Horrifying stories abound in the media, about the widespread death toll of children in Thar; unbearable images of malnourished and stunted children in incubators and hospital wards have been displayed on our TV screens, day in and day out. According to press reports, 398 children died in 2015, and based on anecdotal evidence, this year shall once again see such a high mortality rate.

As more of these breaking stories are highlighted in sensational headlines, the government continues to vehemently deny responsibility for the crisis, claiming that these deaths are normal and occur every year.

There was a lot of hue and cry in the national media when the advisor to the chief minister on information, Maula Bux Chandio, said that children are dying in Thar because of the carelessness of their mothers, and underage marriages — while another minister blamed a Thari mother for not practising family planning, and having a large family.

The government states that malnourishment and death of Thari children is business as usual, and has resorted to woman blaming tropes in their statements, but health experts counter that it isn’t the norm — nor should it be

What these unfounded allegations sweep under the carpet is the failure of the state to provide awareness about, and access to, healthy eating practices and family planning. Another glaring oversight by the government is the lack of initiative in combating famine, prevalent in Thar due to years of drought in the region.

Interviews with doctors, paramedical staff, Lady Health Workers (LHWs), the district health officer, NGOs and a tour to the District Hospital Mithi, indicate that while factors contributing to the Thar health crisis are numerous, they are also, for the most part, preventable; such as access to basic health facilities, and programmes aimed at decreasing malnourishment.

Clinics, clinics everywhere but not a doctor in sight

Most mothers present at District Hospital Mithi displayed symptoms of chronic malnourishment. Unfortunately, such women often live in far-flung areas of the desert, and transport facilities are few and far between, so seeking medical intervention is beyond their reach.

While on paper there are 250 dispensaries in the district, only 160 are functional. In addition, since a majority of Tharis reside in remote villages, accessing basic medical services is difficult. The solution — to have these services closer to where Tharis live — is proving elusive due to a shortage of medical staff, partly due to the government’s inability to hire doctors at low salaries.

Kathau Jani, a journalist working in the area, claims that part of the reason demand hasn’t met supply is due to the authorities’ haphazard hiring practices: “As appointment through the Sindh Public Service Commission was taking time, there were some ad-hoc appointments, and 70 doctors were appointed on contract. After their contracts ended they were not renewed, and these doctors are very upset about it”.

The doctors in Thar also have their own list of grievances, stating that they are severely overworked, as no new appointments have been made, even though hundreds of positions are currently available. As Dr Arjun Kumar, District Health Officer Mithi, points out, “There is a growing need for lady doctors, resident doctors, LHWs, staff nurses, etc but 300 doctors’ posts are lying vacant”.

In addition, Shaikh Tanveer Ahmed, chief executive of the NGO Hands, points out that 20pc of health facilities are non-functional.

Even as many clinics remain devoid of staff, the government has plans to open more; something Ahmed says shall be of no use unless they can attract health professionals to work at such sites. “Two new nutrition centres in Chachro and Nagar Parkar [are to open], but no one is willing to serve there. There should be additional compensation for doctors and paramedical staff to work in such areas,” he claims.

In addition to improving its hiring practices, and providing incentives for healthcare practitioners to work in such remote areas, other innovative solutions such as mobile clinics and dispensaries could also be explored.

For instance, Javaid Nisar Syed, the patron-in-chief of Medibank, an organisation that supplies free medicines for patients across Pakistan, points out that they successfully “initiated a mobile dispensary to reach people residing in inaccessible areas”.

He adds that they are taking a multipronged approach in Thar; and are also working on providing water distillation services, and a deworming campaign, for children.

Last in line

In patriarchal Thar, women’s low standing in the social hierarchy also means that they have little say in family planning, when they get married, and are less likely to access nutritious food.

Dr Sikandar Raza Hanjano, a paediatrician working in District Hospital Mithi, says, “These girls are married off at an early age, have repeated pregnancies, and don’t have a nutritious and balanced diet, which results in underweight and weak babies, who die from preventable diseases.”

Endorsing his views, Dr Bhawan Rap, who is also a paediatrician working at District Hospital Mithi, says, “If the mother is weak, then the child will also be weak and will be [born] prematurely.”

In patriarchal Thar, women’s lower standing in the hierarchy also means they have little say in family planning, when they get married and are less likely to be able to get access to nutritious food.

But Dr Kumar argues that Thari women’s malnourishment stems from the diet they follow due to religious beliefs, and customary practices. “Most women follow a diet rich in vegetables but poor in proteins, and are therefore not able to get the calories they need,” he adds.

However, one can argue that it shouldn’t be too difficult for the government to work with local doctors to come up with guidelines for a vegetarian diet that meets the daily protein requirement.

Knowledge is power

In addition to working towards improving access to healthier food, experts argue that better family planning services, and teaching women to be more creative in providing nutritious diets for their newborns, could go a long way towards mitigating the health crisis in the long-term. The key, according to health experts and the government, is creating more awareness.

“There is an urgent need to educate and synthesise the communities about hygiene, balanced diet and nutritious food, especially the nutritional needs of babies after the age of six months, when mothers should give them semi-solid foods to meet their growing needs,” states Dr Hanjano.

Dr Rap also explained that most babies are malnourished as mothers usually feed them a diet which is inappropriate for their child’s age. “They should be taught about the food requirements after six months, as they should feed the [child] cow or goat milk, fruits, vegetables, pulses, etc,” he adds.

In addition to providing children with a nutritious diet, health experts point out that better family planning should lead to improved health for women and their babies.

Lewanti Bai, 45, who works as an assistant district coordinator for the National Programme for Family Planning and Healthcare, a government-run initiative that trains women to provide healthcare services at a community level, said that the major reason for the high infant mortality rate are large family sizes and a lack of birth spacing. While they are working on increasing awareness about family planning, it’s proving to be an uphill task: “Only 40pc of the district is covered by LHWs, and there is one LHW for 1,000 people,” she adds.

In addition to increasing the number of LHWs, many experts, including Dr Sono Khangharani, chief executive officer of Hisaar Foundation, point out that dais (traditional birth attendants) should also be trained, and that the medical facilities and equipment at District Hospital Mithi need to be improved.

Dr Deesha Kumari, a gynaecologist working in District Hospital Mithi, says, that they are also working towards ensuring better family planning practices among Thari women, through more frequent medical follow ups: “When women deliver a child we ask them to come back after every six weeks for family planning, and if they fail to come we do not take their case in this hospital.”

Not that there is much resistance from society — the older generation of Thari women seem very supportive of family planning. For instance, Sukhio, a resident of a remote village, and a grandmother, says that she “gave birth to 13 children out of which only eight survived, but advises [her] daughters and daughters-in-law to practice family planning and have fewer kids”.

Deputy Commissioner Mithi, Nisar Ahmed Memon, points out that cases such as Sukio’s aren’t isolated ones, and that the government has seen a wider trend of Tharis adopting ‘modern’ medical treatments. According to him, people are going for immunisation, polio drops and child birth in hospitals.

“All these factors signify change in their thinking and attitude, though at a very slow pace,” he says. He adds that the government “is trying to strengthen the institution of LHWs [through] refresher courses”.

Published in Dawn, Sunday Magazine, April 17th, 2016