It started with a tweet. On an average Friday, I saw someone’s tweet asking for help: Madat Balochistan needed a volunteer to accompany a midwife heading to Jaffarabad, Balochistan. Maryam Jamali, 19, and her mother set up Madat Balochistan as a response to the floods in Balochistan. The mother-daughter duo is supported by several volunteers, including Iqra Gellani who helps with logistics from Islamabad.

I slid into their Direct Messages (DMs) and said I was interested and ready to volunteer. This is how, the following Monday, I ended up in a Hiace van and on my way to a small village called Chowki Jamali in Jaffarabad.

The long road ahead

Disclaimer: Before I start sharing my experience, I would like to say this was my first ever visit to a flood-affected area and I had no idea what lay ahead. I had seen coverage of cities and towns inundated with water — on social media and in the news — but nothing could have prepared me for what I witnessed. Weeks later, the visuals still haunt me.

After I confirmed the logistics with a representative of Madat, I started to read up about the area and learnt I would be travelling to where former Prime Minister Zafarullah Jamali was from. I already knew about Mama Baby Fund, an emergency financial fund for maternal and neonatal health, started by Neha Mankani seven years ago. Since the floods this year, Jahan Zuberi, the midwife from Mama Baby Fund and Neha have been holding antenatal clinics across Sindh, including Dadu, Badin and Jacobabad. Jahan would be the midwife on the trip to Balochistan.

Tooba Masood-Khan travelled to Jaffarabad district in Balochistan last month to volunteer with a non-profit organisation providing healthcare to pregnant women. She provides a first-hand account of the massive scale of destruction she witnessed, the lack of basic healthcare and the lengths women were travelling to find dry land to give birth in

I admit, I was a little hesitant to go but I had given my word and Madat Balochistan were doing good work so I felt certain that everything would be okay.

Before the trip, I was coordinating with the team regarding medicines, milk, vitamins and everything that had to go with us to the final destination. On Monday morning, everything was loaded inside and on the roof of the car. We stopped to pick everyone up and were on our way when… We got challaned. Apparently, it is against the law to load luggage on the roof of a Hiace van and drive on the highway — I beg ignorance, as I do not drive and did not know this.

We decided to drive through Sukkur instead of Khuzdar or Dadu (which was completely under water) and I noticed how the route was basically one straight road with water on either side. The water was up to three to four feet on some patches of the road — locals claimed that initially the water stood at least seven feet high and had receded over the last several weeks. There was unimaginable devastation everywhere.

A devastating aftermath

This summer, Pakistan saw the worst floods since 2010. At least 1,700 people and cattle died while thousands more were displaced across the country. Floods and the destruction they bring are directly linked to climate change: unusually heavy monsoon rains and melting glaciers. And the poor infrastructure in the country doesn’t help either.

According to UNICEF, more than 10 million children are in need of immediate support due to the increased risk of waterborne diseases, drowning and malnutrition as a result of the floods.

“Hundreds of thousands of homes have been damaged or destroyed, while many public health facilities, water systems and schools have been destroyed or damaged,” UNICEF states.

“As the floodwaters have receded, the crisis has become an acute child survival crisis. Frail, hungry, children are fighting a losing battle against severe acute malnutrition, diarrhoea, malaria, dengue fever, typhoid, acute respiratory infections, and painful skin conditions. As well as physical ailments, the longer the crisis continues, the greater the risk to children’s mental health.”

Spotted along the route were tent cities created by Al Khidmat Trust, Baitus Salam, UNHCR, China and other aid agencies. I saw children and women bathing in the flood water, washing their clothes in the same water, their remaining cattle sitting idly by, while the men sat on charpais trying to get enough internet coverage to watch a video on Facebook or YouTube.

The trip should have taken eight to 10 hours according to Google, but the condition of the roads, the lack of internet connectivity and bad directions delayed our journey by many hours, which led us to make an unscheduled stop and spend the night in Sukkur. We reached Chowki Jamali the next day around noon.

To be honest, I did not think we would ever reach the village. I had given up. It was like a mirage — close enough but out of reach. The drivers and two other volunteers tried their best to find the shortest possible route, but the one we ended up on felt like it was a road less travelled via a series of unfortunate events. Somewhere in our never-ending journey we crossed the border from Sindh to Balochistan — which is what we had to do, but then ended up in Sindh again! I wanted to cry. I felt like everyone in the vehicle — the two drivers, two volunteers and Jahan — had reached their limit.

I should clarify that, while we were trying to find our way, Maryam Jamali was in constant contact with us. Maryam and her father kept guiding us and it is because of them that we finally reached the only Basic Health Unit in Chowki Jamali on Tuesday afternoon.

By the time we reached Chowki Jamali, it was just Jahan and me. Don’t worry, the others lived. They just went their separate ways after lunch.

Setting up camps

Once we reached Chowki Jamali, Jahan and I started setting up camp. We had the local basic health unit at our disposal and we set up three different stations: registration, check-up and medicine. We took out all the medicine we had — vitamins, antacids, painkillers, antibiotics and other basic medicines — along with infant milk formula, infant cereal and Mama Baby Fund’s birthing and postpartum kits.

What is in a birthing kit: Tarp (clean birthing surface), baby clothes, hand towel, wrapping sheet, panjeeri [traditional nutritional supplement], diapers, antibacterial soap, gloves, sterile blade, thread to tie cord, misoprostol to prevent postpartum haemorrhage. The postpartum kit has similar items such as baby clothes, hand towel, wrapping sheet, panjeeri, diapers and antibacterial soap.

Helping us at the clinic were Maryam and Shehzadi, the dai (traditional birth attendant).

Jahan and I were also staying at Maryam’s house — and what an experience it was to sleep under the open skies on a charpai (with a mosquito net to protect us from malaria). But at the camp, it felt like women were pouring in from every door and window. All of them knew Maryam and Massi Shehzadi — the only dai within a 10- to 15-kilometre radius.

Women in Chowki Jamali and surrounding villages do not have access to basic healthcare facilities, clean drinking water or proper nutrition. The women here, and their families, were still recovering from the floods. Many of them saw their homes and cattle being swept away by the powerful currents of water. Several of these women told us stories about how they had to evacuate their homes within minutes and carry their belongings on their heads.

However, it was interesting for me to see all the women interact. Maryam, who is currently preparing for her A-Level exams, was busy translating for Jahan while Massi Shehzadi was trying to organise and send the women in on a priority basis — which, of course, did not work out because there were so many women and children waiting for a chance to talk to the midwife.

An exhausted Razia walked in. She was seven months along and having her ninth child. She is very weak and says she is done. The floods and finding a safe place to live had just sucked up all her energy. She told us that she had walked along the canal — where she now lives — to reach us at the camp; it had taken her a few hours to get to us.

Life, Disrupted

According to Maryam, the village and its women are currently suffering from a lack of obstetrics and gynaecology (OB-GYN) facilities “In Jaffarabad… My village, my district… We don’t have a single good hospital — government or private — where people can go for good medical care, especially for the women,” she told me. “They have to travel to Garhi Khairo for deliveries and, if they have to go to the hospital, then they have to go all the way to Larkana or Shadadkot (a few hours away on a bumpy dirt road).”

“The floods have disrupted people’s livelihoods, and (usually) women have been relying on private medical care, but when there is less money in the house, this means that even less money will be spent on them (and their health)… And this puts them at a lot of risk. Financially, the people are devastated, and that indirectly has an impact on women’s health.”

Maryam added that, besides this, the other issue in the area was contaminated water in the canal. “Women have to walk a long way to get water — not clean drinking water but water to use for washing etc,” she shared, adding that water from Keethar canal, Saifullah canal and their distributaries was all the contaminated flood water.

“Women who have been using this water have been getting UTIs (urinary tract infections) and suffering from vaginal infections. However, local BHUs (Basic Health Units)… Even the good ones don’t have Panadol, kids’ syrup or something as basic as Cranmax (a cranberry-based medicine) or citrus soda to treat these infections. Resource-wise, women don’t really have a lot to look at, they don’t have access to anything,” she explained.

The initial plan was to go to three to four villages, hold day-long antenatal clinics and see as many women as possible. This was easier said than done.

Between Tuesday to Thursday, we went to four villages, including Sobatpur and Ghulam Muhammad, and saw about 300 women — around 100 of them are due to give birth in the next couple of months. I was certain that I would see a birth…and be asked to help. I was not looking forward to this. Luckily for me, this did not happen.

A laborious road ahead

Many women who came to see Jahan had regular issues — a lot of weakness, aches and pains, itchy hands and feet, burning sensations when they peed, swollen breasts, fainting spells, nausea and heartburn — complaints they said they were comfortable making to a ‘lady doctor’. The doctor who usually sits at the basic health unit is a man. There are no gynaecologists or lady health workers in the area.

“Some of the areas we visited, such as Chowki Jamali and Ghulam Muhammad — which had a newly built Basic Health Unit — the women there were in the last month of their pregnancy but hadn’t seen a care provider at all,” Jahan told me. “Or all their previous births had been at home, which is a common practice, so you know that just speaks to the lack of access and their own ecosystem. This just speaks to the greater need for a stronger healthcare system — which we don’t have and this is unfortunate,” she added.

According to Jahan, there are 25,000 to 35,000 midwives across the country but, unfortunately, they have no support from the government or access to resources and thus, they are unable to do the work needed in communities, especially vulnerable communities and women who need them.

“If we had midwives working actively in their communities along with government support and resources, things would be so different,” she said.

While discussing birthing options, many women said they opted for a home birth with the dai — who is different in different areas, and has no formal training. Some prefer or have access to doctors at the nearest hospitals, which are about 1.5 to two hours away by road.

Women with previous experiences where the birth had become complicated — the child wasn’t in the right position or they were just too scared to give birth at home — preferred going to the hospital. Going to the city to give birth costs the parents anywhere from Rs12,000 to Rs25,000 — which includes the transport, accommodation and hospital services.

A registration of woes

I was tasked with managing the registration process at the camps. I had to remember three of the most important sentences: tai naam chay (what is your name), thai halka/goth chay (which village/area are you from) and naa pin/chuk tharay (how many children do you have). It helped that some women understood Urdu because I kept jumbling my words.

Imamzadi, a mother of one, came in running when we had almost wrapped up. Her feet were covered in mud and she was out of breath. She came running to the BHU when she heard a doctor was visiting.

“I wanted to come see someone because I am afraid of giving birth in the water. I am six months along and don’t want to have this child right now. I became homeless after the floods and am currently living in a tent with 15 family members,” she shared as Jahan examined her pregnant belly.

As Imamzadi spoke her heart out to us, we were shocked to realise how she had managed to reach us. She had literally waded through three feet of floodwater because she temporarily lives on the other side of a massive breach.

Imamzadi, and two of her relatives — one who gave birth during the worst part of the floods — had walked for miles carrying their belongings on their heads, in search of dry land.

Like Imamzadi, I met Hiyati who is seven months along and has excessive itching on her feet and hands; Nazira who is about to give birth; and Samina, who is about to enter her third trimester and walked three kilometres to come to one of the camps.

They were all concerned about the future of their children — how they would work and make money, what would happen next, where they would give birth… Would they survive another home birth?

While Jahan examined different women, Massi Shehzadi pointed at the stomach of a woman who was eight or nine months along. She said this woman’s next delivery would be dangerous and there was a possibility her situation could get worse.

“She had a delivery via C-section but the doctor botched up the operation and this is why she keeps peeing and has had a lot of miscarriages following the surgery.”

I was stunned — is this how women are treated? Is this the value of a woman — just a birthing vessel. Is this ignorance? How could a human being treat another like this?

Similarly, while examining women at Ghulam Mohammad, Jahan came across a woman who had a C-section where the doctor had opened the woman up from the middle (there was a straight line running from below the belly button). She said she had seen this before and told the expectant mother how dangerous this was, as her uterus could literally fall out the next time she gave birth via C-section.

A young girl — not a day over 16 — came to the clinic in Sohbatpur to ask why she wasn’t getting pregnant. She had a child less than five months ago and was eager to have another one. Jahan had to explain that since she had a C-section, it would be impossible to conceive for at least two years.

After seeing her, Jahan examined Laiba, who was expecting her first child and was in a lot of pain. She couldn’t sleep comfortably on either side. Laiba will have to undergo a C-section and will have to travel 10 to 15 kilometres on her husband’s motorcycle to give birth in a big hospital in the city.

An exhausted Razia walked in next. She was seven months along and having her ninth child. She is very weak and says she is done. The floods and finding a safe place to live had just sucked up all her energy. She told us that she had walked along the canal — where she now lives — to reach us at the camp; it had taken her a few hours to get to us.

Grim ground realities

During our three days of camp, I noticed one recurring issue: abortion. Many women who came in had a minimum of three to four children, some had as many as eight. A few women who came to the clinics were stressed because they wanted to ‘zaya’ (terminate) their child because of a lack of finances, but had no access to a doctor or medicine.

While talking about abortions and miscarriages, I met Sabra. She is from a village called Ghulam Mohammad and is five months along. She has four kids while another three were 'zaya'. She doesn’t want any more children but has no way to get rid of the child in her belly, as she doesn’t have access to a proper doctor or healthcare.

On the other hand, many women were shocked to learn that they could not have children as frequently as they wanted or that they were approaching menopause.

According to Jahan, the women of Chowki Jamali, Sohbatpur and Ghulam Mohammad had some common problems. Besides a lack of access to healthcare, several women were anaemic and undernourished.

“What these people have been through is hard to imagine,” said Jahan. “They are currently living on a bund (embankment), having lost their homes and all their belongings… They don’t have any options. It has been really difficult seeing how land is extracted for the global economy and then that just leaves the people who work on the land malnourished and in poverty…and nobody, like the government, is coming to help them.”

I was shocked to see the state of affairs and digest it all. Our first camp at the local BHU at least had lights, fans, doors, a bed for the patient and a desk for the doctor. At the other camps, we had to make do with the bare minimum. In Ghulam Muhammad, for example, I was appalled to see that the rooms we had been given just had one, singular lightbulb. We were dependent on natural sunlight. Somehow, we managed.

The more difficult part, however, was crowd control. Unlike the system we had at the BHU, where Shehzadi would let three women in at a time, in Ghulam Muhammad, it felt like the women would just barge in. And they did.

I had to physically stand in front of the door to ensure that no one would break and enter. No one wanted to wait. But I don’t blame them. Pregnant women standing outside in the heat for hours, waiting for their turn. The other problem was that none of them wanted to return home empty-handed. A few women that I spoke to said that their husbands would beat them up if they didn’t bring bag ration bags.

Similarly, in Sohbatpur, the camp was held in a small room, which was either under construction or being used to store construction material. There was a pile of rocks on one side dominating the room, while the other side had a bench, table and chair. I was struck by an intravenous drip (IV) hanging from the window. I wondered who had sat on a pile of rubble to get the IV.

All this made me wonder: what would these women do if they actually had access to better infrastructure, health facilities and education — and why did the government not do anything about this? Or were they doing something and was I not able to see it? It left me with mixed emotions. I was upset and did not know how to process it.

Roadblocks to stability

The on-ground situation was bad to say the least — there is no electricity in the area, most families who live there use solar panels and batteries. Internet comes and goes. Most of the area is still under water. And if things couldn’t get any worse, there is a malaria outbreak in the area as well.

I didn’t realise how bad things were till the third day of camp. When we were heading back from Sohbatpur to Chowki Jamali, we became stuck in a traffic jam near the Cadet College. We initially thought that there was a traffic issue — there was no way to go around as there was water on both sides. But within minutes we realised that something was not right.

We learnt that a flood victim had been shot dead and his relatives/other victims were blocking the road in protest. A bystander told us that a foreign aid agency was distributing goods and somehow there was a stampede, which prompted the local police to open fire. A man was injured in the incident. The body was then taken to the nearest city for an autopsy. According to a report in Dawn, hundreds of people had gathered after a foreign NGO announced to distribute relief goods, including tents, food and other items among the flood victims.

“When the officials started distributing relief goods, people began pushing and snatched relief goods, which resulted in a stampede,” the report said. “Amid the ruckus, the police baton-charged the flood victims to disperse the crowd. Jafferabad Senior Superintendent Police Jawad Tariq, while confirming the casualty, said an FIR has been registered against police officials upon the heirs’ complaint.”

“The firing happened when the police were dispersing the mob gathered at the site to protect NGO officials,” Tariq was quoted as telling Dawn on the phone. After the firing, the victim’s relatives and locals blocked Dera Allahyar-Usta Muhammad road in protest, suspending all kind of traffic.

It seemed like forever before we could get back to Chowki Jamali. Jahan and I were convinced that we would have to delay her return. A relative of Maryam’s asked us to walk past the traffic and protestors as he waited for us on the other side, to drive us back to the village.

The way back was quite uneventful but I thought a lot about what I had seen. I was trying to digest the situation there and felt unsettled.

After the trip, I spoke to Jahan about our trip to Jaffarabad and what she said made sense to me. It is what I was feeling too. She said the one thing that stuck with her was the amount of water we saw on our way to the district. She said it was unbelievable when you thought of the politics of water, of land… “It gets pretty complicated because of the feudal land system, as people do not have ownership over land, which then plays into other areas of their lives and not having autonomy over anything, including health. I was very struck by that,” she said.

“I just have this constant ache in my heart that all this relief work is really important but we are not addressing the structures and systems that play into the conditions of these people,” she said. “They live in poverty, they don’t have access to healthcare in the first place.”

But what really got to me is when she asked: “What is it going to take for us to have an awakening on how to do right by each other? One third of the country is already under water.”

The writer is a journalist and researcher based in Karachi. She is currently working on a book ‘Society Girl’ and collaborating on the podcast ‘Notes on a Scandal’.

She tweets @tabahitooba

Published in Dawn, EOS, December 4th, 2022