Growth 'creates new problems', says former Pakistan PM


The great ambition of poor societies is, naturally enough, to get richer. That is what development is all about. But affluence can bring new burdens. The focus of public health in poor counties is on infectious diseases such as malaria, TB, typhoid and cholera.

But as poor people surge into cities in search of work and as their diets and lifestyles change they begin to suffer from all sorts of new maladies and ailments. They begin to get the diseases traditionally associated with affluence such as heart disease, cancer, diabetes and, perhaps more unexpectedly, stress-related illnesses.

So how should developing countries respond? Shaukat Aziz is the former Prime Minister of Pakistan. For the BBC's Business Daily, Justin Rowlatt spoke to him at an international conference on public health in developing countries held at Oxford University.

The full transcript is below:

Shaukat Aziz: Urbanisation is one phenomenon which the developing world is facing, and when you have large numbers of population moving to cities in a country, the infrastructure gets strained and stretched. That gives rise to disease, lack of sanitation, lack of water, lack of housing. So, as the demographics and the dynamics of a city change, the health problems go with it.

Justin Rowlatt: So what differences are we seeing in terms of health issues in cities as this urbanisation takes place?

Shaukat Aziz: Yes. First of all, we see pressure on water supply, sanitation. That in itself is a big challenge. Then you see, as urbanisation takes places, it is not just communicable diseases which affect the people, it is diseases like cardiovascular heart diseases and the main one is mental stress and diseases. So, these are -

Justin Rowlatt: But, I want to know why are people - because these are new people who have come to a city relatively recently and would tend to be quite poor, so how come they are suffering from diseases that are associated with wealthy lifestyles - heart disease, diabetes?

Shaukat Aziz: No, the heart disease, diabetes and mental disorders don't relate to income levels only. Stress is the biggest thing you get in a large urban centre. When you come to a city, you are hungry to do better. You want to make a good living. You want to live in this huge place and create a niche for yourself. That gives you pressures, which you won't get in the other cities.

The other thing is that when you have a large influx of population in the developing country cities, by definition you are increasing the slums which exist, because there are not enough homes, people live in shanty towns and the rich/poor divide gets more pronounced. People don't have access to sanitation. They don't have access to toilets. So, when you come in an urban area, your lifestyle changes, your pattern of living changes and hence the problems. That's why we focused on this. We got a group of 50 people together at Oxford University, and we got the experts of the world trying to address these issues and suggest ways and means to improve them.

Justin Rowlatt: So, what do we do? How do you improve public health facing these challenges?

Shaukat Aziz: First of all, one of the problems you see in large cities is the disconnect between the federal government, the state government or provincial government, and the city government.

Unless you have clear divisions of responsibility, with more responsibility with the city government closer to the people, you will not get the results you need.

Now, we had three mayors in this group: Bogota, Karachi and Budapest giving their experiences. Bogota had a very good experience because the mayor was empowered to deal with human security issues and health issues. So, he could plan, he could line up the resources. Plus, this is not only government, you need civil society to be mobilized, you need philanthropists to come in.

So, if you are living in a slum and somebody opens a clinic for mental diseases or for diabetes that helps the community. It can't always be the government and that's where leadership comes in. Cities are 15 to 20 million people. This is bigger than the size of many European and other countries. So the mayor of the city is a very important politician.

Justin Rowlatt: Mr. Aziz, of course you have experience of leadership, how much did health improve in Pakistan while you were Prime Minister?

Shaukat Aziz: We had a lot of improvement in healthcare. The indicators got better. First of all, measuring it was a problem, so we started the household surveys and getting all the information. Then we came up with policies. We improved health care and one of the things we did very well is encourage private sector and non-profit organisations to become part of the delivery chain.

Justin Rowlatt: I mean you will acknowledge of course there were lots of complaints that some of your policies meant that some people became poorer. There was increased poverty in Pakistan and disease associated with that?

Shaukat Aziz: Actually poverty reduced by half. Poverty reduces when you increase income levels. If you look at the rural areas, the best way to increase rural income is through agriculture. Our agricultural growth rates went up. Then in the urban areas, jobs - there was growth in industry, growth in the service sector

Justin Rowlatt: There was economic growth in Pakistan during your tenure; there is no question about that. But, I was looking at some indicators before you came in, Mr. Aziz, and Pakistan has twice the rate of heart disease than most developed countries and four times the average rate of infectious diseases. I mean these are really bad indicators, aren't they?

Shaukat Aziz: Yes. Because of the various factors which exist in that country, we have to focus on preventive. Mostly, our diseases are waterborne diseases. Cholera is one of the worst waterborne diseases, and we have reduced it.

Justin Rowlatt: But these are associated with poor infrastructure, aren't they?

Shaukat Aziz: Yes. May I say, we had a dramatic increase in that when we had natural calamaties. We had a huge earthquake and now floods. So suddenly, the infrastructure is gone. You move from a home to a camp, there is nothing there and so on and so forth, and pools of water - dengue fever, mosquitoes.

Justin Rowlatt: Do you think the UN needs to do more to combat the chronic diseases we have talked about, which are now such an issue in developing countries, because they make a priority for dealing with communicable disease with infectious diseases, but chronic disease aren't part of what they call their universal framework for development. Is that a mistake by the UN do you think?

Shaukat Aziz: Yeah. Actually, the focus goes on communicable diseases, because they are more "crisis" in nature. Cardiovascular disease spread doesn't create a crisis in terms of the environment or public health.

Justin Rowlatt: But if you look at absolute numbers of death, then…

Shaukat Aziz: It would be increasing.

Justin Rowlatt: …that's in chronic. My question was, do you think the UN should be doing more, because should it make it a priority?

Shaukat Aziz: The UN organ which deals with these issues is the WHO, the World Health Organisation out of Geneva, and I was told that they are now focusing on both sides of the equation, but epidemics create more public reaction for the WHO to act and they have done a good job. So, yes, I think the focus goes on the epidemic side and communicable diseases. More needs to be done on the rest, and I think if we look at health security and human security, by definition you have to look at both sides. And one of the things which came out of our deliberation is that heart diseases, diabetes and mental health are key areas of focus which needs to be done.

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