Sunday, January 20, 2019
By Nicholas KristofMany Americans would welcome some traits of the island’s free, universal health care system.
Claudia Fernández, 29, is an accountant whose stomach bulges with her first child, a girl, who is due in April.
Fernández lives in a cramped apartment on a potholed street and can’t afford a car. She also gets by without a meaningful vote or the right to speak freely about politics. Yet the paradox of Cuba is this: Her baby appears more likely to survive than if she were born in the United States.
Cuba is poor and repressive with a dysfunctional economy, but in health care it does an impressive job that the United States could learn from. According to official statistics (about which, as we’ll see, there is some debate), the infant mortality rate in Cuba is only 4.0 deaths per 1,000 live births. In the United States, it’s 5.9.
In other words, an American infant is, by official statistics, almost 50 percent more likely to die than a Cuban infant. By my calculations, that means that 7,500 American kids die each year because we don’t have as good an infant mortality rate as Cuba reports.
How is this possible? Well, remember that it may not be. The figures should be taken with a dose of skepticism. Still, there’s no doubt that a major strength of the Cuban system is that it assures universal access. Cuba has the Medicare for All that many Americans dream about.“Cuba’s example is important since for decades ‘health care for all’ has been more than a slogan there,” said Dr. Paul Farmer, the legendary globe-trotting founder of Partners in Health. “Cuban families aren’t ruined financially by catastrophic illness or injury, as happens so often elsewhere in the neighborhood.”
In Havana, I shadowed a grass-roots doctor, Lisett Rodríguez, as she paid a house call on Fernández — and it was the 20th time Dr. Rodríguez had dropped in on Fernández’s apartment to examine her over the six months of her pregnancy. That’s on top of 14 visits that Fernández made to the doctor’s office, in addition to pregnancy consultations Fernández held with a dentist, a psychologist and a nutritionist.
This was all free, like the rest of the medical and dental system. It’s also notable that Cuba achieves excellent health outcomes even though the American trade and financial embargo badly damages the economy and restricts access to medical equipment.
Fernández has received more attention than normal because she has hypothyroidism, making her pregnancy higher risk than average. Over the course of a more typical Cuban pregnancy, a woman might make 10 office visits and receive eight home visits.
Thirty-four visits, or even 18, may be overkill, but this certainly is preferable to the care common in, say, Texas, where one-third of pregnant women don’t get a single prenatal checkup in the first trimester.
Missing a prenatal checkup is much less likely in Cuba because of a system of front-line clinics called consultorios. These clinics, staffed by a single doctor and nurse, are often run down and poorly equipped, but they make health care readily available: Doctors live upstairs and are on hand after hours in emergencies.
They are also part of the neighborhood. Dr. Rodríguez and her nurse know the 907 people they are responsible for from their consultorio: As I walked with Dr. Rodríguez on the street, neighbors stopped her and asked her about their complaints. This proximity and convenience, and not just the lack of fees, make Cuba’s medical system accessible.
“It helps that the doctor is close, because transportation would be a problem,” Fernández told me.
Home visits are also a chance to reach elderly and disabled people and to coach dysfunctional families, such as those wracked by alcoholism (a common problem), and to work on prevention. During Dr. Rodríguez’s visits to Fernández, for example, they discuss breast-feeding and how to make the home safe for the baby.
“It’s no secret that most health problems can be resolved at the primary-care level by the doctor, nurse or health worker nearest you,” said Gail Reed, the American executive editor of the health journal Medicc Review, which focuses on Cuban health care. “So, there is something to be said for Cuba’s building of a national primary-care network that posts health professionals in neighborhoods nationwide.”
Each consultorio doctor is supposed to see every person in the area at least once a year, if not for a formal physical then at least to take blood pressure.
All this is possible because Cuba overflows with doctors — it has three times as many per capita as the United States — and pays them very little. A new doctor earns $45 a month, and a very experienced one $80.
The opening of Cuba to tourism has created some tensions. A taxi driver who gets tips from foreigners may earn several times as much as a distinguished surgeon. Unless, of course, that surgeon also moonlights as a taxi driver.
Critics inside and outside the country raise various objections to the Cuban system. Corruption and shortages of supplies and medicine are significant problems, and the health system could do more to address smoking and alcoholism.There are also allegations that Cuba fiddles with its numbers. The country has an unusually high rate of late fetal deaths, and skeptics contend that when a baby is born in distress and dies after a few hours, this is sometimes categorized as a stillbirth to avoid recording an infant death.
Dr. Roberto Álvarez, a Cuban pediatrician, insisted to me that this does not happen and countered with explanations for why the fetal death rate is high. I’m not in a position to judge who’s right, but any manipulation seems unlikely to make a huge difference to the reported figures. Outsiders mostly say they admire the Cuban health system. The World Health Organization has praised it, and Ban Ki-moon, the former United Nations secretary general, described it as “a model for many countries.” In many ways, the Cuban and United States health care systems are mirror opposites. Cuban health care is dilapidated, low-tech and free, and it is very good at ensuring that no one slips through the cracks. American medicine is high-tech and expensive, achieving some extraordinary results while stumbling at the basics: A lower percentage of children are vaccinated in the United States than in Cuba.
The difference can also be seen in treatment of cancer. Cuba regularly screens all women for breast and cervical cancer, so it is excellent at finding cancers — but then it lacks enough machines for radiation treatment. In the United States, on the other hand, many women don’t get regular screenings so cancers may be discovered late — but then there are advanced treatment options.
As Cuba’s population becomes older and heavier (as in the United States, the nutrition problem here is people who are overweight, not underweight), heart disease and cancer are becoming more of a burden. And the lack of resources is a major constraint in treating those ailments.
There’s a Cuban saying: “We live like poor people, but we die like rich people.”
By Sadiq SaleemOn January 29 last year, Chief Justice Saqib Nisar had suddenly asked the question, “Where is Husain Haqqani?” in the middle of a case about voting rights for overseas Pakistanis. He then went on to reopen the seven-year old Memogate case, which had been shelved by four of his predecessors.
Almost a year, and several hearings later, Justice Nisar has retired as Chief Justice, adding 2,125 more cases to the list of 40,000 cases pending in the SC. Haqqani continues to live in the United States and travels all over the world.In his quest for Haqqani, Justice Nisar first discovered that there were no criminal charges registered anywhere in Pakistan against the former ambassador. Apparently Haqqani had been bad-mouthed in Pakistan’s media from 2011 (when he stepped down as ambassador) until February 2018 without a single criminal charge being filed against him.
This anomaly was clumsily rectified by hurriedly filing various FIRs around the country by several people on grounds of treason even though the law clearly states that treason charges can only be filed by the state.
Ironically, former President General Pervez Musharraf, who faces a treason case brought against him by the government through due process, remains out of the country. CJ Nisar made no serious effort to repatriate Musharraf, making his enthusiasm against Haqqani seem misplaced.
Moreover, anyone with a modicum of knowledge of international law would have known that treason is defined as a ‘political offense’ and is not subject to extradition.
The many court hours wasted on pursuing a man who has committed no crime beyond having views some Pakistanis do not like, could be used to deal with the tens of thousands of pending cases
It was embarrassing when warrants issued against Haqqani were rejected by Interpol on grounds that refusal to appear before the Supreme Court in a political case and charges of treason were both outside the jurisdiction of Interpol.The outgoing Chief Justice continued to discuss, in open court, how Haqqani could be brought back after Interpol’s refusal to act. He even appointed an Amicus Curiae, a lawyer supposed to be an expert in international law to figure out how to repatriate Haqqani.
It was almost comical for a Chief Justice to be saying, “I want this man back, so let us find a case that will lead Interpol or other governments to act against Haqqani.” Normally, judges should not encourage invention or initiation of charges against individuals.Subsequently, corruption charges were filed against Haqqani on advice of the Deputy Attorney General and the Amicus Curiae in the hope that these might force his repatriation.If anything, filing of charges seven years after Haqqani’s resignation as ambassador and without any new evidence only made it apparent that the former ambassador was being hounded.A First Information Report claiming that a crime was committed seven to 10 years ago is hardly credible and runs contrary to statutes of limitations in most countries. In the U.S., a case must be filed within five years of an alleged crime.
Interpol refused to act against Haqqani a second time, recognising the political nature of the proceedings. The CJ then decided to conduct hearings in camera. At the last hearing, Justice Nisar seems to have been told that an extradition request to the U.S. government could be one way of repatriating Haqqani. Given the lapse of time and other factors, it is impossible that the U.S. would extradite a former ambassador and a prominent scholar. If filed, the extradition request would certainly have been turned down.
The former Chief Justice was obviously taken in by the hype over the so-called Memogate case, not realising that it has no resonance beyond Pakistan’s noisy electronic media.
It is time to bury the Memogate case, which was taken up by then Chief Justice Iftikhar Chaudhry as part of his political agenda against the PPP, and then president Asif Zardari. Memogate was a product of media noise, aided by Justice Chaudhry’s love for media attention.
The petitioner in the case, Mian Nawaz Sharif, later acknowledged he had made a mistake in bringing the petition before the Court at the urging of hidden hands.CJ Nisar erred in his populist enthusiasm in reopening the case after four Chief Justices between him and Iftikhar Chaudhry chose not to even schedule a hearing of the matter.Now that Mian Saqib Nisar has retired, his successor should consider pursuing the original Memogate petition as infructuous.The Supreme Court is not a trial court and the original issues in the petition, which were controversial to begin with, have become redundant over time. The sole ‘witness’ and accuser in the matter, one Mansoor Ijaz, seems to have disappeared from public view; Haqqani cannot be brought back; and most jurists agree that the grounds on which the petition was decided were flimsy at best.
Condemning Haqqani’s opinions, and talking about ways to force his return, might generate headlines in the local media but they do not affect his ability to write and speak internationally. What, then, is gained from keeping the so-called Memogate case alive?
The many court hours wasted on pursuing a man who has committed no crime beyond having views some Pakistanis do not like, could be used to deal with the tens of thousands of pending cases that affect the lives of people.
There is reason for hope in the fact that the judgement was announced in difficult times, but there is also the reality that the verdict was followed by a right-wing backlash from some sections of society.
Indeed, Mr Jinnah’s words — that Pakistanis are free to go to their respective places of worship, and that religion has “nothing to do with the business of the state”, have yet to translate into a secure reality for the minorities.
The truth is that minorities in Pakistan do not feel safe as society has moved far from the intentions of its founding father, and the state has done little to rein in those who spew venom on adherents of a faith not their own. It has simply stood by as various minority communities have for years been relentlessly targeted by hardline groups.
Whether it is the Christians of Gojra, the Hazaras of Balochistan, the Hindus in Sindh, or the Kalasha people of Chitral, despite all the laws on the books Pakistan has proved a formidable environment.
The only hope lies in the stringent implementation of the law, where those that harass and threaten beleaguered communities are pursued and successfully prosecuted.
This was envisioned as a country where minorities have exactly the same rights as the majority population. It will not do to target religious differences that have for centuries made this region unique.
The dark clouds under which Pakistan’s religious minorities labour are a reality that will require much effort to dispel. It is time to return to Mr Jinnah’s vision.
Published in Dawn, December 25th, 2018
In his message, the PPP Chairman said that the killings of the citizens are a vivid proof that the government of PTI has made Punjab a Police State.
“The killings are a message to the people of the country that they should not go out with their children”, he said, adding, “The killings of parents in front of their children has exposed all tall claims of ‘good governance’ of the ruling PTI.”
Bilawal Bhutto Zardari said that the government had shamefully disappeared after the killings of parents in Sahiwal, which perhaps they believed to be the best of their governance.
He said that the PTI government and the PM claimed to transform Pakistan into a welfare state of Medina but they don’t know that the head of the Medina state used to hold responsibility for anything that would hurt the people.
He said that the announcements for enquiry into the killings of parents and children by the government are sheer face-covering things while nobody trusts the government. Those who shuffled ranks and positions in Police just to please friends can never ensure justice.
Bilawal Bhutto Zardari said that the entire government is dependent on twitter handles and they are only experts in maligning tactic. The fact is that ‘Law of jungle’ has been imposed ion Pakistan under PTI’s slogan for ‘New Pakistan.’