Maryam tenderly cushions her son Kamal on her lap as she feeds him with a small spoon. The boy looks around from the safety of his mother’s warmth with the curiosity of any toddler, his big eyes wide open and full of life. Maryam brought her two-year old to Jamshoro Hospital in southern Sindh because he had been feverish and refusing to eat for two weeks. “When he arrived he was pale and lethargic” says Dr Quatulain Saeed of the hospital’s stabilization centre for paediatric acute malnutrition. “He could not walk, stand or even sit up. He weighed five kilos, the weight of a six month old baby”.

 “Malnutrition is one of the biggest problems in Pakistan” says Professor Salma Shaikh, director of the hospital’s paediatric ward. Even before the floods, global acute malnutrition levels among children under 5 years old were 13% across the country, according to the last national nutrition survey. “The rates are even higher in Sindh and Baluchistan” adds Professor Salma. The concentration in camps of large numbers of internally displaced people (IDP) who were previously scattered over vast areas and the influx of international humanitarians for the flood response have brought the issue to the surface. “Many people in the camps are seeing a doctor for the first time in their lives”, explains Professor Salma, “and this is how and why many of these children are being referred to the stabilization centre.  “Some of the children are so severely malnourished that half of them would most likely die without treatment” concludes Professor Salma.

WHO established Jamshoro Hospital’s stabilization centre in September this year following a visit from Dr Guido Sabatinelli, the WHO Representative to Pakistan. After Dr Sabatinelli’s tour of the hospital’s Diarrhoea Treatment Centre (DTC), set up as part of WHO’s response to the floods, Professor Salma invited him to visit the paediatric ward that she directs. After seeing the severe state of malnutrition amongst some of the children in her ward, and noting the limited resources Dr Salma was working with, Dr Sabatinelli pledged WHO’s support. “WHO’s mandate is not centred on nutrition” explains Dr Sabatinelli, “yet we could not have a DTC in this hospital and remain unresponsive to the needs of the malnourished children next door. We had to extend our efforts, and we will continue to do so”.

 WHO has now established three stabilization centres in Sindh Province, as well as four oral rehydration centres (ORCs) in IDP camps that also serve to screen children for malnutrition and refer them to the stabilization centres if needed. In addition, WHO has donated 12 ambulances and is covering their running costs, and has held four training courses for medical staff on the management of acute malnutrition. WHO and UNICEF are drafting a joint plan to address malnutrition in the most efficient and cost-effective way, to ensure they reach as many children as possible.

On arrival at the stabilization centre, Maryam’s son was immediately put on WHO’s standard protocol for acute malnutrition. “In just a few days he has gained 1.5 kilos, 20% of his own body weight. He is now sitting up and holding toys. We will be able to release him very soon”, says Dr Quatulain with a smile to Maryam. After release, mothers are asked to come back to the hospital for regular check-ups. Children living in IDP camps are monitored by one of the ORCs there.  

A contrasting story

”Not all children are as fortunate as Maryam’s son”, says Dr Quatulain soberly. “Many of them have malnutrition with complications”. Javed, a three-year old lying next to Maryam and Kamal, suffered asphyxia when his mother gave birth to him alone in their hut. Javed was brought to the hospital because of fever and loss of motion. “His story is not unusual in this area”, says Dr Quatulain. “The mother claims that he was not fed for five days after birth because she had no milk in her breast and that she eventually fed him by bottle, most likely using unclean water and powdered milk. When he was five months old, his mother began feeding him tea and biscuits. He is now stunted and has a severe delay in development. He will never catch up with kids his age”, says the doctor. “It is difficult for me to see all these patients sometimes”, she adds sadly.

Unawareness

According to Dr Salma, many mothers are unaware their children are malnourished. Most of them bring their children to the hospital for other reasons, or because they have been referred by the ORCs in the camps. Poverty does not allow these mothers to give their children an ideal diet. Nonetheless, argues Dr Salma, ”with the few resources they have they could improve their children’s diets, but they need education”. When Dr Quatulain arrives at the hospital in the morning she finds mothers sitting in the corridor giving tea to their small children. “I keep telling them not to do it but they do it nonetheless. It is common practice”. The mothers are very often malnourished themselves. “Some women are very anaemic” says Dr Salma. “We give them supplements, iron, milk and bananas, but this is becoming a whole new problem for us, how to support the mothers.”

In addition to being themselves in poor health, mothers often have other children back home they need to care for, which may hamper them from finishing treatment at hospital or coming back for follow-up care. “They don’t see why they have to, and they are often overburdened caring for large families. They think they got all they could from the hospital, and they don’t generally want to come back” says Dr Quatulain. Ironically, children living in the camps are often in a better position than those living at home, as they will be monitored through the camp OTCs.

The coming food crisis: an emergency after the emergency

The floods will have a long-lasting impact on the country’s socioeconomic situation. Dr Sabatinelli fears that a famine may follow because of widespread loss of animals and crops. “Many people in this area were very poor before the floods, and the disaster has made the situation worse: the irrigation system, the seeds have been destroyed, even the topography of the land has changed. It is very difficult for people to recover the little that they had”, says Dr. Sabatinelli at the graduation ceremony for 15 doctors who have just completed one of WHO’s training courses on the management of malnutrition. “In the coming months we are likely to experience a severe food crisis, and we must be prepared to respond to this unfolding scenario. What we can do with the resources we have is just a drop of water in the sea. Nevertheless, 523 children, half of whom would have had a very slim chance of survival, have been successfully treated since the stabilization centres were put in place. We have probably saved 260 children from death and that in itself is a huge achievement”.