Islamabad — When Shabnam Rehman brought her six-month-old baby to the Holy Family Hospital for pneumonia treatment, she had not expected the medical diagnosis awaiting them.
“My child had pneumonia, but the doctors told me she is undernourished and needs to be admitted,” Mrs. Rehman told Media for Transparency at the Rawalpindi public hospital’s nutrition stabilisation centre.
Mrs. Rehman’s toddler, Ayesha, weighed only 40% of the ideal baby weight for her age.
In medical terms, Ayesha is “underweight”, one of the four conditions that constitute “undernutrition”, according to the World Health Organization (WHO).
Undernutrition conditions also include stunting (when children’s height is lower for their age), wasting (when children have lower weight for their height), and micronutrient deficiencies (where children are not getting enough important vitamins and minerals).
According to the most recent National Nutrition Survey, 31.5% of Pakistani children under five were underweight. The 2011 survey conducted by the federal health ministry in collaboration with Aga Khan University and UNICEF was based on 30,000 households around the country. It also showed that 43.7% of Pakistani children under five were stunted and 15.1% were suffering from wasting. UNICEF data also suggests at least one in three Pakistani children suffer from stunting.
The issue of child malnutrition, which includes undernutrition as well as obesity, gained national prominence when newly-elected Prime Minister Imran Khan mentioned it in his first address to the nation after assuming office in August 2018.
“We are among the top five countries in the world where children die because of malnutrition…,” PM Khan said in his address, after displaying a diagram comparing the brain development of a two-year-old undernourished child and a healthy child. “We are talking about 45% of Pakistan’s children, that is almost every other Pakistani child suffers from this disease. I am worried because we are not able to give them food completely and they are not getting nutrition too, and thus they are left behind in the race of life. They can not compete.”
This direct acknowledgement of the problem from the country’s highest executive office has renewed the focus on Pakistan’s fight against undernutrition in children.
Nutrition Stabilisation Centres
The Nutrition Stabilisation Centre at Rawalpindi’s Holy Family Hospital is one of 42 centres established in Punjab. Sindh has stabilisation centres in nine districts and Balochistan in seven districts. Data for Khyber Pakhtunkhwa was unavailable but the provincial government there has allocated just under Rs. 15 billion on programmes related to health reforms including nutrition and stunting prevention.
The functional stabilisation centres only take inpatient cases of Severe Acute Malnutrition (SAM).
“Mild cases are ideally to be detected and treated by BHUs (Basic Health Units),” Dr. Israr Liaquat, a pediatrician at Holy Family Hospital, said. “If the cases are moderate they would be referred to the Tehsil Headquarters (THQs) or Regional Health Centres and if they are severe they should be sent to us, at the district level.
The Holy Family centre, established in 2015, has managed around 400 cases and screened over 1,500 children in the past three years. The one-room centre has three beds lined in an L shape, a curtained-off feeding area in one corner, a small swing for the kids, a nurse’s table, and a fridge. A chamber at the back is being converted into a small kitchen.
“We are still waiting for funds to further develop the area,” a nurse at the nutrition stabilisation centre said. “It can (presently) only accommodate three children with their mothers, at a time.”
Dr. Liaquat said the hospital only manages primary malnutrition cases, which means “children who aren’t getting the right diet but should be healthy otherwise.” He said children from poor families are given a priority.
The screening process to determine if a child is undernourished takes only five minutes. After the children are screened, they are asked to check into the hospital for a period of two months.
“It takes about two months or fewer for the children to start showing positive results to the supplements provided,” Dr. Liaquat said.
But the first strategy is breastfeeding.
“We usually try and re-initiate breastfeeding if it has not been too late,” the doctor said.
Otherwise the government provides high caloric milk – F-75 and F-100 – and sachets of RUTF (Ready to Use Therapeutic Food), which they are supposed to consume as directed by the physician.
“These are imported and highly expensive supplements which the government provides for free,” Dr. Liaquat said.
After and during the two-month period, the family is counselled and taught about dietary plans that they can and should use for all their infants and then referred back to their local BHUs, which need to keep a check on the child.
“Lady health workers usually follow up with them by visiting them at their homes and restocking the supplies,” Dr. Liaquat said.
The medical follow-up is important. More than 177,000 children in Pakistan die every year before their fifth birthday because they or their mothers are malnourished, according to a report launched by the Pakistan Scaling Up Nutrition (SUN) Secretariat in collaboration with the United Nations World Food Programme (WFP) in February 2017. The report further highlights that malnutrition is causing Pakistan a loss of US$7.6 billion, or three per cent of its Gross Domestic Product, every year.
But why are Pakistani children left so vulnerable to undernutrition?
The Uneven Distribution of Food
The Planning Commission’s Annual Plan 2018-19 report stated that during the year 2017-18 “sufficient food was available to meet the overall national requirements”. According to the report, this meant the “availability of about 2,500 calories per person per day compared to the requirement of 2,350 calories per person per day.”
If enough food was produced and available in the country, the natural question to ask is why the nourishment needs of children are not being met?
“The issue lies in the uneven distribution of food around the country or food insecurity, no education on malnutrition, the reluctance to breastfeed, and no public-private partnership,” Muhammad Aslam Shaheen, Chief of Nutrition at the Ministry of Planning, Development and Reform, said.
The United Nations Food and Agriculture Organization defines food security as “a situation that exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life.”
In 2011, only 42% of households at the national level were food secure, according to the nutrition survey. A majority of households experienced some form of food insecurity, with nearly 10% declared as “food insecure with severe hunger”. As of 2016, the cost of a basic nutritious diet was around Rs. 2,100 per capita per month. But nearly a third of Pakistan’s population lives below the poverty line of Rs. 3,000 per adult per month.
“Poor socio-economic conditions play a major role in nutrient insufficiency in the country,” Mr. Shaheen said.
He stressed that the government is trying to help in this regard but mothers should also do their part.
Breastfeeding and Weak Mothers
Ayesha Rehman, the six-month-old at the Holy Family Nutrition Stabilisation Centre, was not getting enough milk when she got pneumonia.
“Her father cannot earn enough to provide her formula or cow milk every day,” Mrs. Rehman said.
She said she has to ask for alms every day in the hospital to buy pampers and other necessities for her daughter.
Mr. Shaheen said the first 1,000 days from the day of conception to the child’s second birthday is the “brain’s window of opportunity”.
“Mothers and their children need to consume the most nutrients in this phase,” he said.
He said even if a mother looks weak, her body is still capable enough to produce milk for the child.
“The first six months, the child shouldn’t eat or drink anything but the mother’s milk,” Mr. Shaheen said.
Dr. Liaquat said he believes there is now a “trend” in urban and rural areas to feed formula milk to infants.
“There are innumerable myths about food and milk in all parts of the country,” he said. “They also believe cow’s milk will make them stronger than mothers’ milk will.”
The irony is that even the cow’s milk is diluted with water.
“They cannot afford to feed the child cow’s milk or formula milk and end up feeding the child only water,” Dr. Liaquat said.
Mr. Shaheen said breastfeeding not only saves lives but also money.
“We hear women complaining about the cost of formula milk,” he said. “But what is freely available is not used.”
He said breastfeeding helps prevent malnutrition and ensures food security even in the poorest of areas.
“There is a law which clearly states that mothers shouldn’t be prescribed formula milk unnecessarily, yet we have found that only 38% women in the country breastfeed their children,” said Dr. Basheer Khan Achakzai, the director of the nutrition programme of the Federal Ministry of Health Services, Regulations and Coordination.
Dr. Achakzai said if mothers exclusively breastfeed their newborns for six months, stunting can be reduced to 37% from the existing 43% in the country.
It all boils down to the lack of health education in the country, which allows health myths to spread unchallenged.
“We try to educate the parents as much as possible when they are at the hospital, but we have no idea if it has had impact,” Dr. Liaquat said.
Both Dr. Liaquat and Mr. Shaheen felt It is essentially the job of lady health workers in rural areas and small clinics in urban areas to educate mothers and mothers-to-be about malnutrition.
“The grassroot mechanism is not very functional,” Dr. Liaquat said. “Not a single case of severe acute malnutrition has been reported to us from a BHU or a THQ since the (nutrition stabilisation) centre was established in 2015.”
It is also hard for parents to keep their children in the hospital for two months.
“They say we are poor, or have more children at home and cannot stay in the hospital,” Dr. Liaquat said. “I guess even if the BHUs or THQs did refer them to us, they wouldn’t come due to their lack of resources.”
The Government’s Plan
After the PM’s pledge, the government is in the process of launching a comprehensive national-scale malnutrition programme.
In Punjab, the stunting prevention programme has been allocated Rs. 7 billion. Sindh is spending Rs. 4.5 billion on its nutrition support programme, and Rs. 1 billion annually on an accelerated action plan for reduction of stunting and malnutrition. Khyber Pakhtunkhwa has allocated Rs. 796 million for its Stunting Prevention Rehabilitation Integrated Nutrition Gain project. In Balochistan, the Nutrition Programme for Mothers & Children and the Multi-sectoral Nutrition Specific and Sensitive Interventions Programme have been allocated Rs. 1.5 billion each.
At the federal level, nutrition awareness-raising activities are planned for 2018-19 with a budget of Rs. 1.2 billion. Half a billion rupees in funds have also been set aside for the 2018 National Nutrition Survey to provide the latest data on malnutrition in the country.
“We are planning to give packages to weak mothers which will have local substitutes,” Dr. Achakzai, of the federal health ministry, said.
The local substitutes, such as WaWaMum and Maamta, are prepared within Pakistan. The current cost of providing nutritional supplements per mother per month is around US$50, but the government’s alternative local supplements would cost the government only US$10 per mother per month, the doctor said.
Dr. Achakzai said the political commitment remains weak.
“In the past 10 years, we have not invested in a National Nutrition Plan,” he said. “There is no PC-1 (planning documents) in place for malnutrition as there are for malaria, tuberculosis or other diseases.”
He was also of the view that doctors need to be further trained and not overburdened.
“A single gynecologist at any district level hospital sees up to 150 patients per day,” he said. “Can you imagine her being able to guide every patient in the time frame?”
Dr. Achakzai said he believes the primary health care department should be made stronger first and then work should continue upwards.
“According to our numbers, Rs. 5 million need to be invested per district to eradicate undernutrition,” he said. “Before and during this process we also need to work on our primary, secondary and district units of health.”
He still feared about the continuous supply of funds for the programmes to keep rolling and to ultimately eradicate undernutrition.