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Nourishing the Earthquake Children

© UNICEF/PAKA1987D/Zaidi
Tasleem, 12, holds her acutely-malnourished sister Sobya, 4, in the UNICEF-supported TFC at Abbas hospital.

by Bronwyn Curran

MUZAFFARABAD, Pakistani-Adminstered Kashmir:  Raabya weighed eight kilograms when she was brought into a tent clinic for malnourished children at Muzaffarabad’s Abbas hospital - the average weight of a 10-month old baby. But Raabya was 10 years old.

“She was the worst case we’ve seen so far,” said Dr Ijaz, a Kashmiri paediatrician in charge of the new UNICEF-supported Therapeutic Feeding Centre at the Abbas Institute of Medical Sciences.

Dr Ijaz and his team of young doctors and nurses have treated 45 chronically malnourished children since the clinic was set up by UNICEF in February, four months after the South Asia earthquake.

The clinic – the first dedicated centre for malnourished children in this region – operates out of a sterilized white tent on the lawn of the hospital, on the rubble-strewn outskirts of the pulverized capital of Pakistani-administered Kashmir.
 
The clinic treats children who weigh less than 70 percent of the average weight for their height, the barometer for acute malnutrition.
UNICEF pays staff at the centre and supplies food items like high-protein biscuits and therapeutic milk.

Raabya had suffered from chronic (ie long-term) malnutrition for so long that her growth had stunted. She was less than one metre tall.

“She was not only suffering from severe-acute malnutrition caused by food scarcity and lack of nutritional awareness, but another illness: pulmonary tuberculosis,” Dr Ijaz said.

Five of Raabya’s siblings had died from the same condition before their 10th birthdays.
If not for the October 8 earthquake, Raabya would probably have been the sixth.

The earthquake has provided a first-time window on to the health problems long existent in Pakistan’s remote mountainous northeast. For agencies like UNICEF, it’s a chance to tackle chronic problems like malnutrition for the first time.

Before the 7.6-magnitude quake killed 73,000 people and left three million people homeless, the rate of chronic malnutrition in Pakistani-administered Kashmir was 38 percent. Acute malnutrition was estimated at between five and 10 percent.

“Repeated infections, lack of awareness, scarcity of food: these are the contributing factors. The impact of these factors has been exacerbated by the displacement caused by the earthquake,” said Dr Ijaz.

“The people’s environment has changed, they’ve lost their shelter, they’ve lost their crops, and there is a shortage of food. Sanitation and water is a problem. More significant to us is the lack of education and awareness about nutrition and healthy habits.”

While the calamity aggravated conditions leading to malnutrition, it also brought to light chronic illnesses in children in remote mountain villages.

© UNICEF/PAKA01986D/Zaidi
The UNICEF-supported Therapeutic Feeding Centre, in the grounds of Abbas hospital in Muzaffarabad, is the first clinic in Kashmir dedicated to treating severe malnourishment.

As part of a long-term recovery plan, UNICEF and its partners have been training villagers in basic medicine and hygiene so they can monitor families in remote areas and refer serious cases to doctors.

Hundreds of UNICEF-supported Community Health Workers and Lady Health Workers are already in the field, checking the health of the families assigned to them, coaching them in hygiene, and referring the ill and severely malnourished.

“We received Raabya as a referred case. We treated her tuberculosis, provided nutritional support, and she was discharged in very good health. By the time she left she weighed 11.6 kilograms,” Dr Ijaz said.

Local health workers had found Raabya in Chenari, an 85-percent-destroyed village on the remote Line of Control separating the Pakistani-ruled portion of Kashmir from the Indian-held side.

“We think what we are seeing at Abbas hospital is only the tip of the iceberg,” said Dr John Egbuta, UNICEF Project Officer for Nutrition.

“The problem is not because of the earthquake, but the earthquake is causing an aggravating situation.”

At the end of June four children were being treated at the clinic. Three of them had pulmonary tuberculosis.

Crying and clinging to 12-year-old Tasleem was her wasted four-year-old sister Sobya, her limbs withered, her face wrinkled, stomach distended, and head disproportionately larger than her body.
 
Sobya was 63 percent of the average weight for her height on admission. She had diarrhea, a chest infection, vomiting and had to be put on a rehydration drip. She’s being treated for acute malnutrition, tuberculosis, and multi-nutrient deficiencies. After five days in the clinic she has gained 600 grams, around five percent.
 
In the bed next to Sobya lay two year old Hasnain, nursed by his 25 year old mother Nasreen. He had regained healthy weight after an earlier stint in the clinic, but had to be readmitted after his weight plummeted again back in the village. 
He also has tuberculosis.

“Many families live beside their cows and drink raw cow milk. The cows spread bovine tuberculosis. Whole families are living under the same shelter so there’s more chance of picking up TB,” said Dr Ijaz.In the bed opposite Hasnain lay 15-month-old Daanish. His mother Parveen breastfeeds him 7 to 8 times a day. Daanish is lucky: many other mothers stopped lactating after the earthquake.

“Women don’t have milk…Even if they have milk, they don’t feel like breastfeeding. These people have had such a terrible experience. People have been pushed from their houses to tent villages, mothers have been separated from children. Many are now single parents. Living in crowds, mothers don’t feel comfortable feeding their child.”

UNICEF’s response to the emerging collective lethargy towards breastfeeding is to re-launch a vigorous campaign in rural areas and clinics so that mothers can return to the time-tested child survival strategy of exclusive breastfeeding.

Parveen’s poor diet is typical of most in rural Kashmir, and one of the worries for doctors trying to boost nutrition rates.
Breakfast is oil-soaked bread and sweet milky tea, lunch is bread and oil-soaked vegetables, dinner is rice - perhaps once a week with meat.

“Lots of carbohydrates and fat, little protein. This is the whole story of food in rural areas,” lamented Dr Ijaz.

To combat malnutrition in children before it reaches acute levels, UNICEF plans to set up 50 Nutrition Surveillance-Supplementary Feeding Centres in rural areas as part of its two year recovery plan. Lady health workers trained to recognize malnutrition would treat sufferers with Wheat Soya Blend, a nutrient-rich cereal. Severe cases would be referred to the Therapeutic Feeding Centre in Muzaffarabad. Thus the Nutrition Surveillance-Supplementary Feeding centres would serve as tributaries to the TFC.

“The whole strategy is designed to enable us to reach the unreached,” said Dr Egbuta.

“As an organization we want to be able to halt the trend whereby children drift from moderate malnutrition to severe malnutrition.”

For Dr Ijaz, the Supplementary Feeding Centres are urgent.

“The need is still to find those children who need support …otherwise things will deteriorate, no matter what.”

 

 

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