Health and Invisibility
In October 2023, the Government of Pakistan told millions of Afghan refugees to leave the country by 1 November 2023, or they would be forcibly sent back. By January 2024, the government boasted that half a million refugees had “returned home”. Pakistan guarantees birthright citizenship, and a significant number of Afghan refugees were born in Pakistan. Technically, they are citizens of the country – in reality, they are stateless, meaning that they not only lack citizenship documents, but also rights to access appropriate healthcare and education. In addition to millions of Afghan refugees who were from Afghanistan, or were born in the country to Afghan parents, there are estimated three million Bengalis who actually did not come from any other nation state. They were born in Pakistan yet have remained outside the rights and entitlements of citizenship.
While there has been rigorous scholarship on the theoretical dimensions of statelessness, the impact of statelessness on the denial of essential services, including healthcare, has not received adequate attention. How have the stateless navigated healthcare access? In my recent book, We Wait for a Miracle, I have tried to answer this question by looking at healthcare access among communities that have received relatively less attention in the academic and public discourse. The situation in Pakistan is important for several reasons. First, the size of the forcibly displaced population is among the highest in the world, second Pakistan has both refugees and stateless communities, and finally, the awareness in Pakistan about stateless communities is astonishingly low.
Statelessness in Pakistan has historic roots. At the time of the country’s founding in 1947, there were two parts of the country, a western part and an eastern part. The eastern part was mostly ethnically Bengali, and despite having a larger population, it was discriminated against by the western part, where the seat of the government was located. Prejudice, discrimination and injustice against the Bengali speaking population led to a bloody civil war in 1971, culminating with east Pakistan becoming Bangladesh. Since West Pakistan was economically better off, many socio-economically disadvantaged Bengalis moved to West Pakistan (which was now just Pakistan without the prefix ‘west’). Many of them were employed in the growing fishing industry of the southern port city of Karachi. In essence, these people were simply moving from what was one part of the country to the other. In the aftermath of the civil war, however, there was now an increased hostility towards Bengalis in Pakistan. The Government of Pakistan issued a decree saying that only those persons were entitled to citizenship who were living in Pakistan, on or before 16 December 1971. In a country where government issued documents were rare, this was an impossible task for many. These ethnic Bengalis were too poor to return to the newly created state of Bangladesh, that was neither economically stable nor interested in having hundreds of thousands of people return.
As a result, a large number of ethnic Bengalis got stuck in a near permanent state of statelessness. Their children, who were born in Pakistan, inherited statelessness from their parents. The absence of an ID card meant almost no access to healthcare, education and employment. This was exacerbated by the move, in 2000, by the Government of Pakistan to create a National Database and Registration Authority. They also introduced computerized national ID cards (CNICs). The digitization of the national ID cards has been hailed as a major achievement by privileged citizens who can now apply for passports and other documents online. But those who were already stateless, or viewed with suspicion by the government, or had been previously granted an ID card, could now be excluded (along with their entire families) from the national system by the single touch of a button. Around the same time, the ethnic Bengali population was coerced to register as aliens – thereby formalizing their exclusion from the citizenship of the country that they were born in.
Most of the stateless Bengalis in Pakistan live in urban slums, including Machar colony, a strip of reclaimed land near the Arabian sea. With little access to education, hazardous working conditions in the informal sector, minimal sanitation services, and a state sponsored denial of healthcare services, residents of Machar colony seek care through untrained and unlicensed providers or go in high debt to afford private healthcare. During COVID-19, anyone without a CNIC was explicitly excluded from vaccination for several months until the policy changed. There were no formal testing sites in the colony and no effort was made to generate awareness. With Pakistan among the countries most vulnerable to the impact of climate change, the stateless community is likely to be among those who will be affected the most.
Unfortunately, there remains negligible interest among the national, provincial or municipal policy makers to recognize, let alone, address the issue. International organizations committed to address the issues of forcibly displaced communities seem just as uninterested. Lack of funding, awareness and research has meant little change in the condition of stateless communities. The impact of this apathy is perhaps most prominent in the denial of healthcare. The campaigns for universal health coverage, nationally and globally, are only going to work with those who exist in the eyes of the state. There is no such privilege for those who do not exist in the official census. Along with a lack of understanding and awareness, there is a long history of systematic discrimination against the stateless, in Pakistan and elsewhere. Despite the global slogans that describe technology as a great equalizer in health, digitization has made exclusion easier. It is now easier than it ever to erase someone from the national system and deny them the right to life and health.
