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By Sandhya Srinivasan
Public health is and must remain, the responsibility of the State, not of the private sector, NGOs or international organisations, says Dr Zulfiqar Ahmed Bhutta, leading authority on public health in South Asia. But in the era of structural adjustment, with India and Pakistan spending just 1.5 and 1 per cent of their GDP respectively on health, diseases associated with poverty and malnutrition are actually on the rise. Whatever happened to structural adjustment with a human face?
 Zulfiqar Ahmed Bhutta is a paediatrician with a special interest in neonatology and nutrition, who gravitated over the years into public health research, in the areas of maternal and perinatal health. He is professor of paediatrics at the Aga Khan University in Karachi, Pakistan's premier medical institution, where he balances his teaching responsibilities and clinical workload with his research interests. These research projects extend from squatter settlements in Karachi to rural community settings in Sindh province and Gilgit in the northern region of Pakistan.
Dr Bhutta's essay in the British Medical Journal ('Why has so little changed in maternal and child health in south Asia?' BMJ, September 30, 2000, see www.bmj.com), raises a number of provocative questions on the role played by structural adjustment programmes on health, health care and health research in the subcontinent.
Excerpts from an interview with Dr Bhutta at a workshop in Karachi on the ethics of health research in developing countries:
What are the issues in women's and children's health in India and Pakistan?
The issues are very similar, though they may be a little more stark on our side, and they pertain to the socio-cultural roles of women in society. By and large, both in rural India and in rural Pakistan, women live as second-class citizens, and this is reflected in their overall health. South Asia is responsible for almost three-quarters of all babies born underweight in the world. These low birthweight rates are largely related to issues of maternal care, women's position in society, fertility rates, and nutrition. The causes of childhood mortality and their determinants, have been the same in both parts of the subcontinent for decades, and the solutions are fundamentally the same.
And what are these causes?
It is a pity that more than 50 years after independence, the total level of spending on public health, on education, on nutrition, on the general welfare of our societies, is still minuscule compared to what it ought to be, and (the needs of) the region.
The Indian government spends only about 1.5 per cent of its Gross Domestic Product (GDP) on health...
Pakistan is not too far behind; it may be around 1 per cent of our GDP, but, that's 1 per cent! What are we spending the rest of our money on? On non-developmental expenditure, on so-called 'defence' expenditure, which is really an offence expenditure. This is a subcontinent with nuclear capabilities, with the brains that are responsible for global information technology, and it cannot look after its people.
To what extent does health research in the subcontinent address its health problems?
India has rapidly progressed to undertake a fairly broad platform of research, ranging from biotechnology, basic science, to applied research, and to its credit has done tremendously well. To its discredit, a lot of this research is still not focussed on public health issues in India. At a recent meeting a major leader of Indian biotechnology presented his company's achievements and was asked how many of his products related to issues of developing countries. His answer was: none! There was no profit in it. We're working on issues of importance to developed countries. Very little research in India or Pakistan links to the countries' public health needs and policies. Even (relevant research) does not necessarily get translated into public health programmes.
Can you give an example of that?
For example, on your side, elite institutes such as the All India Institute of Medical Sciences do all kinds of research. The products of that research do not necessarily get translated into national and public health policy. On our side, the Aga Khan University has been the leader in much public health research, but not much gets linked to national programmes. There is disparate research, which does not necessarily lend itself to addressing the issues germane to maternal and child health.
What is the role of the government in research?
Building research capacity and ethics capacity in nation-states. If nation-states do not have the research capacity, external organisations will be dictating norms.
The Pakistan government's own spending on research ($20,000 annually) is nowhere near the recommended levels, nor is Indian health research spending anywhere near the country's needs. We are dependent for our research agenda on funding from outside, so we should not have major qualms about people funding research from outside having their own agendas. If we talk of an independent national health research agenda, we should put our funds where our mouths are.
What are the consequences of structural adjustment programmes (SAPs) in South Asia?
SAPs are things by which countries commit slow hara-kiri. Clearly they have led to an increase in food prices and in poverty levels. So we should expect to see some impact on nutritional status. We do not have the data over this period to confirm this objectively, apart from some cross-sectional surveys and some of the work we are doing. We do have some figures on stunting, wasting and maternal anaemia rates over different time trends, which show an increase in the last decade. We are beginning to see, in our public hospitals, problems like scurvy and pellagra (diseases of extreme malnourishment) which we thought had disappeared. I imagine these are not entirely among the refugee populations but among our indigenous populations as well.
My biggest critique is the absence of the so-called social security net that is supposed to exist in these programmes to protect the most vulnerable. Nobody would object if SAPs led to increased taxation of people who can pay more. But when people are disenfranchised, where democracy is actually an autocracy, the SAPs shift the burden to the disadvantaged, to the poorest who have no voice. It's not that industrialists or feudal agriculturists pay more taxes, in Pakistan they don't. Every time fuel, gas or electricity rates go up, they hit the middle class, the poor.
What role can be played by international organisations like UNICEF and WHO?
They have a tremendous role as a conscience, particularly UNICEF which has worked so closely with the community, and has in the past raised its voice against structural adjustment. Its Structural Adjustment with a Human Face was a landmark publication. The problem is that they have to work with the government, and can only, therefore, play a dissenting role within limits.
On the other hand, WHO can potentially play a huge role in policymaking. Its limitation is that it is by and large a representative body of member-States. The representative in WHO from that particular State may not necessarily represent the community.
So it boils down to much more than such agencies, to the relative strengths within society of non-governmental organisations (NGOs) and organisations of national associations, who have their finger on the pulse of what's happening and are better placed to address and highlight some of the issues. In Pakistan, NGOs are largely funded through external donor support. You have to identify those who are truly representative, subject to scrutiny, and who have the faith of the government, as well as the communities themselves.
What is the role of the State in people's health?
Public health is fundamentally a State responsibility, a basic human right. It cannot be the responsibility of NGOs or international organisations. If there hasn't been any improvement in public health, human rights, literacy rates of women and children in South Asia, it is because of our governments. I think it is inexcusable that South Asia has still not instituted the Hepatitis B vaccination programme for its infants and children, when the cost of such a national programme is much less than a fraction of the cost of maintaining a nuclear device.
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