Abdul Karim Yousuf, a 13 month old, who has been treated over the last 3 months in the government dispensary in the village of Muhammad Khan Malkani on June 30, 2011. Severely malnourished, he has gained half and inch in height since he was born. – Photo by Sam Phelps/Dawn.com

It’s a year since the worst floods in the history of Pakistan devastated the lives of an estimated 20 million people, most of who were already struggling to feed their families.

Communities in rural Sindh are living in fear of this year’s monsoon rains, terrified the floods will return and sweep away the remaining fragments of their lives. Fragments they’ve been clinging on to since floodwaters swallowed up their homes, livestock and livelihoods. The UN estimates at least 2.2million hectares of agricultural land were washed away. In total an area the size of the UK was submerged under water for weeks.

According to the District Health Officer in Thatta, Sindh, an estimated 30,000 people were made homeless.  At least 8 million people across Sindh were displaced; many forced to find safety and shelter in tented camps where they remained for weeks after the floods, too terrified and traumatised to return to their villages. Schools, roads, shops, mosques were washed away, at least 22 health clinics in the district were badly damaged to the point of being too unsafe for doctors to work in and treat patients.

The floods have had a catastrophic impact on the health of the population and as always in disasters it’s the weakest and the vulnerable who suffer the most, children, women and the elderly.  Sindh is Pakistan’s third largest  province and is the country’s ‘breadbasket’. Miles and miles of agricultural land, a patchwork quilt of rice, wheat, cotton, chillies, lined with fruit trees. Yet, despite this, Sindh, has some of the highest rates of malnutrition in Pakistan, highest rates of illiteracy and staggering levels of poverty.

Women wait to be attended by health workers at the Government Health Clinic in the village of Babrio Jat, Thatta, Sindh, Pakistan on July 2, 2011. – Photo by Sam Phelps/Dawn.com

The Government of Pakistan’s National Nutrition Survey, over a decade old, states that national malnutrition rates stands at 13.2 per cent.  The 2001 -2002 survey carried out in collaboration with the UN questioned a sample of 786 households across the country concluding global malnutrition rates of 23.1 per cent in northern Sindh and 21.2 per cent in southern Sindh.  The UN measures malnutrition as being a critical emergency if it reaches 15 per cent. The levels of malnutrition in Sindh are higher than in some parts of Africa. The Sindh Department of Health has identified critical levels of malnutrition.

A two hour drive from Thatta on a road that has been badly damaged by floods, less road and more rocks, stones and dust, I travel with a group of doctors and a health specialists to a remote village, Sheer Ali Shah. I’m on my way to see a government health clinic that is offering a lifeline to malnourished children and women in collaboration with international health organisation Merlin providing doctors, health workers and medicines.

The roads make travel difficult in a car as does the intense heat, most people who arrive at the clinic walk for up to an hour to reach the health facility or travel by donkey cart. Imagine being heavily pregnant or very sick and having to travel on the bone-shaking road.  The small building housing the clinic is almost bursting with the number of people crammed inside. The electricity has gone off and the humidity makes it hard to breathe.  People are squashed together taking up any space they can find. Women squat in corners using their duppatas to keep flies away from their babies. A health worker looks at his or her books and informs me she has registered over 200 people today, nearly all of those seeking help are women and children. In most cases people have walked over an hour to attend the clinic where their weight is being checked, children’s arms are measured to identify those who are malnourished, women are checked for to see if they are anaemic and vitamin B deficient.

Bachiee Hasib is seven months pregnant with twins, she looks exhausted and it’s hard to believe that her tiny 25-year-old frame is destined to deliver two more babies into the world.  She says she walked over and hour to reach the clinic carrying her 32-month-old baby Marvi Hasib. Bachiee tells me she also has four other children.  She’s at the health facility to get iron supplements, as she is weak due to a lack of food at home.

A one hour old baby with birth complications including mucus in the lungs is treated with oxygen in the Bautoro District Hospital, Thatta, Sindh, Pakistan on July 1, 2011. – Photo by Sam Phelps/Dawn.com

Marvi  is receiving treatment in the clinic.  “When she first arrived she was severely malnourished, she was crying a lot and her eyes had sunk into her face. After two weeks of treatment she is now classified as moderately malnourished. We are happy with the progress she is making”, says a health worker.

As the doctor sees to Marvi, more and more women and children are arriving at the clinic and it’s becoming harder to hear Bachiee over wailing children. “When the floods came last year we lost everything. We had to rebuild our home again using mud to patch up the old house and we survived due to Allah’s mercy. I was so scared and held on to my children. We escaped with our lives. We are poor; we can’t access hospitals, as we don’t have the money for transport. I eat roti every day, I sometimes eat it with onion but mostly with crushed chillies.  I feed my children the same.”

Dr Ijaz Habib, a nutrition specialist with Merlin, has seen the impact of the floods on people’s health: “People are hoping and praying the monsoon will show mercy on them this year as they are still picking up the pieces of their lives. What happened last year was like nothing anyone has seen before.”

Shaista Aziz is a freelance journalist.

Sam Phelps is a freelance photojournalist currently based in Pakistan. http://samphelps.photoshelter.com/