Migratory and Vulnerable Cave-Dwelling Populations of Pakistan

by Noor Sabah Rakshani,  2011-2012 PRB Policy Communication Fellow and student in Health Care Management and Leadership at the Johns Hopkins Bloomberg School of Public Health.

The last of the permanent cave villages in North America, of the Anasazi Indian tribes, existed about 1000-1300 AD. But in some parts of the world in Africa, Asia, Europe, and the Middle East, people still live in caves. As civilizations have evolved over millennia, we no longer expect humans to be living in caves. The photo below, however, contradicts our expectation of human living conditions in the 21st century. The girl in the photo is receiving oral polio vaccine and lives with her family in a cave in the southwest province of Balochistan, Pakistan. Her family might have been forced out of their settled dwellings due to a number of reasons such as recent floods or ongoing insurgency, which has displaced millions out of their homes, or because of abject poverty.

Photo: Balochistan Vaccination Program Office

I hope this is a temporary settlement for her and other children in similar living conditions, but this also points to a larger neglected issue: the migratory population in Pakistan. This population can be categorized mainly as:

1)      Seasonal migrants. The exact number is not known as they are not counted in the census by default because they don’t live in enumerated houses. In Pakistan, seasonal migrants, which include women and children, are either: pastoral, moving with their livestock in search of grazing land; farm workers moving according to the crop harvests; or nomad tribes migrating to escape the harsh climates of summer and winter. These populations are also missed by the national Demographic and Health Surveys (DHS), so we have little to no substantial data on their living standards and health status. A study that was done on seasonal migrants in the province of Balochistan stated that 74 percent of the families never got their children vaccinated, let alone completed the immunization schedule in a timely manner. This group is unaccounted for in national and provincial planning and development, not reached by NGOs, and lacks access to health and education.

2)      Internally displaced. Following the floods of 2010, almost half a million people are still displaced in the Indus river region and almost one million are displaced due to armed conflict. The insurgency and ongoing wars in the two western provinces of Pakistan have resulted in the displacement of millions who had to flee their homes to less-volatile regions. The majorities of the internally displaced are poor and continue to live in areas with inadequate water and sanitation arrangements resulting in poor health outcomes.

3)      Economic migrants. According to the Pakistan Federal Bureau of Statistics, 2 percent of the population moves from rural to urban areas annually. The rural-urban migration is at times preceded by step migration, whereby people first move from a village to a small town and then to a larger city in search of economic opportunities. The resulting pattern of rapid growth of small- and medium-sized cities in Pakistan is also reflected globally. But moving to urban areas does not ensure higher living conditions, as at least one in every three city-dwellers in Pakistan lives in an urban slum.

The Government of Pakistan and the international community will have to make long-term and robust efforts to improve the living conditions of poor and vulnerable populations, but in the short term, evidence-based, low-cost interventions and policy changes can improve their health. Among public health interventions, vaccines have proven their merit to reduce death and disability among children under five years of age. Vaccines are most effective when given in a timely and complete manner, according the schedule specified by health authorities. According to the Pakistan 2006-07 DHS, among children who start the Expanded Program of Immunization-specified schedule, 27 percent fail to complete it. Nationally, among children ages 12 to 23 months, 78 percent receive the anti-tuberculosis BCG vaccine (the first vaccine in the schedule), but only 50 percent of the children receive the Measles vaccine (the last in the schedule). This situation is much worse among households in the lowest wealth quintile, among less educated, in less-developed regions, and among the migratory population. However, according to the same DHS results, children who had a vaccination card at the time of the survey were 50 times more likely to complete the vaccination schedule, even after accounting for the low socioeconomic status of the parents and the development of the region. Providing children with a rip-proof, smudge-proof, waterproof, and easily stored vaccination card can help in improving the timely and complete vaccination of children. Such an intervention will not only help children with migratory parents, but will benefit the country as a whole.

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