| 28 April 2004 | Wednesday | 07 Rabi-ul-Awwal 1425 |
Prevention is still better than cure
A special licence
Last week the chaos in Iraq deepened on almost every front. While the decision to close down the publication of the weekly broadsheet that Moqtada al-Sadr published from Baghdad and the decision to lay siege to Fallujah, may have triggered the violence, and while the perpetrators of violence may well be ex-Baathists, foreign insurgents and disgruntled Shias making a bid for popular support, there is no doubt that the violence touched its present levels by tapping into the deep discontent and disillusionment of the general populace.
The results are grim. In the words of an American correspondent: "There's no such thing as an even approximately safe road in Iraq". A rocket attack on the American base at Taji, within the so-called safe "Green Zone", killed at least five American soldiers. With this the death toll for American soldiers rose to 98 in April and to almost 600 since President Bush proudly declared in May last year that the war in Iraq had ended.
A suicide boat attack on the oil terminals around Basra failed, according to initial reports, to reach the target but a number of soldiers were killed when boats exploded in the vicinity of the vessel sent out to intercept them.
Reminiscent of the attack on the S.S. Cole in Yemen but potentially much more devastating in the impact it would have on the Iraqi economy if it succeeded, it gives the coalition forces a new worrisome factor to contend with.
Together with the earlier attack in Basra city, this also signals a new level of insurgency in a hitherto relatively peaceful area.
The Basra attack was carried out, according to Iraqi security, by insurgents from Fallujah. There are reports that the mortar attacks on Sadr city, in which 13 Iraqis were killed and 30 wounded, was also the handiwork of Sunnis though the inhabitants of Sadr city attribute it to American helicopter gun ships.
These attacks make it improbable that the British contingent entrusted with the responsibility of peacekeeping in Basra will be in any position to extend its area of operations beyond the south to help the Americans cope with the departure from the Najaf and Karbala areas of the Spanish contingent.
Even more ominously from the perspective of the Iraqi people, it may indicate that the infamous Zarqawi plan of inciting the Sunnis to fight not only the Americans but also the Shias is being implemented.
If such incidents continue and Sunnis are identified as perpetrators of violence in Shia areas and vice versa, the present turbulence in Iraq will appear trivial compared to the horrors of the civil war that is likely to ensue.
Last week in Najaf, Moqtada Al-Sadr's fiery Friday sermon held out the threat of launching suicide attacks against the Americans, saying that he had been advocating restraint to his followers who were seeking martyrdom but if there was "an assault on our cities or on our religious authorities, we will be time bombs and will not stop before destroying enemy forces".
The Americans may want to but cannot dismiss this as an empty threat. It is clear that Sadr has not been able to muster the groundswell of support from the Shias that he claims to have.
It is also clear that he would get this support if any of the holy cities - Karbala, Najaf or Kufa - were to be attacked. He would also get it if there were evidence that Sunnis were targeting Shias.
Ironically, in Fallujah the initial American assaults in which a large number of civilians were killed, led to an outpouring of sympathy for Fallujah residents from both Sunnis and Shias. It seemed that Fallujah had become a symbol of Iraqi nationalism overcoming ethnic and sectarian divides. But such sentiments could rapidly dissipate.
On another plane, it seems that Iraqi outrage as also the worldwide concern about the number of innocent civilians killed in the initial American actions has given the Americans pause in their planned action in Fallujah.
The tribal leaders and city elders that the Americans have been negotiating with have not been able to secure either the apprehension of the killers of the Americans or the surrender of heavy weapons.
The Americans first said that the issue needed to be resolved in days and not weeks. Now however the Americans have apparently been persuaded not to launch a full-scale assault.
At least for the time being they will proceed with implementing a new agreement under which the carrying of arms in Fallujah would be banned and joint patrols by the US army and Iraqi security personnel in the city would start towards the end of April.
The more cautious approach has been occasioned not only by the well-publicised civilian casualties that have occurred in Fallujah or by the resignations in protest by members of the Governing Council but also by what must now seem to be credible warnings from such prominent Sunni leaders as Sheikh Ahmad Abdel Ghafur Samarrai, that the resumption of an offensive on the benighted city would trigger a national uprising.
So there is temporizing in Fallujah and there is temporizing in Najaf. A wise course, but will American commanders be prepared to live with it?
The deteriorating security situation has made it difficult to maintain the "coalition of the willing". So far only Honduras and the Dominican Republic have joined Spain in arranging a hasty withdrawal of their military contingents from Iraq. But other countries are also getting skittish.
Powell and other American officials have worked hard to prevent further desertions. It is indicative of America's political clout as much as of Powell's diplomatic skills that for the time being the 30 nations now in the coalition are leaving their troops in place. Their concerns, however, are strong and are being publicly articulated. Statements by American officials suggest that they expect further desertions if the security situation does not stabilize.
The loyalty and competence of the Iraqis the Americans have trained has been called in question. Speaking of their performance during the last few weeks an American general said, "About 50 per cent of the security forces that we built over the past year stood tall and stood firm.
About 40 per cent of them walked off the job because they were intimidated and about 10 per cent actually worked against us." This is probably an accurate estimate but newspaper accounts of the Fallujah and Najaf situations would appear that far fewer than 50 per cent "stood firm".
It was almost inevitable in these circumstances that the plans for rotating out 20,000 of the 135,000 American soldiers in Iraq have been postponed and already there are proposals by such knowledgeable observers as Republican Senator John McCain that an additional 10,000 American soldiers need to be sent to Iraq.
If there is anywhere a silver lining to be seen, it lies in the decision by the CPA administrator to recognize belatedly and with only the reluctant assent of his superiors in the defence department that the de-Baathification policy had been carried too far.
These former Baathists, representing the cream of Iraq's managerial and technical talent, will now be reemployed and it is probable that much of the apolitical technocratic interim government that is to replace the Iraqi Governing Council in July will be drawn from their ranks.
The problem with this silver lining is that while it is the right thing to do, it may have come at a wrong time. There is every likelihood that the Shias will see this, or pretend to see it, as an attempt to bring back Sunni domination of the power structure. One hopes that the merits of the proposal have been explained to Shia leaders.
Much has been made of the role that the United States wants the UN to play in Iraq. The credit for the modification of the de-Baathification policy and for the proposal that the entire Governing Council be replaced by new Iraqi faces is given to Mr. Brahimi.
It is not yet clear however that the Americans are prepared to define the UN's "vital role" in Iraq as going much beyond being responsible for the holding of elections.
The current plan as laid out by American officials in testimony before Congress would give the UN authority to propose the composition of the interim government that would replace the Governing Council and help this interim government to plan the elections, which, according to the proposed timetable, would be held in January 2005.
Further, it is envisaged that a new UN Security Council resolution could "structure a role for the United Nations in the new political framework, particularly in supporting the process towards elections".
Lakhdar Brahimi, for whose appointment the Americans had pressed the UN, has now blotted his copybook in American eyes by asserting that the handover of power in Iraq is being complicated by Israel's policies in the West Bank and Gaza and by the perception of the people of the region of the 'injustice' of Israeli policy compounded by the 'thoughtless support' of the US. He also suggested that the US start negotiating with the UN secretary-general about the UN's role in Iraq after the change of government in Iraq on June 30.
The UN spokesman has termed Lakhdar's remarks about Israel as unacceptable. Lakhdar has offered some clarification of his remarks but he may well have caused irrevocable damage to his standing in Washington not only with regard to Israel but also for having suggested obliquely that the UN should not accept the limited role the Americans were envisaging for it.
Unless there is a drastic change in the ground situation it seems unlikely that a new government can be installed by June 30. Even if a new regime is installed and is theoretically chosen by the UN alone, it is unlikely to have the support of the Iraqis since it will be subordinate to American forces.
It is also clear that few countries will join in providing troops for the envisaged multinational force under US command in Iraq. The Americans will therefore be largely on their own in coping with the expected turbulence.
American analysts recalling Vietnam, the discredited justification for the war, the burgeoning costs and the divisions within the Bush cabinet questioned the willingness of the American people to support such a venture and by implication suggest that Bush will be voted out of office.
Surprisingly however a number of polls, taken while the bad news and body bags from Iraq were pouring in, indicated that Bush was clearly ahead in the presidential race and there was no suggestion that his popularity was owed to the change he had effected in American policy on Palestine. Whether this will continue to be true further down the road is not clear.
The writer is a former foreign secretary.
Prevention is still better than cure
The message carried year after year by WHO's World Health Reports is that "progress in health depends largely on viable national and local health systems". The 2003 report speaks of the need for "effective health promotion and disease prevention services" to give people a chance to lead a long and healthy life. The 2002 report focused on the reduction of risks to health and held this to be the primary responsibility of the government.
Of course, it is generally recognized that the people themselves and the health professionals should also be involved in the task of preventing diseases and reducing the risk factors. But it is the government, in its capacity as the policymaker and the one controlling the purse strings, which is expected to play the leading role.
In Pakistan this basic fact has not been sufficiently recognized. Where the push has come from outside agencies and success has depended on vaccination campaigns or distributing medicines, some progress has been made. That would explain why polio may well be eradicated in the near future.
But other preventive medicine and public health measures have carried little weight with our policymakers. The political will seems to be lacking. In other societies, programmes such as those for potable water, sanitation, immunization, malaria eradication, etc receive priority as they are known to improve the health and the quality of life of the people. Economists and medical professionals have even devised methods to calculate the economic value of health.
Now we are not being told only about life expectancy at birth. Every country has a figure called DALYs which calculates the disability adjusted life years - which stands for the number of years a person will lose because of illness. Life expectancy at birth is not given so much importance.
It is HALE (healthy life expectancy) that matters. The life expectancy for a Pakistani at birth is said to be 61.3 years but HALE is only 51.3 years with nearly 10 years being lost on account of illness.
The moot question is why doesn't the government want to spend on measures which could avert a lot of agony caused by disease? It would also save it the expenditure incurred on the treatment of disease and the economic losses resulting from illness and absenteeism.
The WHO report for 2002 lists some risk factors, which are controllable to a great extent. The major ones that are most relevant to our conditions are childhood malnutrition, lack of potable water and sanitation, tobacco, overweight and air pollution.
The illogic of negligence and failure to address these factors are not easy to explain, especially when we know that these lead to the high prevalence of diabetes, cardiovascular diseases, kidney problems, infectious diseases, cancer, malaria and tuberculosis - just to name a few.
According to cardiologists, nearly 10 per cent of the adult population in Pakistan and 50 per cent of those above 50 years suffer from hypertension. Nearly 12 million adult Pakistanis are diabetic or have impaired glucose tolerance.
Twenty million suffer from one renal disease or the other with 10,000 dying every year because of end-stage renal failure. Tuberculosis kills 60,000 people every year.
It is well known that all these diseases are preventable to quite an extent. But that calls for behavioural changes in the people, with the idea of effecting modifications in their lifestyle.
For instance, it has been proved that diet and exercise have a direct impact on the prevalence of many diseases such as diabetes and cardiovascular disorders. The quality of drinking water and cigarette consumption are related to kidney problems, diarrhoeal diseases and many types of cancers.
Behavioural changes in people can be brought about basically through education. Although health education is imparted primarily by the health professionals when patients visit them, the government also has a role to play in facilitating this education.
By launching public campaigns through the mass media, the authorities can play a key role in imparting information to the people which is the essential first step to persuade them to change their behaviour.
Health education should start from childhood and the government has the capacity to determine what is taught to the children and ensure that every school has a playground and the children have compulsory PT periods.
The government can also help by providing information and education to physicians, who are the first point of contact for the people seeking medical assistance for their health problems.
With new technologies and research-based knowledge emerging by the day, health professionals are also in need of continuing education. Many professional bodies of medical specialists are undertaking this with a sense of commitment. But it is important that the government also play a bigger role in the process of disease prevention.
There are significant areas of public health and preventive medicine where the government's intervention can make a vital difference. This intervention may take the form of legislation, imposing taxes on items to be discouraged, executive action or policy measures.
For instance, laws can be adopted to regulate the sale and publicity of cigarettes, encourage breast feeding by banning advertising and free distribution in maternity clinics of infant formula, control environmental pollution caused by traffic and industries, and institute safety measures in work places and on the roads and highways.
The government has adopted a number of legislative measures on all the above-mentioned issues, but it is a pity that many of these laws are not being implemented.
Take the smokers' and the cigarette manufacturers' lobby which has managed to bypass many of the new restrictions imposed by the Anti-Smoking and Protection of Non-Smokers Ordinance and nearly 37 per cent (a third of men and four per cent of women) are habitual smokers in Pakistan. As a result 100,000 people die annually of cigarette-related ailments (cancer and cardiac and respiratory diseases)
Environmental pollution has the same sorry story to tell. The laws have remained unimplemented. Measures to get autorickshaws to have silencers fitted and the move to penalize drivers of smoke-emitting vehicles on the road have met with open defiance. According to WHO, nearly eight per cent of deaths in a Third World country are attributable to air pollution.
Policy measures that have a direct bearing on the health of the people are those pertaining to water supply, sewerage, sanitation and garbage accumulation. These are under the direct control of the municipal authorities but they have not acted effectively because of resource constraints and lack of commitment. Unsafe water and sanitation lead to 3.1 per cent of deaths.
One wonders why the government does not feel the compulsion of adopting such measures which, in the long run, prove to be more cost-effective. After all, preventive measures are cheaper than the cost of treating patients suffering from cancer, tuberculosis, renal failure, etc.
It is probably because the government is gradually withdrawing from the health sector. According to the Human Development Report 2003, the Pakistan government spends 0.9 per cent of its GDP on health while the private expenditure on health care amounts to 3.2 per cent of GDP.
What is more, the government's health expenditure has not registered a substantial increase over the years in terms of percentage of GDP. Hence the growing burden of ill-health has to be borne by the people.
In the absence of any feasible and widely accepted health insurance plan, in a preponderance of cases it is the patient who pays for his own treatment.
Another problem is that we have no precedent of successful litigation by people for compensation when they have suffered because of the negligence of the authorities or any party responsible for causing pollution or creating a public health hazard. The need of the hour is for greater emphasis on prevention than on cure as is at present the trend.
A special licence
How unfortunate are some of the highly developed nations of the Europe, and even the United States itself, that they have no VIPs of the kind that we have here. What does the common man in those countries look up to become? From Germany came the news some time ago that the foreign minister there was fined for parking his car at a wrong place, and that he paid the fine. obviously he was not treated as a VIP.
It seems the people of Germany - or, for that matter, any other European country - do not know how to pay proper respect to their government leaders, despite claims of having advanced so much in the field of public service and practice of democracy.
It is one thing to raise the level to which ordinary people must be honoured in a democracy and quite another to drag leaders down to the plebeian level. This is something we don't do in Pakistan in spite of our backward ways.
We neither promote the people nor do we demote the leaders, no matter how dismal the record of the latter may be in respect of character and performance. We believe in the status quo of more than fifty years ago.
One thing is certain. Had the German foreign minister been in Pakistan, or there had been Pakistan's own foreign minister in his place, he would have been a distinguished citizen, a VIP, and wouldn't have had to submit to he indignity of a traffic challan. Had he chosen to park his car in the middle of Islamabad's Constitution Avenue or Karachi's Bunder Road and blocked the traffic, the police would have smiled indulgently and invited him to do it again.
Come to think of it, it would not have been possible for the German FM to park his car anywhere in any city in Pakistan for the simple reason that his chauffeur would not have permitted him to do so.
VVIPs and VIPs don't drive their cars in this country. It is considered infra dig. In fact even an IP, the lowest in the hierarchy comprising mostly middle order bureaucrats, would rather be seen dead than driving his car himself.
The other day one of them confessed to me that he didn't know Lahore roads at all, although he had lived and worked in that city for many years. He explained that when his chauffeur was at the wheel he himself was either looking at the morning newspapers (probably to see if any postings and transfers had taken place overnight) or reading his own noting on an important file.
On a visit to Sweden, the then prime minister Zulfikar Ali Bhutto gave a return banquet for the late (and great) Olaf Palme. He had to stand in the porch of the Pakistan embassy for quite a while for the Swedish PM's car to arrive. Suddenly Mr Palme walked up to the porch, his topcoat on his shoulder, and apologized for the delay. He said he had gone to park his car in the parking lot of the embassy.
But that is not our way. The way we pamper and glorify our government leaders (ministers, elected representatives, senior officers) is probably unmatched anywhere else on the world. It would be difficult to find another country, barring a few in Africa, that does it better than us.
This we do by way of the perks and privileges that a grateful nation showers on them for condescending to take part in public life. Although the nation can never repay them enough for finding time from their nefarious, sorry, multifarious preoccupations to spare a few moments for the country's welfare at the cost of their personal interest and comfort.
What we do is to issue these leaders a special licence that makes them immune from any state exaction or responsibility. During their tenure in office they may not only park their cars wherever they like, they are also at liberty not to pay bills and taxes, obtain bank loans without surety, drive about under police escort in the red traffic light, never be punctual at public functions, enjoy every entertainment free of cost, delay railway trains and even call back PIA flights after take-off.
They can bring in any number of contraband goods from abroad, spend as much money from public funds as they can lay their hands on, ride in three staff cars at one time, and do a lot of other things that they couldn't do without this special licence. They can even get a second wife without fulfilling the legal provision of securing the first one's permission. And many of them do.
Most of the VIPs and IPs think the licence is a sort of insurance that also covers death by accident - death of others of course, not their own. And they are right. If a man gets killed by their car, he is usually challaned for jay-walking.
But then, in their public spirit the VIPs are also generous enough to let him off, the fellow being dead in any case. This cover-all licence is availed of by all the blood relations and relations by marriage of the (Very) Important Person.
No description of the VIP in Pakistan will be complete without a mention of Mrs VIP, or rather Begum VIP. She is invariably more important than the burra sahib, her husband. People working in his office are more afraid of her than of the boss, and she makes greater demands on their time and attention (and sometimes on their purse too) than he does. The boss may overlook a lapse and forgive a fault, but the Begum? Never.
The wives of most government leaders soon begin to believe that they are as much ministers and senior officers as their husbands. They make this quite plain to the personal staff where privileges and other facilities are concerned, since all these must accrue to them as a matter of right. For isn't it understood that the special licence is also meant for near and dear ones?
On their part, official leaders think of themselves as the government's sons-in-law, as we say in Punjabi about persons who tend to appropriate authority. Elected or appointed by the public as servants of the people, they treat the people like domestic servants and become indignant at the slightest neglect of their imagined position.
Witness, for example, the spate of privilege motions in the legislative assemblies. One feels sorry for the poor senators, MNAs and MPAs whose sense of self-importance is hurt so easily.
The only time they work really hard is when they are fighting for their perks and privileges. This is equally true about senior civil servants. In fact this is the only point on which the two breeds think alike.