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.

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

“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.

Photos by Fahim Siddiqi / White Star

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.

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

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.

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

On a mobile phone? Get the Dawn Mobile App: Apple Store | Google Play