MEN of vision all over the world have tried to reduce human suffering brought about by illness by providing free and subsidised health care so that people without means will not be left unattended.

Many western European countries and Canada subscribe to this humane policy and try to provide their citizens a National Health Service (NHS) which is equitable and efficient.

Such a service has become difficult to sustain financially because of the increasing cost of drugs, rising wages and greater expense of high-tech medicine. All these countries are therefore trying to reduce wastage and bring down costs, but none are planning to abandon the NHS in favour of a privately run health service based on commercial lines. Here is an overview of a few health services which can act as a model for Pakistan.

Britain was the first country in western Europe to introduce the NHS soon after the Second World War when the Labour Party came to power. In the beginning, the NHS provided completely free service which included consultation, hospitalisation and cost of drugs. As of April 2007 there is a prescription charge for medicines of 6.85 pounds irrespective of their real cost. People over 60, children under 16, patients with certain medical conditions and those with low incomes are exempt from this charge. Charges are also made for various dental procedures.

The NHS budget for 2007-8 is 104bn pounds and it currently employs 1.3 million people, apparently making it “the world’s fourth largest employer after the Chinese army, the Indian Railways and Wal-Mart”. The NHS is not funded by insurance but by taxpayers’ money and is fully supported by the public.

In 2001, the WHO made the first major effort to rank the health-care systems of different countries. France was placed at the top as the NHS of France gave the public greater freedom to choose the health provider. The US was way down at 37th position.

The US health-care system is insurance-based and meant to cover the whole population but about 45 million are without any insurance and many more millions have only partial coverage. In addition, the US is one of the worst countries in terms of equity as the quality of care which the poor get is much inferior to that received by the rich (The New York Times, Aug 12, 2007).

Americans are reluctant to carry health insurance mainly because of the high premiums. The insurers claim that the high premiums are due to malpractice coverage and escalating cost of drugs. A recent issue of the British Medical Journal (Dec 1, 2007) carries an editorial, titled ‘The market has failed’, revealing the shortcomings of the US system. Michael Moore’s prizewinning film on this subject, Sicko, is worth seeing, especially by people who are formulating health policy.

Realising the difficulties which a significant number of Americans face in obtaining health care, Hillary Clinton has proposed a plan which provides tax credits for working families so that they never have to pay more than a limited percentage of their income in the form of insurance premiums.

Australia is trying out a new system, based on a sliding scale of compulsory insurance, with a public-private mix and it seems to be working. However, some changes may take place with the Labour Party’s victory in the recent elections. On the whole, Australia is a very healthy nation with the exception of the Aboriginal population who live in great distress. The Labour Party may now rectify this historical injustice.

In Asia, a few nations such as Sri Lanka, Malaysia, Taiwan and Singapore have done well in providing health care and in some cases their health statistics are comparable or even better than those of western countries. For example, the infant morality rate in Singapore is 2.10 per 1,000 live births and average life expectancy is 79.70 years, compared to an infant mortality rate of five per 1,000 and life expectancy of 77.6 years in the US.

The financial aspect of Singapore’s health-care system is quite unique in that the total burden does not fall on the government. Under the ‘Medisave’ scheme, every working individual is required by law to save six to eight per cent of his or her income in a personal Medisave account held by the government. This money can only be used for hospitalisation.

‘Medishield’ is an insurance scheme, also run by the government, to cover major or chronic illnesses. The premiums are within the reach of an average citizen. ‘Medifund’ is yet another scheme and acts as a safety net for people who are poor and have no or very small savings.

Therefore, no Singaporean is deprived of medical treatment because of an inability to pay. The quality of treatment available in government hospitals is as good as in any private institution. In fact, government hospitals lead in new technology and research. However, individuals are free to choose private hospitals and still use their Medisave account.

China has recently adopted a more privately oriented and insurance-based approach to health care. At present there is an imbalance in China between cities, where most of the hospitals exist, and villages where medical facilities are poor. To correct this imbalance the Chinese government has earmarked 20bn Renminbi or yuan (US$2.4bn) to improve rural health services over the next five years.

In Latin America, the Cuban health-care system is most outstanding. Cuba’s infant mortality rate is five per thousand live births which is the same as that of the US. Cuba has one doctor per 200 citizens compared to one doctor per 400 citizens in the US. Cuba has 21 medical schools which produce 4,000 doctors annually and education is free. Doctors are sent to other Latin American countries if needed and a contingent was sent to Pakistan after the earthquake.

In the year 2000, the secretary general of the UN, Kofi Annan, said that “Cuba should be the envy of many other nations. Cuba demonstrates how much nations can do with the resources they have if they focus on the right priorities — health, education and literacy”.

In the Pakistani context what can be borrowed from these models? We need some form of national health service which works in tandem with the private health-delivery system. It is obvious that because of the high cost, private hospitals are inaccessible to the poor and the middle class. More government hospitals and clinics are needed across the nation and the quality of care in existing hospitals needs to be improved.

Emphasis should be placed on preventive medicine and family planning. China was criticised by the West for its one-child family policy but this did play a part in improving the general standard of living and conservation of resources. Poverty cannot be eradicated if the family size is not reduced.

The health of a nation depends on a holistic approach in which people are provided with clean water, proper sewage and refuse disposal, mosquito and fly control, reasonable housing and, last but not least, health education. In this respect both the electronic and print media have an important role to play. To implement these measures the financial resources for health and education need to be increased and some holy cows trimmed. There is really no other alternative.

IT is ironic that with all the power and resources at their command, the writ of the ruling elites is weakening. In many countries the authoritarian regimes run by powerful oligarchies not only succeeded in solving economic problems but also provided basic infrastructure to their people, while maintaining law and order with an iron hand.

Our misfortune is that although we have suffered over 30 years of military rule, our basic problems have remained unresolved.

Pakistan is a classic case of a country that started off well and at one time was commonly presented as a ‘model of development’ for newly independent nations but then started slipping.

Today we stand at a point where in addition to political instability, which is the bane of our lives, we face multifaceted crises, with mal-governance being the foremost.

If we had continued to move forward steadily, the way we did in the initial years, by now the majority of our population would have been free of poverty, hunger, disease and illiteracy.

Our misfortune should be studied to highlight (a) what happens when the ruling elites have no vision, concentrate all powers in their hands, indulge in politics of exclusion, give priority to individual and group interests at the cost of national interest, and slowly destroy all existing institutions; (b) who occupies the space left vacant when institutions become weak or extinct; and (c) how this situation impacts on the lives of ordinary citizens.

In the developed world the private sector has largely replaced the government as far as provision of basic services is concerned, but in Pakistan it has neither the capacity nor the willingness to do so. As a result, the vacuum left by the public sector has been filled mostly by the ‘informal’ sector, which no doubt provides many essential services. But a thin line separates the ‘informal’ operations from those that resemble the mafia in their modus operandi.

In a country like Pakistan where 74 per cent of the population survives on two dollars a day, people expect the government to provide basic services like potable water, electricity, housing, sanitation, health, education, micro finance, etc, but when the government fails to do so they start looking for alternatives. They have to survive one way or another.

The role of the informal sector starts with basic services, but once this phenomenon is triggered it spreads its tentacles into other areas as well.

Examples include the rise of the ‘building mafia’ in the inner-city areas 20 years back, the billboard mafia in the late nineties, and the recent mega-development mafia that wants to grab all open spaces and the coastal belt in Karachi with the backing of global capital.

The weakening writ of the government and large-scale corruption has allowed the mafias to cause huge losses — both financial and social — to our country. Everyone knows that there are powerful organised groups which indulge in large-scale smuggling that accounts for nearly 25 per cent of all our imports. Then there are drug mafias, human traffickers and gunrunning mafias which have destroyed the lives of millions of people.

There are ‘factories’ which produce spurious medicines and supply them to government hospitals; ‘booti’ mafias which rule the examination halls; student organisations which control universities and professional colleges; and ‘bhatta’ groups which collect billions of rupees annually on one pretext or the other. In the courts there are ‘zamanat’ mafias and ‘nazarat’ mafias. Let us explore a few cases from Karachi and observe the effects created by the absence of appropriate institutions of governance.

Take housing first, because it touches the lives of the bottom 60 per cent of the city’s population who earn close to Rs10,000 per month. Till the early eighties, development authorities provided land at affordable prices or built-up units to these people in various housing colonies. Therefore the number of katchi abadis was small and the housing shortage had not assumed the proportions of a major crisis.

This was the time when the term ‘land mafia’ was heard for the first time. In the absence of any control it soon assumed the role of a parallel system for provision of land to the poor.

A 1985 survey showed that the land mafia was grabbing nearly 1,000 acres of state land every year and earning Rs250-300m by selling it to needy people.

Today this is a multi-billion-rupee business, and more than 55 per cent of Karachi’s population now lives in katchi abadis. From the police and board of revenue officials to politicians and local musclemen, everyone is involved and they get their respective share from the mafia. During the last three to four years this activity has assumed epidemic proportions but no action has been taken to stop it.

The reasons are obvious. If the land mafia is working on the periphery of the city, the ‘building mafia’ dominates the city centre and old residential areas. It makes billions by violating building regulations with impunity.

Next let us turn our attention to transport. Karachi is perhaps the only city of its size that does not have a public transport system. At least six million people commute daily and are forced to use either their own vehicles or private buses.

There is nothing wrong in leaving the transport system in private hands, provided its financial needs are taken care of by the government, there are enough buses and the system is properly regulated. In the absence of any such framework, the bus operators in Karachi are a law unto themselves and care two hoots for traffic rules. They also ignore all laws pertaining to fitness of vehicles and usually employ untrained, uncouth and underpaid drivers. They treat the commuters with utter contempt and physically assault them if some one dares to raise a voice.

All this happens because the transporters pay regular ‘bhatta’ to the traffic police. If action is initiated against violators under public pressure, they resort to strikes which cripple the whole city. Karachi, as a matter of fact, is hostage in their hands.

Karachi has another distinction in the area of basic civic services: over 50 per cent of its total water supply (650 mgd) is either stolen or wasted. The ‘tanker mafia’ plays a major role in this theft. There are only a few legal hydrants but no one knows how many illegal ones exist. Conservative estimates show that this mafia generates an annual income of over Rs40bn. As a result the majority of citizens, specially those living in low-income areas, get little or no supply at all. If this theft, wastage and mal-distribution is controlled, every person in Karachi can get enough water for daily use. But who would dare control the tanker mafia, as most of the powerful people, with the connivance of government agencies, are involved in this lucrative racket.

The rise of these mafias clearly shows that we have reached a stage of institutional exhaustion. The state can neither provide the needed services to the people, nor can it control the illegal activities of the mafias. This is a bleak scenario. Some may call it cynical but given our conditions we cannot expect any improvement in the foreseeable future.

A DEBATING club, called the Berlin Wednesday Club, invited its members in 1783 to respond to the question: “What is enlightenment?”

A strenuous debate followed. The philosopher Immanuel Kant joined in the fray with his well-known essay: ‘An answer to the question, what is enlightenment?’ Kant defined it in simple words: “Enlightenment is man’s release from the self-incurred immaturity which is his inability to make use of his understanding without direction from another. Sapere aude! Having courage to use your own reason! — that is the motto of enlightenment”.

Kant’s call of Sapere aude is an invocation of a new standard of reason, meant to challenge all a priori truths that we accept without reasoning due to cultural conditioning or overt indoctrination. To begin with, the Enlightenment refers to the historical epoch which began with the English Revolution in 1688 and culminated in the American Declaration of Independence in 1776 and the French Revolution in 1789.

There was no one unified movement called the Enlightenment that swept through all of Europe simultaneously. There were, rather, a series of debates and critiques directed against the authority of inherited intellectual and religious traditions.

These were led by a new class of intellectuals, who made a living by writing for newspapers, periodicals and cheap novels; and by giving lectures on current sciences in coffee houses and pubs.

For all the national differences, the movements included in the rubric of the Enlightenment were marked by, to quote Alan Kors, the editor of a new Encyclopaedia of the Enlightenment, “an increasingly critical attitude towards inherited authority, a sense that armed with new methods and new powers, the human mind could re-examine claims upon it including the claims of religion.” Sapere aude — dare to know — was the motivating force behind the entire movement.

Finally Enlightenment is the precondition to any progressive politics. As Stephen Bronner writes in his book, Reclaiming the Enlightenment, nearly all aspects of modern life, especially the ideals of personal autonomy, tolerance, reason and secularism, developed against the backdrop of Enlightenment’s protest against the exercise of arbitrary power, the force of custom and ingrained prejudice that justified social misery.

On this reasoning, it was Enlightenment that made real the ideals of modernity that were only latent in the Reformation, the Renaissance and the Scientific Revolution. Enlightenment, that is Sapere aude (dare to know), is considered by many historians as the true beginning of modernity.

Against this background, let us once again return to Kant’s motto. Why did he make Sapere aude — the courage to use your own reason — the distinguishing mark of his times? After all the Age of Enlightenment was hardly the first to apply the power of reason to comprehend nature and society.

Human beings in all societies and in all epochs have exercised the powers of observation, logic and experimentation, along with imagination and insight, to understand and materially manipulate the force of nature. What was so special about reason in the Age of Enlightenment that Kant turned it into a rallying cry for freedom?

While the philosophers of Enlightenment exhorted their fellow citizens to live by the light of reason, they were simultaneously redefining reason by setting limits on what can legitimately be known, given the kind of sensatory apparatus and reasoning powers human beings are endowed with.

The philosophers and architects of the age of reason, from Locke and Hume to Voltaire, Diderot and Montesquieu, Kant, Lessing and Marx and Jefferson, Paine and Franklin were impressed by the success of the scientific revolution, especially the disciplined empiricism of Newton.

This, to the philosophers of Enlightenment, was in refreshing contrast to the method of the theologians.

Newton’s method became the paradigm of reason for the Age of Enlightenment. This was a monumental change. This was the philosophical core of Enlightenment, the rallying cry of enlightened human beings.

A rationalist offensive against superstition can only be meaningful if it is a part of a larger political movement that can meet people’s aspirations for existential security and justice in this life.

Iqbal is also a standard-bearer of Kantian Sapere aude. He says:

Cut your path with an axe of your own,

It is sin to tread the beaten path of others!

If you achieve something original and unique,

Even a sin becomes a virtue.

Once again, indeed over and over again, Iqbal never tires of proclaiming originality of thought and action.

A renaissance of national life!

It is a source of life’s miracles,

Transforming granite into the purest of pearls.

He sums up:

Would you ensnare the phoenix of knowledge,

Rely less on belief and learn to doubt.

2007 will be remembered as a year of extremism. It was in this year that “the extremists became very extreme”, to quote from the president of the PCO Republic. It was in this year that the extremists on the mountains of Waziristan killed and captured more soldiers than at any other time in the history of Pakistan.

It was in this year that the extremists in Islamabad fired a long-distance, high-speed PCO missile that knocked out one’s own strategic assets such as the Constitution and the judiciary.

It was in 2007 that we became the only country in the world that suspended and ‘house-arrested’ its own chief justice twice in the same calendar year. It was in this year that a militant legislation transferred all state powers to a single individual — perhaps the only person in the world who has a nuclear button in his pocket and whose constitutional amendments cannot be challenged.

Also in this year the political parties displayed unparalleled greed and spinelessness by legitimising extremely substandard PCO products like the PCO president, PCO judges, PCO PM and PCO Election Commission.

No wonder the Chinese calendar calls 2007 the year of the animal we do not like to talk about.

But there was also a new sense of energy and resistance in the air that began to give hope to the dark despondency of 2007. It was for the first time that Pakistanis, forgetting their many differences, closed ranks and began to take positions around a single dividing line. The line that separates the civil and the uncivil society. A divide along the lines of conscience on the one hand and compromise on the other.

What are the dynamics of this new development? While the traumatic events of 2007 may have been a triggering factor, this new wave reflects an accumulated disillusionment of people from 60 years of uninterrupted deceit, corruption and lawlessness. Gradually but firmly, people have come to perceive their leaders (both civil and military) as corrupt, self-serving and power-hungry whose only interest is to use the placebo of clichés, deceptive manifestos and hollow slogans to dupe the masses.

The educated middle class — lawyers, teachers, students, doctors, professionals, individual citizens and groups — which has traditionally kept itself at a distance from mainstream politics is awakening to a realisation that it has stayed on the sidelines for too long.

There is a growing realisation that years of inaction, silence and cynicism have only resulted in people being taken for a long ride. In a classic replay of Pastor Niemöller’s famous lines, the home-made Nazis have already come for the judges, the lawyers and the media. A scary realisation that people must stand up and speak for themselves as there is no one left to speak for them.

What separates the civil from the uncivil society of Pakistan? One simplistic understanding would be that anyone who directly or indirectly was a party to the mutilation of the Constitution and launch of the draconian PCO, who took oath as a PCO judge, cut power deals with the US, tried to seek indemnity against past crimes, supported the military regime, accepted a position under this unconstitutional arrangement or granted legitimacy to these actions by taking part in elections is a part of the Uncivil Society. All others may prima facie be assumed to be part of the civil society.

One does not, however, become a part of the civil society by merely suffering in silence. Even a weekend vigil or periodic public protests are not good enough. A society is called civil when its members individually and collectively follow ethical principles and practices in their working lives.

They relate their work to larger social and political causes. They support ethical and principled stands. They protest peacefully and lawfully against tyranny and injustice.

They are willing to contribute their time, effort, money or expertise for a cause or community. They are willing to rise above their party positions and cushy jobs, to raise their voice when the rulers indulge in unethical practices, and finally they care and work for the betterment of a larger society instead of a privileged few. While it may still be many miles to the land of the civil society, there are clear signs and symptoms that people in Pakistan are already taking the most difficult first steps. May 2008 be the year of the civil society.

naeemsadiq@gmail.com