Sitting in his rather spartan clinic in a poor neighbourhood of Rahim Yar Khan, Dr Mohammad Saeed Tahir feels concerned about malnutrition affecting the health of the senior patients that he comes across in his practice.

“As per routine, I ask my senior patients to eat well,” he says. “But now I have stopped, because most of them become silent when it comes to eating nutritious food. For most of them it is a question of affordability.”

Rampant malnutrition and its intermittent treatment among the elderly is no less than an unconscious euthanasia, says Dr Tahir. While malnutrition for the mother and child remains a much-discussed issue, malnutrition also has catastrophic health impacts on senior people.

The Council of Common Interests, a federal institution established to deal with the matters that are a shared responsibility of the provinces and the federation, approved an ambitious project of 350 billion rupees on November 11, 2020, to curb malnutrition-induced stunting in Pakistan. This indeed is a laudable step. But in Pakistan, traditional nutrition programmes only include children under the age of five, pregnant and lactating women, school-aged children, persons in emergency situations and other vulnerable groups (such as those who are food insecure and slum dwellers). The list of the beneficiaries of the governmental programme omit older persons, who actually become more vulnerable because of malnutrition.

It is high time that the implications of malnutrition on the health and productivity of seniors are prioritised, understood and addressed

The recently established National Nutrition Coordination Council by the Government of Pakistan, with its secretariat in the Poverty Alleviation and Social Security Division may be a step in a right direction. But it has failed to realise the importance of addressing the growing problem of malnutrition among seniors in Pakistan, and its implications for the economy and society.

During the Covid-19 pandemic, the Social Protection Resource Centre (SPRC), a think tank I work with, reached out to many older people to know about their diet. One of the people researched is Aslam, a lab technician in a private university, who lost his job without any benefits, as the university closed because of Covid-19. Presently, he is a driver for an online cab service.

“I have to pay rent and feed my entire family,” Aslam says. “My only source of income was my salary from the university. Now my small amount of savings is coming to an end. When I worked at the university, I would have my lunch at the university canteen. But, things have become very expensive and, to save money, I usually skip lunch. I am in my 50s and sometimes I feel weak. The fear of falling ill makes me nervous.”

Among the working or labour class in society, there is little awareness about nutritional values and food intake is usually limited. In a 2018 document on ‘Dietary Guidelines for Better Nutrition’, the government’s Planning Commission took note that limited or negligible work had been done to assess the nutrient requirements and intake of seniors. Despite the fact that many small cross-sectional studies reveal that the diet of older people in Pakistan is deficient in almost all macro- and micro-nutrients — thus contributing directly to an increased disease burden — the government has put in place hardly any programme to address their nutritional and health needs.

As the government upgrades its nutrition programme, it is high time that the implications of malnutrition on the health and productivity of seniors are prioritised, understood and addressed.

According to WHO, in Pakistan, the average life expectancy at birth is 66 years and the number of persons above 65 is only 4 percent. Compare this, for example, to China where the number of persons older than 65 is 7 percent. If we look at the class disaggregated data, life expectancy is pushed up in Pakistan partly because of improvements in the treatment of fatal diseases, but largely due to external determinants — the most important being socio-economic status. In other words, medical developments go to waste because of poverty, which has become one of the key external determinants of health, mainly because of malnutrition among children, women and seniors.

In Pakistan, according to WHO, the average ‘healthy life expectancy’ stands at around 57 but, in poorer sections of society, it is estimated to be lower, in the early fifties. Healthy life expectancy in the case of women in Pakistan is even worse than men. According to a recent survey by SPRC, women in Pakistan do considerably worse on almost all the indicators of old age well-being, such as work, health, functionality and income protection.

Financially-challenged elderly individuals, especially those who have multiple medical conditions that require medications, often have to choose between paying for medication or food.

Zaheer Abbas, a motorcycle mechanic, lives with his mother in Ali Pur Chattha, Gujranwala. Being the only son, he brought his mother in her late forties to the city from Pindori Kalan, District Gujranwala, when his father passed away a few months ago. His mother’s health was not that bad in the village, but she had put on some excess weight. When she started complaining of low energy almost all the time, Sarmad took her to the doctor, who diagnosed her with high blood pressure, diabetes and anaemia.

But diagnosis is only part of the issue. “I cannot afford to follow the diet that the doctor suggests,” says Abbas. “Already the cost of medicine is too much for me. Also, my mother does not eat food without oil and sugar. When she was moving with me to the city, my mother told me she would work as a cleaner or a domestic worker but with these health issues, she cannot.”

Because of negligence in healthy diets in our society, very often people in their 50s become ill and hence frail and weak, which leads to them losing their jobs or their taking early retirement.

Pakistan has limited social security/work-based old-age benefits. Seventy five percent of the senior people in Pakistan have no old-age benefits whatsoever. The little income that comes in for the poor through the Benazir Income Support Programme is often used for household expenses. In most cases, it is hardly used to address malnutrition. Culturally, older people would also rather see their grandchildren eat well than focus on their own diet.

The government should consider launching a nutrition programme for seniors to stem the wastage that sets in the lives of our elderly, particularly among impoverished classes, and to reduce the deadly burden of nutrition-sensitive diseases.

Just the way that, in the case of children, ‘lunch at school’ programmes have made a big impact the world over, in some countries, ‘community lunches’ for seniors have helped fight against hunger and malnutrition. Direct financial support to seniors and providing health services with food through extensive awareness campaigns could also be helpful.

In Pakistan, according to the State of Old Age Well-being Report 2020 compiled by SPRC, presently, around seven percent seniors live completely on their own. A good number of them are highly susceptible to hunger and malnutrition. They may lack motivation and interest to prepare meals for themselves. Loneliness also further reduces their desire to eat. They should be the first target group for the government and philanthropists to reach out to.

The writer is the Executive Director, Social Protection Resource Centre in Islamabad ed@sprc.org.pk

Published in Dawn, EOS, December 6th, 2020