Bhutta, Zulfiqar Ahmed

Nundy, Samiran

English

eCommons@AKU

eCommons@AKUDepartment of Paediatrics and Child Health Division of Woman and Child HealthApril 2017On the brink of conflict: the people of South Asiadeserve betterZulfiqar Ahmed BhuttaThe Aga Khan University, zulfiqar.bhutta@aku.eduSamiran NundyGanga Ram Postgraduate Institute for Medical Education and Research, New Delhi, IndiaFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_women_childhealth_paediatrPart of the Pediatrics CommonsRecommended CitationBhutta, Z. A., Nundy, S. (2017). On the brink of conflict: the people of South Asia deserve better. BMJ, 357(j1528), 1-2.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_women_childhealth_paediatr/356HEALTH IN SOUTH ASIAthe bmj | BMJ 2017;357:j1528 | doi: 10.1136/bmj.j1528 1On the brink of conflict: the people of South Asia deserve betterCountries must work together for enduring peace and wellbeing in the regionNearly two decades ago, coincid-ing with overt nuclear tests con-ducted by Pakistan and India, we highlighted in The BMJ the huge risks of beginning a nuclear race in the subcontinent1  and its massive costs.2  Today, South Asia is once again at the brink of conflict, with massive deployment of armies on the borders between Pakistan and India. Insurgency and unrest affect major regions in Kashmir, Baluchistan, Assam, and the tribal and Maoist controlled areas in both India and Pakistan.3 Afghani-stan has seen incessant conflict and suffer-ing since the Soviet invasion in 1979. Nepal has emerged from decades of a debilitating Maoist insurgency, and Sri Lanka has just begun rebuilding the north after years of war and devastation.Terrorism, which had been relatively rare, is now a daily threat affecting the lives and livelihoods of millions in South Asian states. Conflict, civic unrest, and insurgency have cost the region dearly. Despite continued economic growth and development, South Asia remains one of the poorest and most unequal regions of the world. Alarmingly, poor social determinants and development have fuelled grassroots rebellions and  insurgency in some instances4  and in others underlay large scale despondency and  suicides.5 6Some may argue that nuclear capacities have prevented large scale war between India and Pakistan, but it has not deterred smouldering conflict. The Siachen conflict, a meaningless confrontation to contest an invisible boundary at an average height of 6000 m above sea level, is a case in point. This dispute alone has cost India and Paki-stan almost 0.1% of their gross domestic product annually since 1984 with over 2000 lives lost because of inclement weather and avalanches.7  The weaponry, missile delivery systems and warfare tech-nology cost both countries over $60bn (£48bn; €55bn)  annually8—money desper-ately needed to alleviate poverty and for healthcare and human development in both countries.Even more alarming is the regression of grassroots movements for peace and resolu-tion of conflict resolution over the past decade. Current generations are fed an incessant daily dose of jingoistic and  nationalistic slogans and a highly selective, mutilated form of history. The growth of social media and communication technology may have increased contacts between people but it has also fuelled hysteria and war mon-gering.It is in this context that revisiting the public health priorities of the region becomes even more imperative. South Asia comprises a diverse set of countries ranging from small nations with popula-tions of less than a million, such as the Maldives and Bhutan, to one of the world’s most populated nations: India with more than 1.3 billion people ( figure). The South Asian Association for Regional Cooperation, set up as a platform for regional collaboration and economic development, is largely dysfunctional and symbolic. Human development indices have improved for some countries (Afghanistan, Sri Lanka, and the Mal-dives) over the past decade, yet for others the situation has hardly changed (table 1).As this special collection of The BMJ underscores, gender disparities, undernu-trition, and social inequities remain ubiq-uitous in South Asia, and over 300 million people in the region remain in abject pov-erty.12 Authors from across the region draw attention to the health needs of peo-ple in South Asia and set out priority actions for governments and health sys-tems in the region.What can and should be done? Firstly, there has to be the political will and tangi-ble action to bring peace, build confidence, and resolve our conflicts. This can be fos-tered by promotion of greater contact and dialogue between people in the region. Although this can be achieved through many avenues, including cultural and sporting activities, we believe that promot-ing health, especially public health priori-ties in the region, can serve as an important bridge to peace. There have been limited efforts to get public health professionals and research bodies to work together. Sci-ence collaborations remain nascent, and opportunities for scientists and student exchanges are few and far between and hampered by restrictive visa procedures. We propose that concerned authorities in all countries of the region as well as the donor community promote and facilitate platforms for joint public health projects, advocacy, training, and research. In addi-tion to governments and public sector insti-tutions, there are huge opportunities for collaboration towards defined public health goals to be explored within the pri-vate sector, professional associations, and civil society.Secondly, South Asia needs to massively increase its investments in human develop-ment. The transition from the millennium development goals13  to the sustainable development goals (SDGs) 14 offers the opportunity to tackle social determinants of health. SDG 16 sets targets for peace, justice, and strong institutions and SDG 17 calls for partnerships to achieve these goals. South Asia’s medical and public health community can lead the way with concrete actions, joint planning, and mutual accountability. Set-ting up a regional task force to monitor prog-ress and support action towards attainment of the SDGs is a starting point.This collection of The BMJ is a step towards building those bridges for peace and development in South Asia. We call on the health community of South Asia to rise to the challenge and take several steps for-ward from jingoism, misplaced nationalism, and a potentially disastrous nuclear arms race. We owe this to our children and the generations that will follow.NepalBangladeshBhutanPakistanAfghanistanIndiaSri LankaMaldivesFigure  | Map of South Asian countriesHEALTH IN SOUTH ASIA2 doi: 10.1136/bmj.j1528 | BMJ 2017;357:j1528 | the bmjCompeting interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.Provenance and peer review: Commissioned; not externally peer reviewed.Zulfiqar A Bhutta,  director1,2Samiran  Nundy,  dean3 1Center of Excellence in Women and Child Health,Aga Khan University, Karachi, Pakistan2Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada 3Ganga Ram Postgraduate Institute for Medical Education and Research, New Delhi, IndiaCorrespondence to: Z A Bhutta zulfiqar.bhutta@aku.edu1 Bhutta ZA. Staring into the abyss: walking the nuclear tightrope in south Asia. Sanctions can only make things worse for the people of India and Pakistan. BMJ 1998;317:363-4. doi:10.1136/bmj.317.7155.363. 2 Bhutta ZA, Nundy S. Thinking the unthinkable!BMJ 2002;324:1405-6. doi:10.1136/bmj.324.7351.1405. 3 David S, Gazi R, Mirzazada MS, Siriwardhana C, Soofi S, Roy N. Conflict in South Asia and its impact on health. BMJ 2017;357:j1537.4 Bhutta ZA. Children of war: the real casualties of the Afghan conflict. BMJ 2002;324:349-52. doi:10.1136/bmj.324.7333.349. 5 Merriott D. Factors associated with the farmer suicide crisis in India. J Epidemiol Glob Health 2016;6:217-27. doi:10.1016/j.jegh.2016.03.003. 6 Nambiar D, Razzak J, Afsana K, et al. Mental illness and injuries: emerging health challenges of urbanisation in South Asia. BMJ 2017;357:j1126.7 Raghavan VR. Siachen: conflict without end.Viking, 2002.8 Stockholm International Peace Research Institute. SIPRI military expenditure database. https://www.sipri.org/databases/milex. 9 World Bank. World Bank databases. http://data.worldbank.org10 United Nations Development Programme. Human development report 2015. http://hdr.undp.org/ sites/default/files/2015_human_development_ report.pdf11 WHO/Unicef joint monitoring programme for water supply and sanitation. https://www.wssinfo.org/data-estimates/12 Akseer N et al. Current issue BMJ South Asia.13 United Nations. Millennium development goals report. 2015. http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf14 United Nations. Sustainable development goals: 17 goals to transform our world.  http://www.un.org/sustainabledevelopment/sustainable-development-goals/Cite this as: BMJ 2017;357:j1528 http://dx.doi.org/10.1136/bmj.j1528Table 1 | Demographics and development indicators in South Asian countries9-11Indicators Afghanistan Bangladesh Bhutan India Maldives Nepal Pakistan Sri LankaPopulation : Total, 2015 (millions) 32.5 161 0.77 1311 0.36 28.5 189 20.9 Total, 2004 (millions) 23.5 14.1 63.4 1126 0.3 25.2 150 19.4  % change 38.4 14.3 22.2 16.4 31.1 13.2 25.7 9.0 Annual population growth, 2015 (%) 2.8 1.2 1.3 1.2 2.0 1.2 2.1 0.9 Urban population, 2015 (% of total) 26.7 34.3 38.6 32.7 45.5 18.6 38.8 18.4Human development index:  2014 0.465 0.570 0.605 0.609 0.706 0.548 0.538 0.757 2004 0.399 (2005 data) 0.530 0.538 0.611 0.739 0.527 0.539 0.755 % change 16.5 7.6 12.5 −0.3 −4.5 4.0 −0.2 0.3GDP per capita, 2015 ($) 590.3 1211.7 2532.5 1581.6 7681.1 732.3 1429.0 3926.2% of population living below national poverty line of $1.08/day (year of data)35.8 (2011) 32.0 (2010) 31.5 (2012) 21.9 (2011) 15.7 (2009) 33.0 (2010) 22.5 (2013) 6.7 (2012)No of physicians, nurses, and midwives per 10 000 population (year of data)6.5 (2012) 5.74 (2011) 12.4 (2012) 24.54 (2011) 64.5 (2010) 6.69 (2004) 14.0 (2010) 23.21 (2010) % with access to improved drinking water source: 2015 55.3 86.9 100 94.1 98.6 91.6 91.4 95.6 2004 37.3 79.1 89.1 84.5 96.6 81.2 89.3 84.2 % change (%) 48.3 9.9 12.2 11.3 2.1 12.8 2.3 13.5% with access to improved sanitation facilities:  2015 31.9 60.6 50.4 39.6 97.9 45.8 63.5 95.1 2004 25.7 49.7 37.4 29.6 87.3 28.3 44.1 85.4 % change 24.2 22.0 34.9 33.8 12.1 62.1 44.0 11.4

On the brink of conflict: the people of South Asia deserve better

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On the brink of conflict: the people of South Asia deserve better

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