By Joan Bolger, Communications Officer, Concern Worldwide US
13-year-old Zahida tells me she cried through the night when her father came back from an evening of gambling and told her he had found a suitor for her in marriage. “I was used as the payment. He insisted because he had no other money to give,” she explained, clutching her 12-month-old son Sanam at the Concern-run program established to treat malnourished children in Rahuja Village, outside of Sukkur in Sindh, Pakistan’s southern province.
Zahida walked for one hour to get to the center so that Sanam could be treated. Here, staff record weight and arm circumferences to determine the severity of child malnutrition. The rates in Sindh province are 18.8 percent, well above the World Health Organization's emergency threshold of 15 percent. In the worst affected areas in the province, Concern nutritionists tell me that malnutrition rates are as high as 50 percent.
Zahida’s new family is desperately poor. Twenty five of her extended family lives in a household supported by her husband and two in-laws. Her 35-year-old husband hasn't lived at home since the baby was born. To get work as a goat herder, he had to move to another village an hour’s drive away. Despite her reluctance to enter into an early marriage and have a child so young, it comes as a bitter surprise to learn that Zahia’s situation is much improved since her days with her own parents: “Things are much better because now I eat two meals a day. My mother is happy too because she no longer has to support me.”
Sanam was referred to the Concern-run Oral Therapeutic Center (OTP) after a Lady Health Visitor (LHV) going door-to-door determined that he was severely malnourished. LHVs are trained by Concern to detect malnutrition and treat for easily preventable diseases like malaria, diarrhea, pneumonia, vitamin a deficiencies, pneumonia and so on. Zahida tells health staff that she feeds her son breast milk and home-made food with rice, but the nutritionists advise her that such a diet is entirely insufficient to meet Sanam's needs at such a tender age of development. Nutritionists tell me that Zahia’s own lack of nutrition and likely her age has drastically affected her ability to produce enough breast milk. “We don’t have milk for everybody because we are too poor to pay for it,” Zahida says quietly.
Najma Ayab, a Concern nutritionist working in Sukkur in Sindh province, nods to Zahida's familiar response: “The problem is that the girls are only starting to develop themselves and don't get enough food even for themselves. Early pregnancies are a huge burden on their bodies. You see it all the time. When the girls reach 30, they look 50. They have problems later in life like weakness in their bodies and menstrual disturbances and their bodies are weak to resist any infection.” Indeed, when asked about her vaccinations. It turns out that neither the baby nor Zahida has received any.
Traditionally older women pass down information about how to care for children which in a lot of cases has led to poorly informed decisions about the types of food children eat or the healthcare they or their mothers receive. Zahida says that she learned how to care for the baby from her live-in sisters-in-law, who also assisted with the birth at their home—a birth that she said was extremely painful, and likely more painful that most. With narrow pelvises, young girls often have extreme difficulty during labor. In all districts Population Welfare Centers distribute contraceptives free of charge, but some of the more traditional families simply do not allow it.
“Only about 20 percent of the mothers in this area are educated. They don’t know anything about nutrition, or health or family planning. We refer both children and mothers for vaccinations to the district health centers where they can receive them free of charge. These are the things they hear about here for the first time,” says Najma.
"When the lady visitors travel to households in the community, they are trained to talk to whole families, and to the elders about the importance of a varied diet, and why mothers must eat dairy products and other nutritional foods and not just rice and maize. They explain that grandchildren need to stay healthy so that they can support their families in the future,” she adds.
Concern is also working to build the capacity of Traditional Birth Attendants (TBAs) who are held in high esteem by locals but are frequently untrained to deliver basic health services. With very little income to spare, the cost of assisted labours at private hospitals is too high for most so TBAs are often call on in times of emergency, when they are called at all.
“Once we have trained LHVs that can cover their own regions, we then move on to other areas, even though we continue to monitor the work that is being done by the lady visitors. We can track the rates of referrals and registrations to make sure we are reaching our targeted numbers. This is how we can scale up, while also ensuring that our feeding programs are reaching those who need it most.”
A half an hour away in the Ahmedpur Basic Health Unit where Concern is running its supplementary feeding program, Abdul Jabar and his daughter Muskan sit with nutritionist assistant Irum Sultan for an appetite test. “The test shows us if the baby is well enough to take the food. If so, we give the parents food to take home, and they come back every two weeks for further screening.”
Though Muskan is extremely weak, she eyes the package carefully and holds her hand out to receive more once the initial sampling test has been given. Abdul says he was advised by a LHV who came to his home to take Muskan to the OTP center. “My wife is pregnant with our second child and was too sick to come,” he explains. Irum tells Concern that Abdul’s wife had stopped breastfeeding their nine month old after she discovered she was pregnant. “They thought that the milk was damaged because of her condition, so they were giving the baby buffalo milk. This caused problems. The baby is still too young and is too weak to digest it,” says Irum. “Now he knows that his wife must resume breast feeding immediately.”
Abdul works as a farm laborer and earns between 100 and 200 rupees a day, equivalent to under $2. Though he is poor, he said that he was happy to pay the 2,000 rupees for a Traditional Birth Attendant (TBA) to deliver the baby at home as he was afraid for his wife’s health.
Misinformation and cultural norms that permeate this rural society continue to have a negative impact on women’s lives. To address that, women like Rehana Blouch, a Concern-supported lady health supervisor says that she has trained an army of more than 60 LHVs who are going from house to house in the area to sit with mothers and inform them about proper health practices, and improved care and nutrition for their children.
With Concern's plans to scale up the LHVs program, their influence will only grow and slowly improve the health of thousands of mothers and children who have never known what it means to receive practical advice or preventable, life-saving treatments. Spending time with Rehanna and Najma, it seems entirely likely that their determination will have the desired affect. Hours after our visit to the OTP site, Najma, herself a native of Pakistan admits that she can't shake the thought of Zahida from her mind. "I cannot stop thinking about this young girl Zahida," she says, clearly offended, and then settling again with the type of patience that defines the collective strength and resilience of her people. Perhaps she is thinking of the slow but steady progress she and her team of LHVs are making. As if to herself and with an almost peculiar practicality for a task so great, she says: "Gradually, we will reach them all."