The room in Dera Murad Jamali’s District Headquarters Hospital is decorated with cartoons and balloons. There are tiny babies, lying on blue beds and inside incubators. Many of them barely weigh above 1kg, even days after birth. The ones below 1kg are usually not admitted as their chances of survival are minimal. The babies are connected to oxygen, fluids and are constantly under observation. They struggle to breathe, to live. Some of them have no more strength left to cry.

Dr Barkat Hussein makes his rounds of the nursery. He checks vital signs with his stethoscope. There are some instructions on the walls: “Dry the baby, assess the tone, breathing, heart rate.”

The doctor takes Chath Bibi in his hands, carefully, so as not to break her neck. She was born premature and has been in the nursery for 18 days. When she was admitted her weight was 1.65kg and now it is 1.43kg. It is normal for babies to lose weight in the early days of their lives. Chath Bibi has a difficult road ahead of her but recovery is underway.

One of the most impacting faces of malnutrition among infants can be seen at this neonatal ward run by the Médecins Sans Frontières (MSF) in the District Headquarters Hospital in Dera Murad Jamali in the eastern part of Balochistan.

More than a quarter of all babies born in Pakistan have low birth weight. In Balochistan, the situation is even grimmer

According to national data from 2011, malnutrition contributes directly or indirectly to 35 per cent of all deaths of children under five in Pakistan. Between a quarter and a third of all newborns are born with low birth weight, and over half of women of reproductive age weigh less than 45kg.

The provinces of Sindh and Balochistan register the highest proportion of malnourished children across the country. The dusty town of Dera Murad Jamali, one of the hottest places in Pakistan, lies in this middle territory. It is close to the Indus River, a crossing point for cultures where people speak almost every language, from Sindhi to Baluchi, and also Seraiki and Urdu.

“Please maintain the ward capacity always,” reads a board at the entrance to the nursery. It is signed by the medical supervisor.

“There is capacity for 13 babies. Normally it is completely packed and we sadly have to reject patients,” explains Dr Barkat. “They are mostly born outside of the hospital, at their homes. When they reach here, the babies are in a lot of distress, and have respiratory problems because of the use of oxytocin.”

Doctors claim that traditional birth attendants and some medics at private clinics often resort to drugs to speed up deliveries. Women also work hard in the fields during their pregnancies, and hence many children are born premature and weak. They arrive at the hospital very sick, often more than a month after being born.

“People bring their children to us for secondary problems. They don’t know if their baby is growing or not. They only know that the baby has pneumonia, diarrhoea or vomiting. When we tell them what is really happening, they come to understand that the child’s basic problem is malnutrition,” says Dr Barkat.

If things go well, the children remain at the nursery for five to six days. In the worst cases they may stay up to three months. This facility is just the beginning of the journey though, and the tiny babies in the most critical conditions demonstrate the extent of the malnutrition issue in the area.

But beyond the neonatal ward there is also a therapeutic feeding programme that reaches hundreds of families every year. The inpatient and outpatient services located in Dera Murad Jamali and in the nearby towns of Dera Allah Yar and Usta Mohammad received more than 9,600 patients in 2013, all of them children under five. There has been an increase in admissions since MSF started the programme in 2010. Up until October this year, 7,639 patients had received care.

For Jongel Bugti, a farmer from Tipul Shah, this is the fourth time he has visited the programme. He is waiting at the Dera Allah Yar hospital for a consultation and to receive medicine or at least some of the high energy therapeutic peanut paste Plumpy’Nut. On this occasion, he is with his one-year-old nephew. The boy weighs only 5.5kg. “The doctors give us some kind of chocolate. With this medicine the children get better – it is not just my experience, everybody says the same here”.

“I work the whole day to earn a living. Our women also work in the fields because we are poor. They don’t have time to breastfeed the children. Our main problem in Balochistan is a lack of education. This is the biggest constraint to changing things for the better,” says Jongel.

His view is shared by Dr Barkat. Poverty, an insufficient number of medical professionals and health structures, and a lack of health awareness and education all contribute to the malnutrition problem. There are also frequent security incidents in Balochistan, and the area had been recurrently affected by floods. Natural disasters tend to aggravate situations where there is little food security, as they destroy people’s livelihoods and worsen their living conditions. The huge floods in 2010 caused widespread destruction and displaced millions, which in turn sparked a food crisis.

On the top of that, some mothers stop breastfeeding their babies very soon after birth or don’t start at all. “They change the pattern of feeding. If they start breastfeeding they also give supportive bottle feeds and other things and then the baby is away from breastfeeding and quickly becomes malnourished,” says Dr Barkat.

Even though it costs money, giving babies formula milk instead of breast milk is a common practice. Women often have to look after several children and don’t have enough time to breastfeed, or believe their milk is not good as they are very weak.

But breastfeeding is very important in the early months of a child’s life because it gives them antibodies with which to fight disease. Breast milk is clean, free of harmful bacteria and is always fresh and available. It also does not cost anything. Unicef and the World Health Organisation (WHO) recommend that children be exclusively breastfed and not given other liquids or food for the first six months of life.

As per the National Nutrition Survey, nearly four women in Balochistan out of every 10 don’t start breastfeeding their children within one hour of birth and many of them don´t start at all. Some families also end up giving nutrition to one child in particular, often choosing the boy over the girl.

Some 15 mothers gather with their children every day early in the morning at the Dera Murad Jamali hospital to attend a health promotion session. During the 20-minute meeting, MSF staff show picture boards and explain how important it is to clean food, to wash hands or give details of the type of feeding required. They put special emphasis on persuading the audience that breast milk should not be replaced by anything else.

“The mothers often have questions and in the end they admit that they need to follow these advices. Their children may suffer problems otherwise,” says Abdul Majit, a nurse.

“I stopped breastfeeding my baby after one month because I thought it was bad for him and I had little breast milk. I started giving him formula milk. Doctors say I should continue breastfeeding and I will try to do so,” says Lal Kahu, a mum in her early 20s. Her four-month-old child arrived at the hospital suffering from diarrhoea and vomiting, but has been on medication for the last few days and is now getting better, so the family will probably leave the hospital soon and get back to their village, located close to rice fields.

Other children have not been as lucky as Lal Kahu’s son. They did not receive treatment in time. In 2013, 84 children died in the MSF wards in Dera Murad Jamali and the surrounding area. Almost every family in the area has experienced the tragedy of losing a child or has a neighbour who has experienced it. Some women have lost up to five children.

This will hopefully not be the case for eight-month-old Abdurraman though. Outside the hospital, eight members of his family wait for him to be discharged. They sit on a blanket with his grandfather, Ahmed Lahi Day. Abdurraman was malnourished but has recovered his strength in the last five days with the support of the medical staff. In the ward, there is only space for his mother, so Ahmed will spend the night sleeping outside, waiting for Abdurraman to leave in the morning.

They are happy to go home. They are just not sure how long it will be until they need to come back.

Igor G. Barbero is the former Communications Advisor for MSF

"We are a family of farmers who work from dawn to dusk, harvesting the rice, drying the crop, and then separating the grain. For the past four or five years, whenever someone is sick, we go the MSF clinic since we cannot afford to go any other medical facility. The doctors here are treating my eight-month-old grandson, Abdurraman, who is malnourished but improving with medicine. Since there is only space inside for his mother, we have to wait outside with a blanket. Soon he will be discharged to go home.

~ Ahmed Lahi Day

Farmer, 65, from Tipul Shah, waiting with relatives outside District Headquarters (DHQ) Hospital in Dera Murad Jamali for his grandson to be discharged.

"My one-year-old nephew weighs only 5.5 kg. This is the fourth time I have visited MSF’s programme. I used to go to the clinic in Sobatpur, my hometown, but now it is closed. Now we have to pay for the transport to come here, but the treatment is good. The doctors give us a chocolate called Plumpy’Nut and the children’s health is now improving. I work the whole day to earn my living. Our women also work in the field and have no time to breastfeed. The lack of education in Balochistan is our biggest impediment to progress.

~ Jongel Bugti

Caretaker, 40. He has brought his nephew to the outpatient therapeutic feeding programme in Dera Allah Yar.

"One hour away from Dera Murad Jamali, we live close to rice fields where we work. I went to a private clinic where the doctor recommended the MSF inpatient programme for treating my child. Here, I am relieved to know that there is always someone in charge of my child who is being given infusions and medication. When we brought the baby here, he was vomiting and had diarrhea but only after four days of treatment, he has improved. I stopped breastfeeding him after one month because I thought it was bad for him.

~ Lal Kahu

Mother, 20, whose four-month-old son has been admitted to the inpatient therapeutic feeding programme.

Published in Dawn, Sunday Magazine, January 18th, 2015

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