleaned by the Ministry of Health. The story of spurious drugs and the problems of DRAP are too familiar to need recounting.

Isn’t it remarkable that the marked decline in health outcomes has been accompanied by a sharp increase in the number of medical colleges and universities, hospitals, doctors, nurses, and midwives. Advances in technology and fancy apps have facilitated diagnosis and treatment. Donors continue their generous funding — Punjab has received a $65 million grant from DFID and the loan of an equal amount from the World Bank. This has  led to the current reform of the ministry of health — two ministers instead of one and two secretaries instead of one.

What is going on? Is it that we still don’t have enough doctors for our population? It is true that the doctor to patient ratio is half that recommended by the WHO. But then, why are so many young doctors unemployed? Why are so many people going to non-doctors? China’s population is five times that of Pakistan. Its Infant Mortality Rate (deaths in children under one year) is 12, seven times less than Pakistan’s and its Maternal Mortality Rate is 27, ten times lower. Yet, China has never tried to get its doctor to patient ratio up to the number recommended by the WHO.  

“The state needs to take charge,” exhorts an editorial in this newspaper (28.2.2018). But the state is firmly in charge. New programs are launched every few months and plans to control communicable diseases in children and provide services to women are articulated in documents PC-1s. Frenzied activity is manifested in fancy new programs such as the health card scheme, the formation of public companies to manage hospital waste, the engagement of expensive foreign consultants, all amidst regular pronouncements from government officials. The state has a panel of technical experts — eminent doctors working in its system — that has been advising governments for the past many decades and continues to do so now. The results speak for themselves. Why would future results be any different if the same experts continue as advisors?  

There are two sets of problems. First, there is no mechanism to critically evaluate the  recommendations of the experts to determine if they are in the interest of citizens or in the self interests of the experts. No oversight is provided either by citizens or by their representatives who either do not know how to monitor or don’t sufficiently care about the situation. Ironically, suo moto notices by the Court call on the same set of experts to provide answers to the problems they should be held accountable for.

Second, the Ministry of Health lurches from one leaking hole-in-the-dyke to another driven by donor is offering funding, bright ideas of dignitaries, or explanations called forth by the judiciary. There is no overarching systemic vision compatible with the country’s constraints and challenges, none that has stood the test of time, regime-change, or public scrutiny. The mindset that survives is that more is better – more consultants, more doctors, more beds, more ministries. The results are staring us in the face as documented in the reports mentioned above.  

Solutions at the margins in the absence of a robust public health system will not resolve the healthcare crisis. Just as more flyovers and underpasses cannot stay ahead of traffic congestion if the city continues to sprawl, increasing the number of doctors or hospitals cannot make up for the growing burden of disease in an unhealthy environment. Take air pollution as an example, where, on average, the exposure of Pakistanis to critical particulates is 6.5 times the safe level recommended by WHO. Asides from adding to morbidity, air pollution killed about 60,000 Pakistanis in 2012 making the country the fifth-deadliest in that category. Here too, we could be vying for first place with the commissioning of numerous coal-based power plants across the country.

The task is by no means impossible and much can be achieved with a simple focus on the provision of clean air, clean drinking water, safe sanitation, a critical education, and gender equality. In 2012, the Infant Mortality Rate in Bangladesh was less than half that of Pakistan’s although the rates were comparable in 1990. This remarkable progress in Bangladesh has occurred despite the fact that it is only two-thirds as affluent as Pakistan in terms of per capita income.    

The Pakistani story has been one of neglecting the basics and channeling funds to intermediaries on half-baked schemes that yield no benefit to citizens. The global rankings provide evidence that is impossible to refute.

The writer is a public health physician and author of So Much Aid, So Little Development: Stories from Pakistan. This opinion appeared in Dawn on March 19, 2018 and is reproduced here with permission of the author.

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Pro-People Policies are Possible in Poor Polities

May 16, 2016

By Anjum Altaf

How much of a useful story can be told with very few numbers?

Look at just one indicator of public welfare, the Under-5 Mortality Rate, in Pakistan, India, and Bangladesh: 86, 56, and 41, respectively in 2012.

The U5MR, which gives the number of children dying between birth and five years of age per 1,000 live births, is a very useful indicator because it captures the effect of many risks to life that occur during the crucial first five years of life – disease, poverty, malnutrition, etc.

What should jump out at the reader is that the 2012 U5MR in Bangladesh is less than half that in Pakistan? Asides from asking how that is possible, this striking statistic should trigger a whole host of related questions.

Let us examine a few obvious ones by way of example. Is it the case that this difference is related to geography, i.e., that the U5MR in Bangladesh was always less than that of Pakistan for climatic reasons. Here are the values in 1990 for the three countries in the same order: 138, 126, and 144. They are roughly in the same range with Bangladesh actually being worse than Pakistan.

Is it the case that Bangladesh is a much richer country compared to Pakistan and has been able to allocate its greater wealth to the improvement of the life chances of the majority? Here are the figures for the Gross National Income per capita in 2012 (in US $) for the three counties in the same order: 1260, 1530, 840. Bangladesh is roughly two-thirds as affluent as Pakistan and yet has a U5MR of less than half.

So what is the explanation for the rapid improvement in the survival rate of children in Bangladesh between 1990 and 2012? A scientifically acceptable answer to this question requires a statistical analysis that controls for all the possible factors that might be relevant. Notwithstanding that, it seems reasonable to assert that the difference does not stem from locational advantage or greater affluence. In all likelihood it is related to some variations of policy. That is the rationale for the claim that pro-people policies that make a difference to the lives of the impoverished majority are possible at low levels of income.

Let us look at one such policy without definitively claiming that it is the causative factor in the observed difference. By way of a speculative hypothesis I have selected the percentage of households forced to resort to open-air defecation, i.e., without access to any form of latrine: In 2015, the percentages for Pakistan, India, and Bangladesh were 21, 50, and 1, respectively. Even accounting for the imprecision of such numbers that is a stunning difference. And to ascribe it very clearly to policy it helps to refer to the fact that the corresponding percentage for Bangladesh in 2003 was 42, i.e., in the same league as the other two countries.

I have selected open-air defecation for a reason. It is well known that it leads to fecal transmission of preventable diseases like diarrhea. But diarrhea has other negative health impacts even when it does not kill directly. For example, chronic diarrhea undermines almost entirely the utility of nutrition programs like school meals. Addressing malnourishment requires meeting physiological needs with sufficient calories and nutritional needs with a balanced diet but it is usually forgotten that these work only when the diet is retained. Persistent diarrhea weakens the retention of food leading to death by other causes.

This observation alone should highlight the importance of a sound public health system. It is only when most people are healthy that a curative care system can function. If most people are exposed to systemic causes of disease the curative system would be overwhelmed as it is in Pakistan.

An analogy should make this clear. In a polluted river one would expect unhealthy fish. Taking all the fish out, nourishing them back to good health, and releasing them back in the same river would be an exercise in futility. Yet, that is the very thing we are doing with human beings.

The fact that public health does not seem to be in the news in developed countries is because they have long ago ensured a healthy base by eliminating systemic preventable diseases. What we see now are the incredible advances in curative care. But, as should be obvious, one cannot put the cart before the horse. The explosion in the number of hospitals and hospital-based physicians in Pakistan is yet another example of misplaced priorities.

The essential pillars of sound public health are safe drinking water and sanitation. If we really care for our people that is where we should be directing our attention and resources. Bangladesh has shown that it is possible to do so in a poor country.


This opinion was published in Dawn on 15 May, 2016 and is reproduced here with permission of the author.

For a remarkable piece written almost exclusively in words beginning with the letter ‘p’, see: PPP Prattle

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Faiz – 2: Bangladesh – An Apriplum

December 19, 2015

By Anjum Altaf

Remembering is one thing; not forgetting another. One of the dates we should not forget is December 16, 1971.

My contribution to not forgetting is an attempt to capture the spirit of Faiz Ahmed Faiz’s Dhaka se Waapsii par, a poem Faiz wrote a few years after the event.

As I have written before (Faiz – 1: The City), I am not attempting a translation, something virtually impossible to manage from Urdu into English. Faiz Sahib’s words in this regard provide the best counsel (in Faiz Ahmed Faiz on Daud Kamal):

“Translating poetry, even when confined to a cognate language with some formal and idiomatic affinities with the original compositions, is an exacting task, but this task is obviously far more formidable when the languages involved are far removed from each other in cultural background, rhythmic and formal patterns, and the vocabulary of symbol and allusion as Urdu and English.”

I lean more towards the sentiment expressed by the John Washington, a translator from Spanish (here). Do keep in mind that he is saying this about prose, not poetry:

“Translating is an act of decontextualization, of deracinating a work and attempting to replant it in foreign soil. The act leads to crossbreeding, to mutation, and to the exposure of unintended or unrecognized aspects of the original—to apriplums and other strange flowerings.”

My own test of a credible translation is very simple: It has to stand on its own as a poem in the translated language – whether it is good or bad is secondary.

An example that should make this clear is the Faiz poem Nazim Hikmet: ZindaaN se Ek Khat which is a translation into Urdu of a poem in Turkish by Nazim Hikmet. If you give just the text of the Urdu version to a reader he or she would consider it an original poem in Urdu without any inkling that it was translation from a foreign language. The critical judgement as to its literary merit as an Urdu poem remains a separate issue.

Going from Urdu to English, as Faiz had warned, is virtually impossible – the cultural background, the rhythmic and formal patterns, the vocabulary of symbol and allusion are all alien to each other. Just the structure of the sentence (Subject-Object-Verb in Urdu versus Subject-Verb-Object in English) presents a major hurdle. Consider the rhythm of the following lines from Faiz’s Aaj Baazaar MeiN Pa ba JaulaaN Chalo:

dast afshaaN chalo, mast-o-raqsaaN chalo
khaak barsar chalo, khuuN badaamaN chalo
rah takta hai sab sheher-e jannaN chalo

It seems impossible to reproduce the rhythm that relies so heavily on the repeated verb ending in a language in which a sentence ends with the object, not the verb.

The one thing I would stay away from is to attempt a line-by-line translation but that seems to the norm in almost all translations of Faiz I have seen.

Take Daud Kamal, for example, regarded highly as a poet in English. Some of his translations (in O City of Lights: Faiz Ahmed Faiz – Selected Poetry and Biographical Notes edited by Khalid Hasan. Incidentally, the volume includes a translation of Dhaka se Waapsii par by Khalid Hasan) reflect that strength but there are others where he too gives in to the problem I had mentioned in the earlier post – translating as if Urdu speakers were looking over the shoulder and sitting in judgement.

Consider these lines from Faiz’s celebrated Subh-e Azaadi:

kahiiN to ho ga shab-e sust mauj ka saahil
kahiin to ja ke ruke ga safeena-e dil

Now consider the translation:

Surely, the night’s turgid sea will breathe its last
On the inevitable shore.

Surely, the boat of the heart’s agony will somewhere
Come to a stop.

These lines only become meaningful if one knows the original. For an English reader not familiar with Urdu/Persian/Hindi, “the boat of the heart’s agony will somewhere/ Come to a stop” would convey some literal sense but I doubt if it would pass for moving verse.

Consider this from Tum Apni Karnii kar Guzro:

ab kyuuN us din ka zikr karo
jab dil tukRe ho jaaye ga

And the translation:

Why talk about that day
When the heart will be broken into pieces

The Urdu ‘dil tukRe ho jaana’ conveys a different sense than ‘breaking the heart into pieces’ which is also quite unpoetic in English.

Given these pitfalls that even established poets in English fail to negotiate, it seems prudent to write a poem in English conveying the spirit of the original than to attempt a literal translation that does not resonate with a non-Urdu sensibility.

This is a very long prelude to presenting my version of Dhaka se Waapsii par which appeared in the Economic and Political Weekly on December 19, 2015 (here). Your critical feedback on the poem and on the travails of translation in general would be greatly appreciated.


So often
I have said it to myself
I wish to say it to you
It should not be difficult
But it is

Do you sense
What I am trying to say
Why I cannot say it

Feelings are feelings
Words, words
So much is lost on the way

What would it take
To trust again
To feel
Without the need
To say

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India-Bangladesh: Beyond Cricket

March 19, 2015

By Anjum Altaf

The India-Bangladesh match ended predictably but in Pakistan its off-field resonance was of greater interest. All the ambivalent feelings about India and Bangladesh that are otherwise submerged bubbled to the surface. It was a rich occasion for some casual explorations in social attitudes.

My limited sample revealed two sets of observations – those on which there was relative agreement and those where opinions were more divided. The first set comprised the following:

First, a sense of pride that four South Asian teams had made it to the quarter finals of a major world championship. It was encouraging evidence of a South Asian consciousness amongst people many of whom had not seen more than one or two cities in their own country.

Second, a fairly objective assessment of the quality of the four teams based purely on their track record. Most people ranked India, Sri Lanka, Pakistan, and Bangladesh in that order.

Third, a decidedly calculus-based preference for a Bangladesh victory which would be “better for Pakistan” by yielding an “easier” contest in the semi-finals. It was a commentary on Pakistani optimism that its team was already projected to be in the semi-finals despite the odds of negotiating Australia in Australia. A chorus of Inshallahs settled all doubts.

The following observations belonged to the set of divided opinions:

First, on whom to support in the India-Bangladesh match independent of the implications for Pakistan? A subset didn’t want India to win under any circumstances. At the other end was the opinion that it didn’t matter who won as long as it was good fight.

Second, if India were the only South Asian team left in the semi-finals, should Pakistanis root for it to win the World Cup? Opinion was sharply divided between those who could never support India under any circumstances and those for whom regional affinities held some attraction for one reason or another.

I noted with interest the correlation of education with opinion in my limited sample of fellow viewers. The more educated in the group were more anti-India wanting it to lose every match; the least educated were open to rallying behind India if Pakistan were out of the competition and to wanting the better team to come out ahead. Opinions about Bangladesh were independent of education.

I questioned once again the widespread belief that education is the attribute that leads to openness, tolerance, and objectivity. Its veracity was not borne out in the sample of viewers and confirmed my doubts based on other independent observations. The paradox may have something to do with the changing content of our education. I was reminded of the late Asghar Ali Engineer who posed a rhetorical question (Why is the educated middle-class more bigoted than the illiterate masses?) and pithily answered it himself – “Because it is educated.”

Perhaps it is a blessing that more than half of Pakistan is still illiterate. There is still time to fix our system of education so that a cricket match is just a match and not a psychic extension of war and a means to settle scores.

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Fireflies in the Mist: An Exploration of Bengali Identity

July 21, 2012

By Kabir Altaf

Fireflies in the Mist, Qurratulain Hyder’s own translation of her Urdu novel Aakhir-e-Shab ke Hamsafar, spans the history of East Bengal from the time of the nationalist movement against the British, to the creation of East Pakistan, and finally to Bangladeshi independence. The novel centers around Deepali Sarkar, “a young middle-class Hindu who becomes drawn into the extreme left wing of the nationalist movement, and Rehan Ahmed, a Muslim radical with Marxist inclinations who introduces her to the life of the rural deprived. Their common political engagement draws them into a quietly doomed love affair.  Through their relationship, Hyder explores the growth of tensions between Bengal’s Hindus and Muslims, who had once shared a culture and a history.”

In his introduction to the novel, Pakistani writer Aamer Hussain notes that Fireflies can be seen as another chapter in Hyder’s epic history of the Muslim presence in the subcontinent, and particularly in the era of the Raj. (more…)

On Argumentation

April 7, 2011

There are two aspects of an argument: its content and its construction. On this blog our focus is almost entirely on the latter; the only reason we have content is that we cannot do without it to construct an argument – an argument has to be about something. However, we have no material or emotional stake in the content; it is just a means to an end. In this post we explore in more detail the specifics of the end we have in mind.

There are at least three attributes of the construction of an argument that are critical: Credibility (whether the argument is supported by evidence); Coherence (whether the argument meets the tests of logic); and Consistency (whether the argument is free of contradictions). In order to illustrate these attributes we will resort to content provided by a participant in an earlier discussion. (more…)

Reflections: Literature and Nationalism

June 14, 2010

By Kabir Altaf

She spoke, with fluency, the Urdu of the enemy. She was unable to pretend, as she saw so many others doing, that she could replace her mixed tongue with a pure Bengali one, so that the Muslim salutation, As-Salaam Alaikum, was replaced by the neutral Adaab, or even Nomoshkar, the Hindu greeting. Rehana’s tongue was too confused for these changes. She could not give up her love of Urdu, its lyrical lilts, its double meanings, its furrowed beat.

—Tahmima Anam, A Golden Age, pg. 47

Literature often yields insights into political events in ways that traditional historical accounts cannot. History tells us of war, rebellion, the process of state formation, but the medium’s strength does not lie in describing the complex human emotions that lie behind such events. (more…)

Reflections: Go Mohammedans?

May 22, 2009

Can you tell me what is meant by ‘sublimated violence’?

I am asking this question to try to answer another that was put to me yesterday. It has left me quite perplexed.

A reader wrote and described the following observation. He was attending a serious talk by an American professional. Somewhere in the middle of the talk, the presenter had occasion to mention he was from Pittsburg. All of a sudden, he swiveled from his hip, pumped up his fist, and shouted ‘Go Steelers.’ And then he continued with his serious presentation.

The question posed by the reader was whether I could imagine a South Asian doing something like that and if not, why not? (more…)

Similar and Different: Bengal Revisited

April 17, 2009

What have we learnt from this extended discourse on similarities and differences? It is time for a recap and a summary.

We started with Vir Sanghvi’s angry pronouncement that Pakistanis and Indians were no longer similar; they may have been 60 years ago but by now ‘they’ were fundamentalist and ‘we’ were secular.

There were immediate rejoinders to this burst of annoyance with hurt pronouncements of sharing the same music and the same sports.

It became immediately obvious that there were two flaws with the framing of this discussion. First, human beings were not one thing or another; rather, they were better characterized as bundles of attributes. (more…)