Sakina Mallah, 21, was married off at the age of 16 to a man 20 years older to her. During the past five years, she has had two miscarriages, besides giving birth to two underweight babies, and is currently expecting her third child. Both she and her younger child were admitted to the Nutrition Stabilisation Centre in Civil Hospital, Thatta, for the treatment of acute malnourishment — known as edema in medical terminology.

Mallah had to be given food supplements and medicines to stabilise her nutritional deficiency and sustain her pregnancy. According to her doctors, Dr Maqsood Ali Memon and Dr Sadia Usman, “Sakina is a textbook example of the rampant malnourishment and food insecurity in the country.”

Millions of Pakistanis experience chronic hunger and malnourishment. According to the Sustainable Development Policy Institute’s 2013 policy review paper, up to 58 percent of the country’s population is food insecure. Women and children suffer disproportionately because of gender discrimination, customary practices and prevalent dietary habits.

Pakistan stands at 106 among 119 developing countries, in the Global Hunger Index (GHI) of the Washington-based The International Food Policy Research Institute, lagging behind India and most African states. The problem of hunger in Pakistan is described as ‘serious’ by the GHI, and the situation could become alarming in the coming years as many rural and urban families live below the poverty line.

With up to 58 percent of the country’s population being food insecure, urgent measures are needed to alleviate the problem

According to the National Nutrition Survey (NNS) 2011, up to 58 percent of households were ‘food insecure’ at the national level. Rural households were more food insecure (60.6 percent) as compared to urban households (52.4 percent). These statistics are projected to become more alarming in the future.

According to the NNS 2011, Sindh is the most food insecure province, with up to 72 percent of the population being food insecure without access to enough food, despite the fact that it is an agrarian society and majority of the people are connected to farming and its associated professions. The Pakistan Demographic and Health Survey (2017-18) reveals that nearly 61.1 percent of children are stunted in rural Sindh, the highest percentage in the country.

Nutritional deficiency and related complications are a grave problem, with dozens of children under the age of five losing their lives because of it. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity. Experts believe that better awareness and education about a “cheap but balanced diet” among parents, especially mothers, can be useful in reducing malnourishment in Sindh.

“We diagnose numerous children with severe iron deficiency (anaemia) or low haemoglobin levels,” says Dr Memon. “Parents often complain that they are unable to afford iron-rich food, such as mutton or beef, for their children. Few are aware that affordable leafy vegetables and dates are also a great source for iron intake. In fact, malnutrition can, to a large extent, be overcome by public awareness.”

“Malnutrition, especially in newborns and children up to five years, is a complex and multidimensional problem,” says Dr Usman. “It involves many factors, such as poverty, lack of awareness regarding nutrition, child marriages, repeated pregnancies, poor birth spacing, customary practices, lack of prenatal and antenatal check-ups, underweight babies, a poor literacy rate, births by traditional birth attendants [midwives], lack of breastfeeding, lack of hygiene, etc.” However, the crux of the problem, Dr Usman elaborates, is that mothers are usually themselves severely malnourished which, along with multiple pregnancies with poor birth spacing, affects the child’s growth and its chances of survival.

Dr Ismail Memon, programme manager of Nutrition Stabilisation Programme, Government of Sindh, explains the measures taken to alleviate the problem in the province. He says, “The government has adopted a multi-sectoral approach to tackle the problem which includes the health, agriculture, fisheries, education and livestock departments, as well as the WASH (Water, Sanitation and Hygiene) programme. All these departments are working together to end the peril of malnutrition once and for all.”

Elaborating further, Dr Memon says that the Sindh government is working to end malnutrition among pregnant and lactating mothers and in children from the ages of six months to five years. “We have taken two types of measures — one is community-based and the other is facility-based,” he says. “Lady Health Workers [LHWs] have been employed to work in the communities and, where LHWs are not available Community Health Workers are employed through non-governmental organisations [NGOs]. These workers screen young children, pregnant and lactating mothers and, in case of any problem, refer them to the Nutrition Stabilisation Centres where they are provided medical treatment.”

Dr Naveed Sarwar Bhutto, lead programme policy officer in the Provincial Fortification Alliance (PFA) Sindh, explains the initiatives taken by the government to eradicate the problem by fortifying food commodities. The Fortification Alliance is presently concentrating on flour, oil and ghee mills for fortifying their products with iron, folic acid, zinc and Vitamin B-12.

Sakina Mallah says that there was not enough food to eat for her children. Traditionally, women of the family eat leftovers after the men and children have eaten. Repeated pregnancies made Mallah weak and frail. To add insult to injury, she never visited a hospital for prenatal or postnatal check-ups, LHWs never visited her and she never had access to family planning services. The men in her house are the decision-makers; the women have no say in any matter regarding family size or women’s bodily rights.

Poverty is a damaging factor which influences every aspect of Mallah’s life — be it nutrition, education, entertainment or mobility.

She was brought to the hospital only when her child was severely ill, and her husband didn’t want to lose his son.

Dr Usman says that initially they focused on the child but when they noticed that Mallah was also expecting, certain clinical tests were conducted to ascertain her nutritional status. When it was discovered that she was severely emaciated, she was given iron, folic acid and other supplements to stabilise her. She was also counselled regarding the benefits of smaller families, birth spacing, hygiene and nutrition.

Dr Lal Mir Shah, medical superintendent and surgeon at Civil Hospital, Thatta, says, “Due to the patriarchal set-up in rural areas, women’s health and nutrition is never a top priority in the family. The men want their children to be healthy but are not ready to give due importance to the health of their wives. They fail to see the connection between the health and well-being of the mother and child. As long as women are malnourished they give birth to underweight babies, who are susceptible to wasting and stunting [both resulting from acute malnutrition].”

Hilda Saeed, one of the founding members of Women’s Action Forum (WAF) and gender expert, says, “Malnourishment, by and large, exists in all social classes, including those who are well-off. There’s a lot of socio-economic disparity in Pakistan, and high poverty levels exacerbate food insecurity and nutrition among the marginalised groups. Then there are myths, such as girls shouldn’t eat eggs once they start menstruating, or that expecting mothers don’t need any special nutrition or care. These and associated facts leave long-lasting micro- and macro-nutritional deficiencies, such as stunting and wasting in children, and extremely high levels of anaemia and calcium and other deficiencies in adult women.”

Several other factors also influence the health of the communities. Adam Malik, regional programme manager working with Medical Emergency Resilience Foundation (MERF) says, “Malnutrition basically is not only a health issue. It can be prevented by improving conditions at community level by providing hygienic food, safe drinking water, the recommended standard feeding practices for infants and children.”

Tahir Hasnain, a researcher and developmental practitioner, explains the policy measure which can help control this problem. “We need a multi-pronged and comprehensive response to tackle malnutrition across the board in all provinces, particularly in Sindh,” he says.

“Firstly, there is a need to review and upgrade food-related laws and policies which should be designed, implemented or evaluated with improved nutrition outcomes in mind. Secondly, more funding should be allotted to nutrition programmes, especially in the areas where malnutrition is prevalent. Thirdly, the government and the NGOs should launch well-planned operations to provide micronutrient supplements and micronutrient fortification to the affected population. Lastly, the government should focus on women’s health because children of malnourished women start their lives from a disadvantageous position and are susceptible to many ailments and infections.”

Apart from these policy measures, Adam Malik, who has extensive experience of the issue, suggests certain other steps to eradicate the problem once and for all from Pakistan. “The government should bring [access to] health and nutrition services closer to women and children,” he says. “It should also address social determinants which are impacting their health and nutritional status as poverty and low position of women in society at large. For this purpose, it can use the ongoing poverty eradication programmes such as Baitulmaal, zakat funds and the Benazir Income Support Programme.”

Malik says that in order to create awareness in mothers about breastfeeding, hygiene and complementary feeding, the extensive network of LHWs could be used very effectively.

Our policymakers would do well to recognise the importance of women and children’s nutrition, a key contributor in achieving the Sustainable Development Goals for the country.

The writer is a member of staff

She tweets @MonizaInam

Published in Dawn, EOS, February 24th, 2019