The skin around five-year-old Mubashir’s lower limbs is dry and scaly. Wearing a magenta pink shalwar kameez suit, which literally hangs on him, he seems detached from the world around him. The set of toy police cars his father just bought him does not excite him either and the gift remains unopened. He is listless and irritable. All that he can manage is a whimper with no energy to cry.

Mubashir was brought from Orangi town to Karachi’s Civil Hospital with an unstoppable bout of diarrhoea and high fever. He was shifted to the Nutrition Ward in the hospital’s paediatric unit where he is being treated for malnourishment while the nurses try to stabilise his fever and diarrhoea. Doctors on duty consider him among the more severely malnourished kids in the room that day. “He just weighs 11 kg, when he should be weighing at least 18 kg,” points out Samina Habibur Rehman, a health volunteer, who has been working in the ward for 27 years.

At the far end of the room, on another bed, one-year-old Rehana has just soiled the sheets. She cries incessantly, clinging on to her father, Haji, as her mother, Perween, tries unsuccessfully to extricate her from him. The family has come from Gharo, bringing along two older kids. With her full face, rounded limbs, Rehana looks far from malnourished. “That’s just an eyewash,” points out Dr Asad Ali, the doctor on duty. He presses her feet leaving a dimple there for a second or two. “She’s suffering from oedema,” he says pointing to the dip on her skin. “The child has swelling which indicates she lacks vital nutrients and is protein deficient,” he explains. “She should be weighing 11kg, but the scale shows her weight to be not more than 7kg,” says the nurse.

Poverty and lack of education leave young children in Pakistan at the door of starvation

Across from the Hajis, lies two-year-old Harmain, who was brought to the hospital just a day before, suffering from the same symptoms as Mubashir’s. Like him, she has a tube and a canula attached with a white tape on her tiny hand so nurses can administer fluids into her tiny body without continuously pricking it. Looking at the ceiling listlessly, she wails loudly. This seems to sap her energy and she becomes quiet again. “She should be weighing 13 kg, instead she is just eight kilos,” says the lady health worker.

FIRST 1,000 DAYS

According to Dr Zulfikar Bhutta, the founding director of the Centre of Excellence in Women and Child Health at the Aga Khan University in Karachi, the first 1,000+ days (from preconception to pregnancy up to the child’s second birthday) are key for optimising childhood growth and brain development.

“If the importance of these early years is recognised by families and parents and the child provided with good nutrition, timely vaccination and optimal sanitation and hygiene practices, we can avert much of the burden of ill health,” he points out.

That’s easier said than done. Over 13 percent of the population still practices open defecation and the country has the fifth-highest number of people defecating in the open in the world.

In addition, the Pakistan Demographic Household Survey (PDHS) 2012-13 states the national coverage for routine immunisation (hifazati teekay) against nine childhood diseases stands at a dismal 53.8 percent (with Punjab at 65.6 percent, Khyber Pakhtunkhwa at 52.7 percent, Sindh at 29.1 percent and Balochistan at 16.4 percent). However, recent reports from the Expanded Programme on Immunisation puts the coverage now to about 80 percent, with Punjab taking the lead and rising to 90 percent coverage.

All of Mubashir’s older siblings (his three brothers) go to school. But because he has been suffering from fever and diarrhoea and has been in and out of hospitals after his first birthday, he remains unschooled. “He can barely walk and then insists I pick him up; he is always irritable, and doesn’t want to play outside with other kids. The most he will do is sit on a bench outside our gate and watch them play,” laments his mother, Sajida.

Bhutta says there is a “direct link of malnutrition to ill health and diarrhoeal illnesses especially in the first 1,000 days.” Pakistan has a particularly high mortality rate from diarrhoea with 105 deaths per 10,000 births. “Often such children are termed ‘stunted’ if their height is low in relation to their age and many can also be ‘wasted’ [have low weight for height],” he adds.

According to the National Nutrition Survey 2011, one-third of all children in Pakistan are underweight, nearly 44 percent are stunted, 15 percent are ‘wasted’, half of them are anaemic and almost one-third of these children have iron deficiency (anaemia). These figures have hardly changed in the last two decades.

“Doctors get very angry with me and tell me I don’t feed him properly,” says Sajida, adding that she gives her son 1/4 kg of chicken every day, which he enjoys eating, but refuses to eat fruit, vegetables or drink milk. She is nonplussed why her other three sons are healthy.

FROM BREAST MILK TO SOLIDS

Dr D.S. Akram, a paediatrician heading a non-profit, HELP (Health Education and Literacy Programme), says mothers are often unaware of their children’s “optimum dietary needs.” Few women know the importance of colostrum that they discard, depriving the newborn of the mother’s first milk which contains essential nutrients and antibodies to fight diseases.

Although mothers know that breast milk is best, they too start their babies on formula, decreasing the support of the infant’s immune system and thereby exposing the baby to a multitude of infections,” Dr Akram explains.

“Although mothers know that breast milk is best, they too start their babies on formula, decreasing the support of the infant’s immune system and thereby exposing the baby to a multitude of infections,” she explains. According to Unicef, formula use is at an all-time high in Pakistan, at 42 percent, with just 38 percent babies being breastfed exclusively during their first six months.

Pakistan stands at 180th position among 185 countries with prevalence of anaemia among women of reproductive age according to the Global Nutrition Report (2016). The World Health Organisation states that 50 percent of Pakistan’s adolescent girls are deficient in iron and of the women who are recommended folic acid and iron during pregnancy, half do not take it for the full duration of six months.

“If the mother is anaemic, her energy levels will be low and she may not be able to breastfeed and cope with her duties and resort to supplementing with formula milk,” says Akram. But she dismisses the myth that these mothers do not produce enough milk for their baby. “The quality and quantity of breast milk will not be affected due to the mother being anaemic; she will only become more deficient in iron and other micro nutrients and grow weaker,” she explains.

According to Ali, families from humble means often believe formula milk is healthier but because it is so expensive. They also want it to last longer than it should by mixing smaller quantities of powder into the water. “If the milk is diluted, it does not provide the right quantity of nutrients and can lead to malnourishment,” he says. Akram agrees it is a common practice with very serious consequences.

Doctors have observed that the bottle and its teat are often not sterilised properly or the water which is added to the powdered milk is unclean, resulting in the child frequently falling sick from diarrhoeal infections which, in turn, leads to malnutrition.

Then there are mothers who continue to give only milk to the baby even after six months instead of preparing and introducing the baby to newer solid foods, say child experts. “Trapped in a cycle of unending housework and responsibilities of several kids and in-laws, [mothers] find this to be an easier and quicker solution,” says Ali.

In Pakistan, according to the PDHS 2012-13, only 16 percent of breastfed children are fed foods from four or more food groups daily. “You need time to prepare the food, make it tasty and attractive and then be persistent about feeding it despite the baby’s initial refusals. The changeover from milk to solids is not smooth in most cases,” says Ali. Mothers often give in to the child’s tantrums, and processed food like candy, cookies, papar and French fries are offered as appeasement.

“She refuses to eat vegetables and curries, so I either make French fries for her, or just buy from the market,” confesses Farhana, Harmain’s mother. “She eats a lot of candy and loves Nimco, paapar and French fries ... so I tell myself at least something’s going into her stomach!” she adds sheepishly.

INSIDIOUS POVERTY

While there are many factors for underlying under-nutrition in children, the most pervasive is still widespread poverty. A 2016 report by the United Nations Development Programme says four out of 10 Pakistanis (or 39 percent) live in multidimensional poverty. The report found that in Fata the figure is 73 percent, Balochistan 71 percent, Khyber Pakhtunkhwa 49 percent, Gilgit-Baltistan and Sindh 43 percent each, Punjab at 31percent and Azad Kashmir at 25 percent. The World Food Programme (WFP) says up to 60 percent people in Pakistan are food insecure.

In Hajis’ household, the breakfast consists of bread, one egg and tea — sharing the egg between the five of them. For lunch and dinner it is bread and vegetable (that they grow in their kitchen garden) but if they can’t have that then it’s just bread with chillies and down it with lassi. With earning anywhere from 200 to 500 rupees per day as a porter loading gunny bags filled with wheat, sugarcane, rice etc, his family probably only has meat and fruits at the occasional wedding feast because there are days when they just have to make do with two square meals. The WFP states that a majority of children under two years of age consume less than half their daily energy requirements, with low levels of vitamins and minerals.

But even Haji is nothing but skin and bones and looks way beyond his 25 years. He looks even weaker than his four-month pregnant anaemic wife. When asked if he wants more children after the fourth baby, he is not sure, and looks at his wife who shakes her head vehemently. Sadly, neither are aware of even one of the several modern contraception methods available in the country, that too, free of cost. However, the Pakistan Demographic and Health Survey 2012-13 findings show that 98.8 percent women know of a modern method, while 73 percent know of a traditional method.

REMINDER TO POLITICIANS

With all-pervading malnutrition, child experts are trying to find ways to reduce under-nutrition. The White Ribbon Alliance Pakistan (WRAP) — working to improve maternal and newborn health — is actively engaging with parliamentarians, reminding them of unfulfilled promises their political parties made to the people in 2013 and what needs to be added to their manifestos.

“We studied the 2013 manifestos and found they talk about health, but the focus is just on curative services, that too, in tertiary care,” points out the national manager of WRAP, Dr Asma Badar. The primary health services, especially the preventive services, have had not been duly incorporated in their book of promises, she found.

“This is absolutely the right time to engage with parliamentarians and other relevant stakeholders in constructive dialogue to ensure nutrition and health makes inroads into the manifestos with necessary budgetary allocations,” says Badar. For its part, WRAP is taking the lead and has already convened three meetings in Sindh (at Sukkur, Hyderabad and Karachi) with parliamentarians of various parties. “Anaemia in the women of Sindh is worse than other provinces,” she explains on why Sindh remains a focus.

GREAT LAWS, BAD IMPLEMENTATION

According to Irshad Danish, National Coordinator of Scaling-Up Nutrition Civil Society Alliance Pakistan (SUN-CSA) — a coalition of over 150 civil society organisations — the country has some good laws and strategies to combat malnutrition. For example there is a law promoting breastfeeding and child nutrition, but it has so far remained on the statute book.

“The national breastfeeding law was enacted in 2002, it took seven years, in 2009, for the rules of business [RoB] to be written and another four years to set up the infant feeding board [IFB] for implementation of these laws,” he says. “After the 18th amendment of the Constitution of Pakistan, in 2010, when health and nutrition became a provincial subject, all the provinces of Pakistan enacted these laws. However, only Punjab and Khyber Pakhtunkhwa framed the RoB and established the IFB. These boards have the authority to take violators to court. But despite blatant and continued violations by companies, not one complaint has been dealt with by the IFB.”

Further, said the SUN-CSA coordinator, the Food Authority Act has been enacted in Punjab, Khyber Pakhtunkhwa and, very recently, in Sindh (but in Karachi alone) tasked with the inspection of hotels, restaurants, food markets, departmental stores, food industries, bakeries, dairy and meat shops, bottled water companies etc and to ensure ban on certain foods from school canteens.

“There is little implementation of the law due to lack of human resources and testing laboratories. You need monitoring and inspections of school canteens for which resources are needed and that, sadly, is where we lose out. Somehow, Punjab remains ahead in implementation of this law due to political will at the higher level,” adds Danish.

Similarly, Dietary Guidelines for Improved Nutrition, developed by the federal government are also on the cards. If implemented, these guidelines will be instrumental in raising awareness and bringing about a change in the behaviour of the public towards consumption of nutritious foods.

Same is the case with the Universal Salt Iodisation Law. “Sindh is the first and only province that enacted the law in 2013 and by 2017 framed the RoB,” says the SUN-CSA spokesperson. “Unfortunately, there is zero implementation on that front.”

Recently, with financial support from the Department for International Development (DFID) and technical assistance from Nutrition International, the Pakistan government has initiated a food fortification programme. “It’s a five-year programme worth GBp 46 million to help 1,100 flour mills [to fortify flour with iron and micronutrients] and over 100 edible oil/ghee factories [to fortify them with Vitamins A and D].”

This is not the first time as similar initiatives, on an ad-hoc basis, have been taking place and then come to a grinding halt.

Therefore, says Danish, unless this programme is backed by legislation, the fortification effort will become lost after five years when this program ends. “The sad part is fortification is not even expensive. It costs less than a rupee to fortify 10 kg of flour but the impact is many times more.” He says several countries had legislated fortification over a decade ago and now reap the benefits of a healthier younger generation.

Published in Dawn, EOS, April 8th, 2018