The tragedy of Thar

Drought, governmental neglect, a culture of dependency, as well as understaffed and ill-equipped hospitals combine to exacerbate Thar’s crisis

By Shazia Hasan

Only when you look closely at tiny Aijaz, admitted to the malnutrition ward at the Mithi District Headquarter Civil Hospital, do you notice his teeth and realise he is not a baby. The note on his cot’s headboard indicates that he is five years old. “His mother cannot tend to him at the hospital as she is busy with her newborn at home,” says Aijaz’s grandmother.

Another cot in the same ward is occupied by 28-day-old Sanam. Her mother, Debu, sitting nearby, says she gave birth to 10 children, of which only four are alive. Sanam, fighting for her life now, is one of them.

Photos by Fahim Siddiqi / White Star

Mithi is the capital of District Tharparkar. The District Headquarter Civil Hospital in Mithi serves about one million inhabitants of Thar, coming from villages and towns, large and small — it is after all the only secondary hospital of the district. Such is the high incidence of malnutrition in Thar that the hospital has set up a separate malnutrition ward.

Roaming the hospital corridors are scores of parents and grandparents — it turns out that the hospital also has a neonatal section for babies under 30 days old. The neonatal ward sees more deaths than the malnutrition ward.

“Some 550 children have been admitted to the hospital since September 2013, of which 439 got better and were discharged while 11 expired,” claims Dr Sikander Raza, a paediatrician at the Mithi District Headquarter Civil Hospital.

Dr Ram Ratan, the medical superintendent at the hospital, says that babies are often born with low birth weight and can be premature, because the mothers are weak due to having many babies without much gap between pregnancies. “Mothers’ health is a major cause of babies dying and babies suffering malnutrition,” he points out.

As with other health facilities in Thar, Mithi’s District Headquarter Civil Hospital routinely sees women giving birth without much gap between pregnancies (above). Meanwhile, the PPHI in Village Kantio wears a deserted look (below).

Thari parents, though, largely believe that if they have reached the hospital — sometimes a two or three-hour drive from their far-flung villages — their child will be saved. “There are times when a child needs greater care; in such cases, we refer them to bigger hospitals in Hyderabad and Karachi,” says Dr Ratan. “But then there are people who take their children away mid-treatment; they think that no doctors will be able to provide treatment. They are not satisfied, they get angry.”

Since 2013, 43 children were taken away by their families after deciding not to get them treated there.

“Let us be very clear: these children are not dying due to hunger; they are dying because of malnutrition,” argues Dr Sono Khangharani, chief executive officer of the Hisaar Foundation. “Malnutrition happens due to three factors: over population, less animal produce, and vanishing of greens from people’s diets.”

The district-wide crisis of malnutrition in Thar has seen many families suffer and mourn the loss of a child. There are only hospitals where parents can rush their children, the secondary hospital in Mithi or the one in the adjoining district of Umerkot.

“Around 500 patients turn up in our out-patients’ department (OPD) every day,” says Mohammad Jam, in-charge at the Umerkot District Headquarter Hospital. “There are no deaths happening due to malnutrition per se, but complications of malnutrition such as pneumonia and diarrhoea.”

The ‘functioning’ blood laboratory in Umerkot District Headquarter Hospital

Jam argues that much of the blame rests with a lack of family planning. “We have many newborn deaths where the babies are underweight due to a lack of family planning. Usually, we find weak babies and those suffering from malnutrition of say around six months of age, whose mothers are not nursing them as they are pregnant again. Family planning is a bigger issue here,” he explains.

For Jam, the problem is also that his hospital is terribly understaffed. “We have no child specialist and no gynaecologist though we have a temporary lady doctor borrowed from another establishment to cover for the eight lady doctor posts here,” he says, explaining that of the 46 vacancies for doctors, only 23 were filled.

The 55-bed Umerkot hospital, which started in 1978-79 as a rural health centre, was promoted to a taluka hospital in 1986 and is now the district hospital since 2002. “The hospital was upgraded by getting a new name each time, without much change in its infrastructure. It is a secondary hospital where the facilities should be increased and upgraded according to our needs,” Jam points out, adding that common ailments in the area include waterborne diseases such as gastroenteritis, hepatitis and typhoid.

The quandary of the hospital extends to more than short-staffing. Senior medical officer at the hospital, Dr Chehnomal, explains that they had an x-ray machine but it was out of order. There are four ambulances but only one driver, and he too had been borrowed from the Health EDO. Still, according to him, they had medicines available and an operational laboratory.

But inside the lab, all kinds of new equipment still lay packed in crates. When asked why they hadn’t been unpacked, the hospital staff claimed that they had no place to set up the equipment. The extra space was consumed by a vacant Congo Virus isolation ward that had been inaugurated by a government VIP.

Photos by Fahim Siddiqi / White Star

“Malnutrition, especially among small children, is a historical problem,” says Dr Khangharani of the Hisaar Foundation. “The first famine recorded in Tharparkar was in 1900, when 1,500 human deaths were registered in one month. Following that, the first famine policy came about in 1906. The policy was such that it would come into action when there would be no rain in August. But all that is forgotten now.”

And yet, the average life expectancy of adults in Thar is more than the rest of the country.

“People live longer here, but the 40 to 70 age group is jobless as machines have taken over what was once the province of manual labour,” says Dr Khangharani. “This contributes to perpetual debt — Thar is the only place in Pakistan where 80 per cent people borrow money to buy food. When you do that, the choice of food is minimised too. With borrowed money, you will only buy necessary things such as flour or rice but no potato, onions or tomatoes.”

Recent trends have shown that the government employs some 3,000 contactors to provide relief in Tharparkar. “They are supposed to distribute a set number of sacks in each drought-affected area, but many contractors keep a few for themselves to sell into the market. These are some of the changing dynamics of Tharpakar that have created a problem here,” explains Dr Khangharani.

Drought expert Ali Akbar Rahim says that drought is a phenomenon that is turned into a disaster due to mishandling by the government. “They need to create jobs here. Around 85 per cent of this desert is part of India (in Rajasthan) but they are not dying from malnutrition or droughts there. We here depend on livestock but when our animals are not able to find food with grazing land drying up, their owners migrate. One drought pushes Tharparkar five to 15 years back and the last rain drops fell here in 2013,” he explains.

Another thing that Rahim was concerned about was the trend of giving away things for free by the government in the mid-1980s. “It has added to the people’s dependency as the issues remain the same with no lasting solution,” he says. A good example of this was seen at one of the Peoples Primary Healthcare Initiative (PPHI) centres opened by Govt of Sindh with the help of USAID in the area where some pregnant women had come in though not really for checkups. They were there because they had heard a rumour about distributing of free blankets.

Putting it simply, Mohammad Juman, a resident of Tharparkar, says that malnutrition was linked to drought and drought was linked to shortage of water. “We need tube wells to experiment with various crops. In a place where there is a tube well, the people there have grown sunflower, peanuts, cumin (zeera), trees and fodder for livestock. Our women work so hard carrying canisters of water for miles and up the dunes but still can’t fill their stomachs even so much as to be able to nurse their babies,” he concludes.

Too weak to breathe

More than a quarter of all babies born in Pakistan have low birth weight. In Balochistan, the situation is even grimmer

By Igor G. Barbero

The room in Dera Murad Jamali’s District Headquarters Hospital is decorated with cartoons and balloons. There are tiny babies, lying on blue beds and inside incubators. Many of them barely weigh above 1kg, even days after birth. The ones below 1kg are usually not admitted as their chances of survival are minimal. The babies are connected to oxygen, fluids and are constantly under observation. They struggle to breathe, to live. Some of them have no more strength left to cry.

Dr Barkat Hussein makes his rounds of the nursery. He checks vital signs with his stethoscope. There are some instructions on the walls: “Dry the baby, assess the tone, breathing, heart rate.”

The doctor takes Chath Bibi in his hands, carefully, so as not to break her neck. She was born premature and has been in the nursery for 18 days. When she was admitted her weight was 1.65kg and now it is 1.43kg. It is normal for babies to lose weight in the early days of their lives. Chath Bibi has a difficult road ahead of her but recovery is underway.

One of the most impacting faces of malnutrition among infants can be seen at this neonatal ward run by the Médecins Sans Frontières (MSF) in the District Headquarters Hospital in Dera Murad Jamali in the eastern part of Balochistan.

According to national data from 2011, malnutrition contributes directly or indirectly to 35 per cent of all deaths of children under five in Pakistan. Between a quarter and a third of all newborns are born with low birth weight, and over half of women of reproductive age weigh less than 45kg.

The provinces of Sindh and Balochistan register the highest proportion of malnourished children across the country. The dusty town of Dera Murad Jamali, one of the hottest places in Pakistan, lies in this middle territory. It is close to the Indus River, a crossing point for cultures where people speak almost every language, from Sindhi to Baluchi, and also Seraiki and Urdu.

“Please maintain the ward capacity always,” reads a board at the entrance to the nursery. It is signed by the medical supervisor.

“There is capacity for 13 babies. Normally it is completely packed and we sadly have to reject patients,” explains Dr Barkat. “They are mostly born outside of the hospital, at their homes. When they reach here, the babies are in a lot of distress, and have respiratory problems because of the use of oxytocin.”

Doctors claim that traditional birth attendants and some medics at private clinics often resort to drugs to speed up deliveries. Women also work hard in the fields during their pregnancies, and hence many children are born premature and weak. They arrive at the hospital very sick, often more than a month after being born.

“People bring their children to us for secondary problems. They don’t know if their baby is growing or not. They only know that the baby has pneumonia, diarrhoea or vomiting. When we tell them what is really happening, they come to understand that the child’s basic problem is malnutrition,” says Dr Barkat.

If things go well, the children remain at the nursery for five to six days. In the worst cases they may stay up to three months. This facility is just the beginning of the journey though, and the tiny babies in the most critical conditions demonstrate the extent of the malnutrition issue in the area.

But beyond the neonatal ward there is also a therapeutic feeding programme that reaches hundreds of families every year. The inpatient and outpatient services located in Dera Murad Jamali and in the nearby towns of Dera Allah Yar and Usta Mohammad received more than 9,600 patients in 2013, all of them children under five. There has been an increase in admissions since MSF started the programme in 2010. Up until October this year, 7,639 patients had received care.

For Jongel Bugti, a farmer from Tipul Shah, this is the fourth time he has visited the programme. He is waiting at the Dera Allah Yar hospital for a consultation and to receive medicine or at least some of the high energy therapeutic peanut paste Plumpy’Nut. On this occasion, he is with his one-year-old nephew. The boy weighs only 5.5kg. “The doctors give us some kind of chocolate. With this medicine the children get better – it is not just my experience, everybody says the same here”.

“I work the whole day to earn a living. Our women also work in the fields because we are poor. They don’t have time to breastfeed the children. Our main problem in Balochistan is a lack of education. This is the biggest constraint to changing things for the better,” says Jongel.

His view is shared by Dr Barkat. Poverty, an insufficient number of medical professionals and health structures, and a lack of health awareness and education all contribute to the malnutrition problem. There are also frequent security incidents in Balochistan, and the area had been recurrently affected by floods. Natural disasters tend to aggravate situations where there is little food security, as they destroy people’s livelihoods and worsen their living conditions. The huge floods in 2010 caused widespread destruction and displaced millions, which in turn sparked a food crisis.

On the top of that, some mothers stop breastfeeding their babies very soon after birth or don’t start at all. “They change the pattern of feeding. If they start breastfeeding they also give supportive bottle feeds and other things and then the baby is away from breastfeeding and quickly becomes malnourished,” says Dr Barkat.

Even though it costs money, giving babies formula milk instead of breast milk is a common practice. Women often have to look after several children and don’t have enough time to breastfeed, or believe their milk is not good as they are very weak.

But breastfeeding is very important in the early months of a child’s life because it gives them antibodies with which to fight disease. Breast milk is clean, free of harmful bacteria and is always fresh and available. It also does not cost anything. Unicef and the World Health Organisation (WHO) recommend that children be exclusively breastfed and not given other liquids or food for the first six months of life.

As per the National Nutrition Survey, nearly four women in Balochistan out of every 10 don’t start breastfeeding their children within one hour of birth and many of them don´t start at all. Some families also end up giving nutrition to one child in particular, often choosing the boy over the girl.

Some 15 mothers gather with their children every day early in the morning at the Dera Murad Jamali hospital to attend a health promotion session. During the 20-minute meeting, MSF staff show picture boards and explain how important it is to clean food, to wash hands or give details of the type of feeding required. They put special emphasis on persuading the audience that breast milk should not be replaced by anything else.

“The mothers often have questions and in the end they admit that they need to follow these advices. Their children may suffer problems otherwise,” says Abdul Majit, a nurse.

“I stopped breastfeeding my baby after one month because I thought it was bad for him and I had little breast milk. I started giving him formula milk. Doctors say I should continue breastfeeding and I will try to do so,” says Lal Kahu, a mum in her early 20s. Her four-month-old child arrived at the hospital suffering from diarrhoea and vomiting, but has been on medication for the last few days and is now getting better, so the family will probably leave the hospital soon and get back to their village, located close to rice fields.

Other children have not been as lucky as Lal Kahu’s son. They did not receive treatment in time. In 2013, 84 children died in the MSF wards in Dera Murad Jamali and the surrounding area. Almost every family in the area has experienced the tragedy of losing a child or has a neighbour who has experienced it. Some women have lost up to five children.

This will hopefully not be the case for eight-month-old Abdurraman though. Outside the hospital, eight members of his family wait for him to be discharged. They sit on a blanket with his grandfather, Ahmed Lahi Day. Abdurraman was malnourished but has recovered his strength in the last five days with the support of the medical staff. In the ward, there is only space for his mother, so Ahmed will spend the night sleeping outside, waiting for Abdurraman to leave in the morning.

They are happy to go home. They are just not sure how long it will be until they need to come back.

Igor G. Barbero is the former Communications Advisor for MSF

Stunted future

We often assume that malnutrition is a purely rural problem. It isn’t

By Faiza Ilyas

Trying to comfort her howling baby, moments after she has been administered a dose of iron supplement, young Salma* appears clueless about how her 15-month-old child, Ayesha*, developed anaemia.

“Ayesha was weak since birth, but has never fallen as seriously ill as now. I brought her here to get treatment for her mouth ulcers and persisting fever. I did not suspect that her illness has something to do with the way I feed her,” says the young mother.

Salma and Ayesha come from Karachi’s old city area of Lea Market, and have been lodged at the paediatric ward of Civil Hospital Karachi (CHK) for the past three days. Around them in the ward are more pale and under-nourished children. Ayesha has been diagnosed with severe Vitamin B-12 and iron deficiencies, which, the doctors say, have made her vulnerable to infections.

Photos by Fahim Siddiqi / White Star

“At 15 months, Ayesha weighs only six kg — this is about half her expected body weight at this age,” explains Dr Muzamil Shabana Ejaz, associate professor at the Dow University of Health Sciences (DUHS) and attending doctor at the CHK’s Paediatric Unit II.

Dr Ejaz has seen such cases multiple times in a day, sometimes, in the same moment too. She argues that malnutrition, encompassing both under-nutrition and overweight, is affecting a significant population in both rural and urban Pakistan, though little awareness exists on the latter. Around 30pc of the total admission per year at the CHK paediatric ward, she says, is either directly or indirectly associated with malnutrition.

The patients include those coming from the interior parts of Sindh, she says, of whom many often report serious complications such as tuberculosis. There are also a large number of critical patients who report at the hospital’s emergency section.

“Among all the causes of death among children under five years, malnutrition is the underlying cause in about 50pc deaths. Malnourished children suffer at every stage of life and miss their milestones. Often when a child is malnourished, the mother, too, suffers from the same problem or vice versa,” says Dr Ejaz, citing a medical research.

According to the Pakistan Demographic and Health Survey (PDHS) 2012-2013, 45pc of children under-five in Pakistan are stunted or too short for their age, indicating chronic malnutrition. Stunting is in fact the most common ailment among children of less educated mothers (55pc); it is more common in rural areas (48pc) than urban areas (37pc); 40pc women are overweight or obese.

Though these statistics are alarming and require immediate intervention, many experts believe that the official data, particularly on the nutritional status of mothers and children, do not reflect the ground reality and believe that the scale of malnutrition among children is much higher.

A recent yet-to-be published research lends credence to this view-point to an extent as it shows that chronic malnutrition (measured as low height for age) is found between 60 and 70pc in children under five years in Karachi.

“Malnutrition is rampant in our low-income urban squatter settlements. The data also show 60pc pregnant women moderately to severely anaemic,” says Dr Anita Zaidi, professor at the Division of Women and Child Health, Aga Khan University.

The impact of chronic malnutrition on a child’s physical and brain development is grave. The IQ level of such children is much lower as compared to those that are properly nourished. Much of the damage is done in the first two years of life, explains Dr Zaidi.

Nutritional deficiencies occur due to multiple factors, argues Dr Ejaz, including poor health of the mother, inadequate/delayed weaning, bottled-feeding, delayed or prolonged breastfeeding, as well as inadequate child care resulting in recurrent infections.

A recent CHK study also links childhood malnutrition to maternal psychiatric illnesses. “We found that over 90pc mothers whose children were malnourished suffered from mental and physical violence at home,” says Dr Fehmina Arif, senior professor at the DUHS and head of CHK’s Paediatric Unit II.

According to Dr Arif, factors such as low birth weight, prematurity, lack of antenatal care, early marriage, large size of the family, unemployment, death of a mother, and having more than two children under five years are also risk factors for malnutrition.

Photos by Fahim Siddiqi / White Star

Scientific evidence, she says, indicates that the first 1,000 days after conception is the most critical period of a child’s development. Poor maternal nutrition within this period will have life-long and life-changing impacts on educational attainment, labour capacity, reproductive health and adult earnings.

Malnutrition, according to Dr Zaidi, is also undermining the fight against diseases that could be prevented through vaccines. Malnutrition, she says, is definitely a factor in sub-optimal responses to oral vaccines such as polio vaccine.

“In Karachi, we have found that among children who have been given multiple doses of oral polio vaccine (OPV) and are well-nourished, 99pc of them have good immunity in their blood after OPV doses. But, in cases where children are chronically malnourished, then despite multiple doses of OPV, 15pc do not develop polio immunity and remain vulnerable to the infection,” she explained.

“Of course, the biggest reason for not having polio immunity is total lack of vaccination. Around 90pc of cases in Pakistan in 2014 (the total number of polio cases reported last year was 297) were due to lack of vaccination, and 10pc developed the disease despite vaccination, most likely due to malnutrition,” she said.

Senior obstetrician and gynaecologist Dr Shabeen Naz, who has recently retired from Sobhraj Maternity Hospital (a government-run health facility) after 32 years, referred to the PDHS survey 2013 that showed over 55pc women also avoided taking iron supplements during pregnancy due to different misconceptions.

“Many women do not take iron supplements in the last three months of pregnancy as they believe that it would make the baby’s complexion dark. Others avoid taking calcium tablets, thinking that it would make the delivery difficult. So, there is huge of lack of awareness among mothers,” says Dr Naz, while pointing to the different challenges in the fight against malnutrition.

In her view, the social mindset that prefers a boy over a girl is also at play, contributing to poor maternal and child health status. She disagreed with a PDHS survey finding that put the number of malnourished women in Pakistan at 40pc. Dr Naz claims the figure actually stands at 70pc.

“Both thin and obese women could be malnourished. Being overweight is a major health issue among Asian and especially Pakistani women. Excess fat around the waist could cause high blood pressure, heart disease and diabetics,” she says.

To improve maternal and child health status, experts suggest an inter-sectoral approach that involves increasing health awareness and school enrolment particularly of girls, focusing on the health of adolescent girls, introducing indigenous fortified food, upgrading primary healthcare services and improving public access to safe drinking water and sanitation facilities.

Names changed to protect privacy

Published in Dawn, Sunday Magazine, January 18th, 2015

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