Fighting Malnutrition in Sindh, One Child at a Time
Jamshoro, Sindh – November 2016: With the distant hum of a whirring power generation plant and the air reeking of burnt coal fumes, the women of Village Imdad Khoso have gathered at the small compound committed as a centre for Community Based Management of Acute Malnutrition (CMAM). Luckily the wind is not blowing in this direction today from the coal powered power plant, so residents of this small settlement can go about their daily chores in peace.
The chatter in a local dialect is interrupted by the children who have been brought here for their bi-monthly nutritional checks. Most of these children are recovering from Severe Acute Malnutrition (SAM), a very common occurrence in this area.
“These women are godsends, they saved the life of my grandson,” says Maai Jeaari whose had to convince her daughter and son in law for the treatment of her grandchild Raza Muhammad. Now 10 months old, Raza had initially come to the CMAM centre at three months of age weighing a mere 2.7 kilograms suffering from SAM.
Families in this area associate such symptoms in children with myths and superstitions, preferring to take children to the local cleric for prayer. “We went knocking at every door trying to save our child, taking him to the Imam, and the local dispenser but they all said that he could not recover. It was only through the effort of these young ladies that he is alive today,” says Jeeari, while praising the CMAM staff for their dedicated support and guidance.
Commercialising Child Health
Raza’s family had been giving formula milk and a diet of commercially available cereal supplement to the 3-month-old, which are aggressively marketed by popular brands as the means of fulfilling a child’s nutritional needs. This led to repeated episodes of diarrhoea, resulting in chronic malnourishment during the critical period of his life.
Back at the Centre for Community Based Management of Acute Malnutrition, staff from UNICEF’s implementing partner Shifa Foundation conducted an assessment of Raza’s condition and counselled his mother for the initiation of breastfeeding. The family had suspended this natural practice in favour of formula milk and diluted cereal on advice of the local dispenser, who markets the commercial supplements in return for kickbacks.
Once exclusive breastfeeding was re-established, it not only helped in controlling the diarrhoeic episodes but also assisted Raza in gaining back the strength he had lost. The recovery was initially slow, as he gained only one kilogram during the next few months. On reaching six months of age, the nutrition staff introduced complimentary food as well as Ready to Use Therapeutic Food (RUTF) supplied by UNICEF, to supplement the mother’s feed. Four months after the treatment began, at seven kilograms of weight, Raza passes as a case of Moderately Acute Malnourishment (MAM), a vast improvement from when he first came.
“I can’t even bear to see the photographs of Raza from that time,” says his mother Sabhagi. “All that matters to me is that my child is now healthy which is due to the efforts and guidance I have received here. I am filled with pride now, when I look at my child. I can see that it was me, his mother, who has helped save his life. One day soon he will be running alongside his brother, without any reflection of what has passed.”
© UNICEF/PAKISTAN/2016/Dania Ali
Raza Muhammad’s family can rejoice in the knowledge that he is growing up as a healthy child, his parents Sabhagi and Abdul Haq pose for a photo with Raza and their elder son Abdullah.
Introducing Diet Diversity
“The dietary patterns of the people in this village lack in fulfilling their nutritional needs, their meals usually consists only of a roti (flat bread) and lentil soup.” explains Mehwish Nazir, Infant Young Child Feeding (IYCF) coordinator for Shifa Foundation. “For them, having more vegetables or any meat is a luxury they cannot afford very often. It remains a mystery to me how the parents were taking out the money to purchase formula milk and cereal supplement out of desperation for their child’s life.”
Most of the men from these households work at the power plant or adjacent coal mines, for a meagre 10,000 rupees (USD 95) a month, which is lower than the government-approved minimum wage. With a very low literacy rate, these people work as unskilled coal miners, drivers and porters, barely earning enough to provide for their families. This has led to a higher number of nutritionally deficient diets and food insecurity among the communities.
Fighting on many fronts: Early Motherhood
Back in her mud house, Noorzadi (17) has too much on her plate to deal with. Her husband works a 12-14 hour shift at the coal mine while she takes care of her two children, born hardly a year apart. She has to run errands and complete the household chores, leaving her four month old daughter Safia with a milk bottle in the hammock tied to her charpoy (bed). Her elder son Karim (18 months) is still recovering from SAM caused by recurrent diarrhoeic episodes.
Noorzadi’s case is a classic example of the social and medical dangers of Child Marriage. Both her children, the first of whom was born to her at the age of 15, had a low birth weight, resulting in childhood malnutrition. Not only that, but her early motherhood led her into post-partum depression and a lack of understanding on her part as a mother. This significantly contributed to the children’s health issues.
© UNICEF/PAKISTAN/2016/Dania Ali
Noorzadi (17) struggles to take care of her children, while her husband works at the coalmines for a meagre income. Her son is recovering from Severe Acute Malnutrition, while her infant daughter is also malnourished.
While many young mothers would never have a chance to realise the problems concerning child health, the opening of a CMAM centre in her village saved her children from the risks of stunting and morbidity. Nutrition staff at the CMAM centre flagged the lack of understanding due to her young age as a huge barrier throughout the course of the treatment. Although grateful for Karim’s recovery, Noorzadi does not understand the importance of exclusive breastfeeding for a child under six months of age, despite attending IYCF sessions at the community centre.
“I cannot feed the child myself as I don’t have anyone else to help me take care of the house,” she responds upon inquiry from the community mobilisers about why she was bottle-feeding the infant. “She would starve if I was to feed her breastmilk alone. I also have to give milk to her brother who needs the strength to grow up into a young man.”
IYCF coordinator Mehwish initiates a counselling session there and then to make Noorzadi understand how the older child can now take supplementary foods, while the younger one cannot yet digest the goat milk she has been given. Prior to training, the CMAM staff had noticed a lack of interest on the mother’s part in her children’s health. She started showing more concern in the children’s wellbeing once she was informed on the dangers of malnutrition and stunting. However, the lack of awareness and work load have led her to take the easy way out when feeding her children.
“She is too young to understand what you are teaching her,” says Maai Jeeari who is regarded as a village elder among the women. “Her husband has to stay at the mines for days on end and the poor soul is left to take care of the babies. From now on, I will come check on her myself to ensure that she is feeding the right stuff to the children.”
© UNICEF/PAKISTAN/2016/Dania Ali
Community mobiliser Maai Jeaari has played an elemental role in building trust among the locals for the UNICEF supported nutrition programme
The kind of bonds people from village communities like Imadad Khoso are rare to find elsewhere. The participation of a village elder like Maai Jeeari has contributed greatly in the success of the programme. She has not only convinced her son-in-law to have Raza Muhammad treated by the CMAM staff but has also assumed the role of a community mobiliser bringing other women from the village to the centre. UNICEF and its implementing partners have designed the nutrition programme on just these lines by engaging locals in an effort to make the most of these linkages which form the very social fabric of these communities.
Support for Healthier Communities
UNICEF’s Pakistan Nutrition Programme is reaching out to vulnerable communities in Sindh province, by providing nutritional assistance with the support from European Civil Protection and Humanitarian Aid Operations agency (ECHO). The intervention targets drought affected districts of Tharparkar, Umerkot and Jamshoro. The main objective of the intervention is to reduce morbidity and mortality among children and pregnant and lactating women, who are regarded as the most vulnerable groups of the population, through provision of comprehensive package of nutrition services.
As part of the intervention UNICEF and its partners have established CMAM Centres where trained Nutrition staff delivers sessions on IYCF, hygiene practices, diet diversity, age appropriate feeding as well as conducting cooking demonstration for the women.
“We teach these women how to cook in a safe and healthy manner,” says Mehwish while explaining what constitutes the community health sessions. “We inform the mothers and grandmothers how important it is to have a clean environment and to maintain diet diversity so that their family’s nutritional needs are fulfilled. Another aim for us is to end open defecation and help the community adapt better hygiene practices for a sustained and healthier environment.”
For children like Raza Muhammad, the nutrition intervention has given him another chance at life. However, numerous other children and families across Pakistan are still struggling with the challenges of overcoming issues and taboos related to malnutrition. According to the Multi Indicator Cluster surveys (MICS), conducted in all parts of the country nearly 43 per cent of children under 5 years of age are stunted, while low nutrition status and poor dietary patterns are common among infants, young children and expectant mothers, putting many more at risk. UNICEF and its partners have embarked on a mission to end this life threatening condition, reaching out to every child in order to provide a safe and healthy environment for them to grow in.