CHAPTER NO.

1
INTRODUCTION

1.1 INTRODUCTION
In the past few years it has become a norm that a few hundred newborn babies and infants will
inevitably die in Sindh’s beautiful Tharparkar desert every year. Conflicting figures are quoted in the media
and by government functionaries, about the number of deaths and their causes. Even if one fully agrees
with the official version, unfortunately, there are no visible actions on part of the government of Sindh or
the federal government to tackle the deadly issue on sustainable basis. As a result, we see the inhabitants
of Mithi offering special prayers in temples amid a rising death toll of children and their helplessness in
the face of it. Irrespective of the fact of whether 200-plus children died in the past 50 odd days or 75
newborns and infants breathed their last in Tharparkar’s hospitals, even a single preventable death is
criminal. Why are we unable to respond to this situation?
Child health and nutrition experts and child rights activists believe that it is due to a lack of
understanding of the issue at the decision-making level and the lack of political will to respond to it. If
someone is going to look at it and try to resolve it from the health perspective only, then we will continue
to see such horrific figures of newborns deaths for the years to come as is the case for the past few years.
It should be understood that there are multiple factors for the current situation in Tharparkar and there
is a need for multi-sectoral interventions to address the social, economic and cultural reasons behind this
mayhem. Similarly, responding to malnutrition also requires a multi-sectoral approach involving health,
education, social protection, water and sanitation, and the agricultural and private sectors. There needs
to be a high-level commitment from the leadership to plan and implement multi-sectoral interventions.

1.2 BACKGROUND STUDY OF FOOD INSECURITY IN DISTRICT THARKARPAR

Food insecurity in Pakistan lurks
ominously as the country lurches from one
crisis to the other. The World Food
Programme assessed that most of Pakistan’s
121 districts face hunger, some to a greater
degree than the rest. Farmers are left reeling
by sky-high fertilizer costs; the price of DAP
(one of the most coveted high-yield fertilizer
brands) has phenomenally increased despite being heavily subsidized by the government.
Grain farmers are left with the unenviable choice of either reducing their use of DAP or switching
to less profitable vegetable crops that require less fertilizer. High costs of producing food items and lack
of facilities have aggravated food security situation in Pakistan. Food insecurity is now considered a silent
killer though sometime public protests erupt ferociously.

The worst-hit place of food insecurity in Pakistan is Tharparkar, largest of the twenty nine districts
of Sindh that is widely acknowledged to lag far behind all other districts in terms of Human Development
Index. Tharparkar is surrounded by the world’s 18th largest desert and the world’s 9th largest subtropical
desert.
Thar desert comprises of high population density keeping in view that it is unlivable at most
places. The inhabitants survive predominantly through animal husbandry because the agriculture aspects
are highly undependable owing to frequent droughts. Overgrazing due to high animal presence, erosions
caused by water and wind has caused serious degradation of cultivable land.
Tharparkar is a tough place to live particularly in respect of food provision. Hundreds of people,
particularly children, lose their lives every year due to acute shortages of food. The endemic poverty of
Tharparkar is evident from the fact that 70% of its population lives in abject poverty. Undernourished
mothers give birth to children who are mostly found to be underweight, stunted and malnourished.

Food scarcity is such that Thar is the only place in Pakistan where 80% people borrow money to buy food
and mostly have no means to pay off their debts. The choice of food is naturally minimised due to the lack
of resources and only bare necessities such as flour or rice could be bought as it is beyond the reach of
people to buy ‘luxuries’ like potatoes and tomatoes.

Reportedly the government has employed a large number of contractors to provide food relief in
Tharparkar and they are supposed to distribute a set number of sacks in each drought-affected area but
many contractors keep a few for themselves to sell rest in the market aggravating the already precarious
situation. Ironically the inhabitants of 85 percent of Thar desert located in India do not witness the
incidents of deaths due to food shortages.

Frequent droughts have exacerbated the situation further as it is observed that every drought takes the
region back 15 years. The mainstay of existence, livestock, is not able to find food with grazing land drying
up and they are also lost in the process or their owners migrate to fertile places. To add to woes is the
general tendency of successive governments to keep people dependent upon official help that has not
permitted them to sort out a lasting solution to their predicament. The dependency level is such that
many pregnant women came to Peoples Primary Healthcare Initiative not to get medically checked-up
but to obtain free blankets they heard were distributed there!

Currently it is assessed that virtually the entire population of Thar is living below the international poverty
line of $1.90 per person per day and it is estimated that three million people face the risk of starvation.
Thar has received fewer resources to stimulate its development than other parts of the country. By way
of contrast, the richest districts in Pakistan receive five times more public funds on average than the
poorest.

Though Pakistan receives substantial financial assistance from international donor agencies but
Tharparkar seems to have received hardly any chunk of such aid. Eradicating hunger is a global priority
but probably it is not an important consideration for Sindh to do something about the large hungry
population of Tharparkar. All seven talukas (tehsils) of Tharparkar; Mithi, Diplo, Islamakot, Chachro, Dahli,
Nagarparkar and Kaloi suffer from the effects of lingering famine-like conditions for the last many years.

The tragedy of Thar appears more to be man-made than caused exclusively by nature although it plays a
large role in it. It is acknowledged widely that the federal and provincial authorities are highly negligent
about the affairs of Thar which they think is too far off to create ripples in their otherwise smooth sailing.
They have consistently failed to prepare detailed plans for the development of the area despite a lot of
concern shown by international agencies.

The example of lack of competence shown by provincial authorities is provided by the dangers faced by
the livestock that is considered the only sustenance available to the population of Thar. The provision of
vaccines, antibiotics, drenching and concentrated feed in time is critical for the survival of the livestock
but the provincial authorities have not been able to handle the situation creating prospects of widespread
increase in food shortage. The apathy of the agencies concerned with Thar indicates that the region will
remain in the grip of suffering for quite some time.
According to the findings of The Lancet as well as leading nutrition and child health experts in the world,
including Pakistan, most of the irreversible damage due to malnutrition happens during conception and
in the first 24 months of life, meaning that the risk begins from the day of conception to up to two years
of age (also referred to as the first 1000 days). Poor nutrition for mothers during pregnancy, too few
calories, poor quality of food, repeated infections such as diarrhoea and malaria, poor feeding practices
and so on are some of the major causes of malnutrition in Pakistan. Tharparkar is no different. Rather,
these issues are much severe there because of poverty, poor water and sanitation resources, high rates
of child marriage, the lack of education, family planning and health facilities in far-flung areas like
Nagarparkar, which makes the situation worse.
The nutrition challenge facing Sindh is substantial. Sindh has a dangerously high rate of nutritional stunting
among children under the age of 5 (49.8 per cent) as compared to 43.7 per cent of the national average.
The prevalence of underweight children is 40.5 per cent as compared to 31.5 per cent of the national
average, while wasting prevalence is 17.5 per cent as compared to 15.1 per cent of the national average.
As per the World Health Organisation’s standards, a national average of 15 per cent or above is labeled
an ‘emergency’. These figures have not changed significantly in the past decade and require special
attention at all levels. I believe the figures in Thar region will be even worse than the provincial figures for
Sindh.
Since the Tharparkar child deaths are viewed as something related to malnutrition and health, the whole
focus is on health response, which is not something new. Traditionally, in Pakistan, nutrition has been
viewed as a problem to be looked after only by the health sector planning commission or the Ministry of
Health at the federal level and Department of Health at the provincial level. This narrow approach then
excludes those remedies that would cater to the wider economic and social contexts that predispose a
community to poor nutrition. Major findings of the National Nutrition Survey 2017 clearly indicate the
urgent need to address malnutrition through an integrated approach, which addresses immediate,
underlying and basic causes of malnutrition. This is a challenge to mainstream nutrition and to ensure that
all relevant departments and stakeholders are cognisant of their roles and have effective coordination.
Responding to malnutrition issues using a multi-sectoral approach was a practice realised a few years back
and the government of Sindh notified the Provincial Nutrition Steering Committee and Inter Sectoral
Technical Working Group in December 2017. The Technical Working Group had a number of meetings
with the support of the Development Partners for Nutrition Group and Sindh became the first province to
adopt the Sindh Inter Sectoral Nutrition Strategy in late 2017.
The Sindh Inter Sectoral Nutrition Strategy is ambitious and seeks to reduce chronic malnutrition in
children under two years of age, by 10 percentage points from an estimated 49.8 per cent to 39.8 per cent
by the end of 2016. Likewise, Anemia in children is to be reduced from 73 per cent to 62 per cent and
maternal anemia from 59 per cent to 49 per cent, through sustainable, effective and inter-sectoral
interventions by the end of 2016. The target group for the nutrition in interventions includes pregnant
and lactating mothers. A 1,000-days-plus approach is used, with nutrition supplies and provision of food
vouchers and meals to women living in difficult conditions.
The strategy further focuses on the introduction of incentives such as conditional cash transfers and food
vouchers to encourage enrolment and daily attendance of children of Benazir Income Support Programme
beneficiaries in schools, mid-day meals through school feeding programmes and the introduction of policy
and strategy for introducing mid-day meals for all students in high-risk areas. The Sindh Inter Sectoral
Nutrition Strategy further calls for increased access to safe water and sanitation through rehabilitation,
improvements, extension and augmentation of schemes. It also calls for ensuring the provision of drinking
water and sanitation facilities in schools operating in prioritised districts in rural areas and to create an
enabling environment for improving food security. In addition, it envisages increasing the ratio of female
agriculture extension officers and field assistants and building training centres for them at district level.
 Now, one simple question would be whether there are more difficult situations or high-risk areas
all over Sindh and not just in Tharparkar alone. What has been done in Tharparkar so far when regarding
the implementation of the Sindh Inter Sectoral Nutrition Strategy? Have any steps been taken to
implement these strategies? What has been done for female empowerment and income-generation
opportunities for women in Tharparkar? What is the status of the implementation of the Sindh Right to
Free and Compulsory Education 2017, the Sindh Protection and Promotion of Breastfeeding and Child
Nutrition Act 2017 and the Sindh Child Marriages Restraint Act 2016? The implementation of the Sindh
Inter Sectoral Nutrition Strategy and all these laws is essential in improving the situation of child deaths
in Tharparkar.
The government of Sindh should take concrete measures for the implementation of the related
strategies and legislation and make budgetary allocation for the implementation of the Sindh Inter
Sectoral Nutrition Strategy. Tharparkar could be made a case study for a pilot multi-sectoral intervention
to respond to this situation. Steps should be taken to promote women employment and income, social
safety nets such is BISP should focus on Tharparkar, increase the number and enhance the skills of health
care providers and lady health workers to promote exclusive breastfeeding for six months. The private
sector should be encouraged as well to play their due role. They can support other sectors in development
and implementation of standardised messages through capacity building of their outreach workers in the
areas of nutrition promotion. The government of Sindh should also promote tourism in beautiful and
scenic Tharparkar to increase income-generation opportunities.
 CHAPTER NO. 3
LITERATURE REVIEW
3.1 THE TRAGEDY OF THAR
Only when you look closely at tiny Aijaz, admitted to the malnutrition ward at the Mithi District
Headquarter Civil Hospital, do you notice his teeth and realise he is not a baby. The note on his cot’s
headboard indicates that he is five years old. “His mother cannot tend to him at the hospital as she is busy
with her newborn at home,” says Aijaz’s grandmother.
Another cot in the same ward is occupied by 28-day-old Sanam. Her mother, Debu, sitting nearby,
says she gave birth to 10 children, of which only four are alive. Sanam, fighting for her life now, is one of
them.

Photos by Fahim Siddiqi / White Star

Mithi is the capital of District Tharparkar. The District Headquarter Civil Hospital in Mithi serves
about one million inhabitants of Thar, coming from villages and towns, large and small — it is after all the
only secondary hospital of the district. Such is the high incidence of malnutrition in Thar that the hospital
has set up a separate malnutrition ward.
Roaming the hospital corridors are scores of parents and grandparents — it turns out that the
hospital also has a neonatal section for babies under 30 days old. The neonatal ward sees more deaths
than the malnutrition ward.
 “Some 550 children have been admitted to the hospital since September 2017, of which 439 got
better and were discharged while 11 expired,” claims Dr Sikander Raza, a paediatrician at the Mithi District
Headquarter Civil Hospital.
Dr. Ram Ratan, the medical superintendent at the hospital, says that babies are often born with
low birth weight and can be premature, because the mothers are weak due to having many babies without
much gap between pregnancies. “Mothers’ health is a major cause of babies dying and babies suffering
malnutrition,” he points out.
As with other health facilities in Thar, Mithi’s District Headquarter Civil Hospital routinely sees
women giving birth without much gap between pregnancies (above). Meanwhile, the PPHI in Village
Kantio wears a deserted look (below).
Thari parents, though, largely believe that if they have reached the hospital — sometimes a two
or three-hour drive from their far-flung villages — their child will be saved. “There are times when a child
needs greater care; in such cases, we refer them to bigger hospitals in Hyderabad and Karachi,” says Dr
Ratan. “But then there are people who take their children away mid-treatment; they think that no doctors
will be able to provide treatment. They are not satisfied, they get angry.”

Since 2017, 43 children were taken away by their families after deciding not to get them treated
there.
“Let us be very clear: these children are not dying due to hunger; they are dying because of malnutrition,”
argues Dr Sono Khangharani, chief executive officer of the Hisaar Foundation. “Malnutrition happens due
to three factors: over population, less animal produce, and vanishing of greens from people’s diets.”
 The district-wide crisis of malnutrition in Thar has seen many families suffer and mourn the loss
of a child. There are only hospitals where parents can rush their children, the secondary hospital in Mithi
or the one in the adjoining district of Umerkot.

“Around 500 patients turn up in our out-patients’ department (OPD) every day,” says Mohammad
Jam, in-charge at the Umerkot District Headquarter Hospital. “There are no deaths happening due to
malnutrition per se, but complications of malnutrition such as pneumonia and diarrhoea.”

The ‘functioning’ blood laboratory in Umerkot District Headquarter Hospital Jam argues that
much of the blame rests with a lack of family planning. “We have many newborn deaths where the babies
are underweight due to a lack of family planning. Usually, we find weak babies and those suffering from
malnutrition of say around six months of age, whose mothers are not nursing them as they are pregnant
again. Family planning is a bigger issue here,” he explains.

For Jam, the problem is also that

his hospital is terribly understaffed. “We
have no child specialist and no
gynaecologist though we have a
temporary lady doctor borrowed from
another establishment to cover for the
eight lady doctor posts here,” he says,
explaining that of the 46 vacancies for
doctors, only 23 were filled.

The 55-bed Umerkot hospital, which started in 1978-79 as a rural health centre, was promoted to
a taluka hospital in 1986 and is now the district hospital since 2002. “The hospital was upgraded by getting
a new name each time, without much change in its infrastructure. It is a secondary hospital where the
facilities should be increased and upgraded according to our needs,” Jam points out, adding that common
ailments in the area include waterborne diseases such as gastroenteritis, hepatitis and typhoid.

The quandary of the hospital extends to more than short-staffing. Senior medical officer at the
hospital, Dr. Chehnomal, explains that they had an x-ray machine but it was out of order. There are four
ambulances but only one driver, and he too had been borrowed from the Health EDO. Still, according to
him, they had medicines available and an operational laboratory.

But inside the lab, all kinds of new equipment still lay packed in crates. When asked why they
hadn’t been unpacked, the hospital staff claimed that they had no place to set up the equipment. The
extra space was consumed by a vacant Congo Virus isolation ward that had been inaugurated by a
government VIP.

“Malnutrition, especially among small children, is a historical problem,” says Dr Khangharani of

the Hisaar Foundation. “The first famine recorded in Tharparkar was in 1900, when 1,500 human deaths
were registered in one month. Following that, the first famine policy came about in 1906. The policy was
such that it would come into action when there would be no rain in August. But all that is forgotten now.”

And yet, the average life expectancy of adults in Thar is more than the rest of the country.

“People live longer here, but the 40 to 70 age group is jobless as machines have taken over what was once
the province of manual labour,” says Dr Khangharani. “This contributes to perpetual debt — Thar is the
only place in Pakistan where 80 per cent people borrow money to buy food. When you do that, the choice
of food is minimised too. With borrowed money, you will only buy necessary things such as flour or rice
but no potato, onions or tomatoes.”

Recent trends have shown that the government employs some 3,000 contactors to provide relief
in Tharparkar. “They are supposed to distribute a set number of sacks in each drought-affected area, but
many contractors keep a few for themselves to sell into the market. These are some of the changing
dynamics of Tharpakar that have created a problem here,” explains Dr Khangharani.

Drought expert Ali Akbar Rahim says that drought is a phenomenon that is turned into a disaster
due to mishandling by the government. “They need to create jobs here. Around 85 per cent of this desert
is part of India (in Rajasthan) but they are not dying from malnutrition or droughts there. We here depend
on livestock but when our animals are not able to find food with grazing land drying up, their owners
migrate. One drought pushes Tharparkar five to 15 years back and the last rain drops fell here in 2017,”
he explains.
 Another thing that Rahim was concerned about was the trend of giving away things for free by
the government in the mid-1980s. “It has added to the people’s dependency as the issues remain the
same with no lasting solution,” he says. A good example of this was seen at one of the Peoples Primary
Healthcare Initiative (PPHI) centres opened by Govt of Sindh with the help of USAID in the area where
some pregnant women had come in though not really for checkups. They were there because they had
heard a rumour about distributing of free blankets.

Putting it simply, Mohammad Juman, a resident of Tharparkar, says that malnutrition was linked
to drought and drought was linked to shortage of water. “We need tube wells to experiment with various
crops. In a place where there is a tube well, the people there have grown sunflower, peanuts, cumin
(zeera), trees and fodder for livestock. Our women work so hard carrying canisters of water for miles and
up the dunes but still can’t fill their stomachs even so much as to be able to nurse their babies,” he
concludes.

The room in Dera Murad Jamali’s District Headquarters Hospital is decorated with cartoons and
balloons. There are tiny babies, lying on blue beds and inside incubators. Many of them barely weigh
above 1kg, even days after birth. The ones below 1kg are usually not admitted as their chances of survival
are minimal. The babies are connected to oxygen, fluids and are constantly under observation. They
struggle to breathe, to live. Some of them have no more strength left to cry.

Dr. Barkat Hussein makes his rounds of the nursery. He checks vital signs with his stethoscope.
There are some instructions on the walls: “Dry the baby, assess the tone, breathing, heart rate.”

The doctor takes Chath Bibi in his hands, carefully, so as not to break her neck. She was born
premature and has been in the nursery for 18 days. When she was admitted her weight was 1.65kg and
now it is 1.43kg. It is normal for babies to lose weight in the early days of their lives. Chath Bibi has a
difficult road ahead of her but recovery is underway.

One of the most impacting faces of malnutrition among infants can be seen at this neonatal ward
run by the Médecins Sans Frontières (MSF) in the District Headquarters Hospital in Dera Murad Jamali in
the eastern part of Balochistan.
 According to national data from 2017, malnutrition contributes directly or indirectly to 35 per
cent of all deaths of children under five in Pakistan. Between a quarter and a third of all newborns are
born with low birth weight, and over half of women of reproductive age weigh less than 45kg.

The provinces of Sindh and Balochistan register the highest proportion of malnourished children
across the country. The dusty town of Dera Murad Jamali, one of the hottest places in Pakistan, lies in this
middle territory. It is close to the Indus River, a crossing point for cultures where people speak almost
every language, from Sindhi to Baluchi, and also Seraiki and Urdu.

“Please maintain the ward capacity always,” reads a board at the entrance to the nursery. It is
signed by the medical supervisor.

“There is capacity for 13 babies. Normally it is completely packed and we sadly have to reject
patients,” explains Dr Barkat. “They are mostly born outside of the hospital, at their homes. When they
reach here, the babies are in a lot of distress, and have respiratory problems because of the use of
oxytocin.”

Doctors claim that traditional birth attendants and some medics at private clinics often resort to
drugs to speed up deliveries. Women also work hard in the fields during their pregnancies, and hence
many children are born premature and weak. They arrive at the hospital very sick, often more than a
month after being born.

“People bring their children to us for secondary problems. They don’t know if their baby is growing
or not. They only know that the baby has pneumonia, diarrhoea or vomiting. When we tell them what is
really happening, they come to understand that the child’s basic problem is malnutrition,” says Dr Barkat.

If things go well, the children remain at the nursery for five to six days. In the worst cases they
may stay up to three months. This facility is just the beginning of the journey though, and the tiny babies
in the most critical conditions demonstrate the extent of the malnutrition issue in the area.
But beyond the neonatal ward there is also a therapeutic feeding programme that reaches
hundreds of families every year. The inpatient and outpatient services located in Dera Murad Jamali and
in the nearby towns of Dera Allah Yar and Usta Mohammad received more than 9,600 patients in 2017,
all of them children under five. There has been an increase in admissions since MSF started the
programme in 2010. Up until October this year, 7,639 patients had received care.

For Jongel Bugti, a farmer from Tipul Shah, this is the fourth time he has visited the programme.
He is waiting at the Dera Allah Yar hospital for a consultation and to receive medicine or at least some of
the high energy therapeutic peanut paste Plumpy’Nut. On this occasion, he is with his one-year-old
nephew. The boy weighs only 5.5kg. “The doctors give us some kind of chocolate. With this medicine the
children get better – it is not just my experience, everybody says the same here”.

“I work the whole day to earn a living. Our women also work in the fields because we are poor.
They don’t have time to breastfeed the children. Our main problem in Balochistan is a lack of education.
This is the biggest constraint to changing things for the better,” says Jongel.

His view is shared by Dr Barkat. Poverty, an insufficient number of medical professionals and
health structures, and a lack of health awareness and education all contribute to the malnutrition
problem. There are also frequent security incidents in Balochistan, and the area had been recurrently
affected by floods. Natural disasters tend to aggravate situations where there is little food security, as
they destroy people’s livelihoods and worsen their living conditions. The huge floods in 2010 caused
widespread destruction and displaced millions, which in turn sparked a food crisis.

On the top of that, some mothers stop breastfeeding their babies very soon after birth or don’t
start at all. “They change the pattern of feeding. If they start breastfeeding they also give supportive bottle
feeds and other things and then the baby is away from breastfeeding and quickly becomes malnourished,”
says Dr. Barkat.

Even though it costs money, giving babies formula milk instead of breast milk is a common
practice. Women often have to look after several children and don’t have enough time to breastfeed, or
believe their milk is not good as they are very weak.

But breastfeeding is very important in the early months of a child’s life because it gives them
antibodies with which to fight disease. Breast milk is clean, free of harmful bacteria and is always fresh
and available. It also does not cost anything. Unicef and the World Health Organisation (WHO)
recommend that children be exclusively breastfed and not given other liquids or food for the first six
months of life.

As per the National Nutrition Survey, nearly four women in Balochistan out of every 10 don’t start
breastfeeding their children within one hour of birth and many of them don´t start at all. Some families
also end up giving nutrition to one child in particular, often choosing the boy over the girl.

Some 15 mothers gather with their children every day early in the morning at the Dera Murad
Jamali hospital to attend a health promotion session. During the 20-minute meeting, MSF staff show
picture boards and explain how important it is to clean food, to wash hands or give details of the type of
feeding required. They put special emphasis on persuading the audience that breast milk should not be
replaced by anything else.

“The mothers often have questions and in the end they admit that they need to follow these
advices. Their children may suffer problems otherwise,” says Abdul Majit, a nurse.

“I stopped breastfeeding my baby after one month because I thought it was bad for him and I had
little breast milk. I started giving him formula milk. Doctors say I should continue breastfeeding and I will
try to do so,” says Lal Kahu, a mum in her early 20s. Her four-month-old child arrived at the hospital
suffering from diarrhoea and vomiting, but has been on medication for the last few days and is now getting
better, so the family will probably leave the hospital soon and get back to their village, located close to
rice fields.

Other children have not been as lucky as Lal Kahu’s son. They did not receive treatment in time.
In 2017, 84 children died in the MSF wards in Dera Murad Jamali and the surrounding area. Almost every
family in the area has experienced the tragedy of losing a child or has a neighbour who has experienced
it. Some women have lost up to five children.

This will hopefully not be the case for eight-month-old Abdurraman though. Outside the hospital,
eight members of his family wait for him to be discharged. They sit on a blanket with his grandfather,
Ahmed Lahi Day. Abdurraman was malnourished but has recovered his strength in the last five days with
the support of the medical staff. In the ward, there is only space for his mother, so Ahmed will spend the
night sleeping outside, waiting for Abdurraman to leave in the morning.

They are happy to go home. They are just not sure how long it will be until they need to come
back.

3.2 STUNTED FUTURE & NUTRITION

We often assume that malnutrition is a purely rural problem. It isn’t
Trying to comfort her howling baby, moments after she has been
administered a dose of iron supplement, young Salma* appears
clueless about how her 15-month-old child, Ayesha*, developed
anaemia.
“Ayesha was weak since birth, but has never fallen as seriously ill as
now. I brought her here to get treatment for her mouth ulcers and
persisting fever. I did not suspect that her illness has something to do
with the way I feed her,” says the young mother.
Salma and Ayesha come from Karachi’s old city area of Lea Market,
and have been lodged at the paediatric ward of Civil Hospital Karachi
(CHK) for the past three days. Around them in the ward are more pale
and under-nourished children. Ayesha has been diagnosed with severe Vitamin B-12 and iron deficiencies,
which, the doctors say, have made her vulnerable to infections.
“At 15 months, Ayesha weighs only six kg — this is about half her expected body weight at this age,” explains Dr
Muzamil Shabana Ejaz, associate professor at the Dow University of Health Sciences (DUHS) and attending
doctor at the CHK’s Paediatric Unit II.

Dr Ejaz has seen such cases multiple times in a day, sometimes, in the same moment too. She
argues that malnutrition, encompassing both under-nutrition and overweight, is affecting a significant
population in both rural and urban Pakistan, though little awareness exists on the latter. Around 30pc of
the total admission per year at the CHK paediatric ward, she says, is either directly or indirectly associated
with malnutrition.
The patients include those coming from the interior parts of Sindh, she says, of whom many often
report serious complications such as tuberculosis. There are also a large number of critical patients who
report at the hospital’s emergency section.
 “Among all the causes of death among children under five years, malnutrition is the underlying
cause in about 50pc deaths. Malnourished children suffer at every stage of life and miss their milestones.
Often when a child is malnourished, the mother, too, suffers from the same problem or vice versa,” says
Dr Ejaz, citing a medical research.
According to the Pakistan Demographic and Health Survey (PDHS) 2017-2017, 45pc of children
under-five in Pakistan are stunted or too short for their age, indicating chronic malnutrition. Stunting is in
fact the most common ailment among children of less educated mothers (55pc); it is more common in
rural areas (48pc) than urban areas (37pc); 40pc women are overweight or obese.
Though these statistics are alarming and require immediate intervention, many experts believe
that the official data, particularly on the nutritional status of mothers and children, do not reflect the
ground reality and believe that the scale of malnutrition among children is much higher.
A recent yet-to-be published research lends credence to this view-point to an extent as it shows
that chronic malnutrition (measured as low height for age) is found between 60 and 70pc in children under
five years in Karachi.
“Malnutrition is rampant in our low-income urban squatter settlements. The data also show 60pc
pregnant women moderately to severely anaemic,” says Dr Anita Zaidi, professor at the Division of
Women and Child Health, Aga Khan University.
He impact of chronic malnutrition on a child’s physical and brain development is grave. The IQ level of
such children is much lower as compared to those that are properly nourished. Much of the damage is
done in the first two years of life, explains Dr Zaidi.
Nutritional deficiencies occur due to multiple factors, argues Dr Ejaz, including poor health of the
mother, inadequate/delayed weaning, bottled-feeding, delayed or prolonged breastfeeding, as well as
inadequate child care resulting in recurrent infections.
A recent CHK study also links childhood malnutrition to maternal psychiatric illnesses. “We found
that over 90pc mothers whose children were malnourished suffered from mental and physical violence at
home,” says Dr Fehmina Arif, senior professor at the DUHS and head of CHK’s Paediatric Unit II.
According to Dr Arif, factors such as low birth weight, prematurity, lack of antenatal care, early
marriage, large size of the family, unemployment, death of a mother, and having more than two children
under five years are also risk factors for malnutrition
Scientific evidence, she says, indicates that the first 1,000 days after conception is the most critical
period of a child’s development. Poor maternal nutrition within this period will have life-long and life-
changing impacts on educational attainment, labour capacity, reproductive health and adult earnings.
 Malnutrition, according to Dr Zaidi, is also undermining the fight against diseases that could be
prevented through vaccines. Malnutrition, she says, is definitely a factor in sub-optimal responses to oral
vaccines such as polio vaccine.
“In Karachi, we have found that among children who have been given multiple doses of oral polio
vaccine (OPV) and are well-nourished, 99pc of them have good immunity in their blood after OPV doses.
But, in cases where children are chronically malnourished, then despite multiple doses of OPV, 15pc do
not develop polio immunity and remain vulnerable to the infection,” she explained.
“Of course, the biggest reason for not having polio immunity is total lack of vaccination. Around
90pc of cases in Pakistan in 2016 (the total number of polio cases reported last year was 297) were due
to lack of vaccination, and 10pc developed the disease despite vaccination, most likely due to
malnutrition,” she said.
Senior obstetrician and gynaecologist Dr Shabeen Naz, who has recently retired from Sobhraj
Maternity Hospital (a government-run health facility) after 32 years, referred to the PDHS survey 2017
that showed over 55pc women also avoided taking iron supplements during pregnancy due to different
misconceptions.
“Many women do not take iron supplements in the last three months of pregnancy as they believe
that it would make the baby’s complexion dark. Others avoid taking calcium tablets, thinking that it would
make the delivery difficult. So, there is huge of lack of awareness among mothers,” says Dr Naz, while
pointing to the different challenges in the fight against malnutrition.
In her view, the social mindset that prefers a boy over a girl is also at play, contributing to poor
maternal and child health status. She disagreed with a PDHS survey finding that put the number of
malnourished women in Pakistan at 40pc. Dr Naz claims the figure actually stands at 70pc.
“Both thin and obese women could be malnourished. Being overweight is a major health issue
among Asian and especially Pakistani women. Excess fat around the waist could cause high blood
pressure, heart disease and diabetics,” she says.
To improve maternal and child health status, experts suggest an inter-sectoral approach that
involves increasing health awareness and school enrolment particularly of girls, focusing on the health of
adolescent girls, introducing indigenous fortified food, upgrading primary healthcare services and
improving public access to safe drinking water and sanitation facilities.

3.3 Malnutrition in Sindh

Malnutrition is one of the foremost socio-economic problems faced by developing countries like
Pakistan. It takes place owing to insufficient or imbalanced nourishment and poor sanitary conditions and
hygiene practices. It results in poor health and education outcomes and impedes economic growth and
human development.
Major nutritional problems in Pakistan are low birth weight due to poor maternal nutrition,
protein-energy malnutrition, anaemia, and iodine deficiency. To combat these malnutrition challenges,
Pakistan has been part of the global movement of Scaling Up Nutrition (SUN) since 2017.
Sindh is severely affected by intensifying malnutrition and stunting indicators. As many as 48 per
cent children under the age of five are stunted while 35pc of them are severely stunted.
The incidence of global acute malnutrition (GAM), a measurement of the nutritional status, in
Tharparkar is 22.7pc followed by Sanghar (16pc) and Qamber-Shahdadkot (13.8pc). The situation is
worsening despite the Accelerated Action Plan (AAP) on Stunting and Malnutrition that the province has
recently adopted. The APP aims to reduce stunting from 48pc to 30pc by 2021 and to 15pc by 2026. It
plans to expand the coverage of multi-sector interventions to reduce stunting.
These figures paint a bleak picture of the overall state of nutrition in Sindh. They demonstrate
that the issue of undernourishment has received little attention from the government and the media.
Malnutrition is a deep-rooted governance problem. Had the government shown any seriousness,
such acute malnutrition conditions would not prevail in many parts of Sindh.
A nationwide multi-sectoral nutrition strategy has been prepared based on similar provincial
strategies to address the alarming nutrition crisis. The policy is aligned with Pakistan Vision 2025. In
addition, national dietary guidelines for better nutrition have also been prepared to provide nutrition-
related information for healthy living to the masses. The food fortification strategy has also been revised
to take sustained action for overcoming micronutrient deficiencies.
Moreover, a number of local and international non-governmental organisations are working in
the malnutrition-hit areas to improve the lives of the poor. We need to take immediate action to bring
strength to the institutions tasked with combating malnutrition. The state should arrange sufficient
resources for these institutions to battle this menace.
The government needs to create a sense of ownership among people working for these
institutions and improve coordination, networking and communication to mitigate stunting and
malnutrition. Workers in the relevant departments should undergo capacity-building and skill
development programmes to be able to better serve the public.
A decrease in malnutrition will prevent child deaths, improve the overall health conditions,
increase school enrolment ratios, raise wages and curb poverty because well-nourished children break
the intergenerational cycle of poverty.
 It is a national responsibility of state institutions to fight malnutrition and stunting. They need to
bring all stakeholders to a single platform and implement policies by mobilising resources from domestic
as well as international sources.
 CHAPTER NO.1
RESULTS & DATA ANALYSIS

RESULTS & DATA ANALYSIS

Food insecurity is crucial phenomena for developing, as well as for the devel-oped countries. Although,
Pakistan is an agrarian economy and this sector contribute20.88 per cent in the total GDP employing 43.5
per cent of an overall labor force,yet it is food insecure. Food insecurity is an important indicator to
measure welfareof individuals, households and states. It shrinks the output of persons and
subvertseconomic growth of a country. Therefore, to combat this issue there is a high needto measure
food insecurity and its principal causes in Pakistan

4.2 FOOD INSECURITY STATISTICS

Food insecurity exists when people lack sustainable physical or economic access and its statistics
insecurity reports where was not sufficient safe nutritious, and socially acceptable food for a healthy and
productive life. The households’ food insecurity incidence, gap and severity results at national and
regional levels are presented in Table 2

The results given in Table 2 reveals that 28.63 per cent population of householdssurvey is food insecure
at national level and is statistically significant. It means that28.63 per cent of the survey households do
not have enough food expenditure tomeet their daily food requirement. These results are consistent with
[FAO (2017)]statistics, according to which 23.1 per cent of the total population of Pakistan
isundernourished. Moreover, by using HIES 2017-08 data set Asghar (2017) foundthat 34 per cent of the
population is food insecure in Pakistan. Thus, it can be seenthat as compared to 2017-08 food insecurity
decreased in 2010-11. Pakistan is morefood insecure than India, where FAO (2016) reports that 015.8 per
cent households are food insecure. However, Pakistan is more food secure than Bangladesh where35.3
per cent households were food insecure [Ahmed, et al. (2017)]. Ref. is 2016.It may be noted that even the
developed countries face the food insecurity problem at their situation is better as compared to the
developing countries. Pakistan is two times more food insecure than the United States of America, where
14.3 per cent house-holds were found to be food insecure [Jensen, et al. (2016)]. The results at regional
level reveal that in Pakistan food insecurity is higher (30.71 per cent) in rural zones as compared to urban
zones (24.47 per cent) and the difference of food insecurity incidence between these areas is statistical;
it is also evident from Figure 1. These results are consistent with NNS (2017) according to which the rural
regions are more food insecure than the urban ones. In rural areas this situation might be due to lack of
income generating opportunities and low level of knowledge about food utilization compare between
umarkor rural areas and major cities of Pakistan.

Food insecurity incidence Competition ratio Between Umarkot (Rural) to Urban cities

hen food insecurity and poverty incidence are compared, it is found that by using the same data set, food
insecurity is higher than than the poverty incidence which was found to be 12.4 per cent and 15.06 per
cent, respectively [Government of Pakistan (2017) and, Cheema and Sial (2016)]. The reason for
difference of poverty estimates is that to adjust inflation between the two years the former used the
consumer price index and the latter used the composite price index. The food insecurity has the same
story regarding regional level as the poverty incidence. No doubt, the incidence of food insecurity is easy
to calculate and understand, yet it is irresponsive with what is happening with those who live below the
food in-security line? Therefore, to know this, the measurement of food insecurity gap is necessary to
quantify the total shortfall of food insecure households from minimum
required food expenditure. It may be inferred as an important indicator of combatingfood insecurity by
allocating essential resources to food insecure people. The resultsof food insecurity gap are also given in
Table 2. There is 5.28 per cent of the food in-security gap in Pakistan. It propounds if government mobilizes
and allocate resourcesthat can fulfill 5.28 per cent of the required food expenditure of each food
insecurehousehold. This would hhelp to bring the household up to the food insecurity andthus the
tentative food insecurity can be eliminated. At regional level, food insecuritygap is higher (5.72 per cent)
in rural areas than in the urban areas (4.4 per cent).

The comparison of results of food insecurity gap with poverty gap shows that the former is more than
double of the latter. According to Cheema and Sial (2016) poverty gap is 2.29 per cent in Pakistan. The
regional level food insecurity gap has the samestory as of the poverty gap. Although, the food insecurity
gap shows as to how muchthese households are below the food insecurity line, yet this gap is unable to
determinethe inequalities among the food insecure people. Therefore, the calculation of the severity of
food insecurity’ is necessary to know the inequalities among food insecure households. Results of the food
insecurity severity are also given in the Table 1 whichreveals that severity of food insecurity in the study
area is 1.46 per cent. It impliesthat food insecure households’ expenditure on food items deviate from
each other,with 1.46 per cent of the required food expenditure at national level. In rural areas the severity
of food insecurity is 1.56 per cent and in urban areas it is 1.26 per cent.Thus, it is higher in rural areas as
compared to urban areas which is evident from Figure 2. The comparison of the results of severity of food
insecurity with poverty severity shows that the former is more than double, of the latter. According to
Cheema and Sial (2016) severity of poverty is 0.55 per cent in Pakistan. The severity of food in-security
has the same story regarding regional level as severity of the poverty

2. Socio-Economic Characteristics of the Households

After explaining the results of incidence the gap and severity of food insecurity it is necessary to
decompose the food insecurity incidence into socio-economic characteristics of food insecure
households. Thus, this part discuss the socio-economic characteristics of survey households like
household size, dependency ratio, literacy status, education level, employment status, industry and
profession of household head in association with the food insecurity at household level.

a) Household Size and Household Food Insecurity

It is generally expected that household size and food insecurity have positive association. Large family size
affects adversely, the attributes of food insecurity because when size of a family increases, additional
burden has to be borne by the family to manage expenditure. The results depict that there is a positive
relationship.

Gap and severity of foo insecurity in Pakistan

Between household size and food insecurity in Pakistan. Figure 3 shows that when household size
increases the incidence of food insecurity also increases. These results are found, both for urban and rural
areas.
b) Dependency Ratio and Household Food Insecurity
Dependency ratio is an important factor to affect food insecurity. As the number of dependents in a
household increases, it leads to more chances of being food insecure which is depicted by Figure 4. The
dependency ratio and household food insecurity have positive relationship.

c) Literacy Status and Food Insecurity

The literature shows that literacy status is very important determinant of household food insecurity. If a
household is literate it has more chances to become food secure as compare to a illiterate household. This
hypothesis is found to be true and is being depicted in Figure 5. The results depict that food insecurity is
greater in those households whose heads are illiterate as compare to the literate one.

d) Food Insecurity and Education

The number of years spent in education are the key factors to affect food insecurity. Education catalyses
the process of information flow and clues the households to explore, as wide as possible the altered ways
of receiving information about nutrition and income generation activities. Adekunle (2017) also depicted
that low educational level was one of the causes that bound economic, social, physical, technical and
educational progress in the developing countries. Results in Figure 6 also present negative association
between household food insecurity and the educational level attainment. It depicts that as education level
increases the chances of household becoming more food insecure decreases.
e) Food Insecurity by Employment Status, Industry and Profession of Households’Head
Income of households is a major determinant of food insecurity which is affected by the households’ head,
employment, industry and profession. Therefore, it is very crucial to check the impact of these sources
towards food insecurity of households. The results of Figure 7 reveals that due to inherited family business
and lands; unpaid family workers and employers are relatively low food insecure and their ratio is highest
among the paid employes and share croppers. Figure 8 shows food insecurity status by different
households head industry. The results also show that households in agriculture livestock and hunting
category are the most food secure. Transport and storage workers, as well as the community and social
services are most food insecure. The profession of the households head plays a very pivotal role in
determination of food insecurity status of the households.
3. Determinants of Food Insecurity
Logit model is estimated to find out the impact of household characteristics on food insecurity in Pakistan.
To do this, food insecurity is taken as dependent variable and household related variables are taken as
independent variables. Urban and rural areas of Pakistan have different socio-economic and demographic
attributes. Therefore, the probability of households being food insecure is also different in both zones.
This study finds out the determinants of food insecurity of households at rural, urban and national levels.
The findings of logistic model are shown in Table 3.
In Pakistan several explanatory variables are assumed to have impact on household food insecurity. The
results reveal that different education levels of household heads, age of heads, foreign remittance,
ownership of livestock, female heads and poverty status of households are found to be significant whose
heads have never attended school or are less educated. The sign of coefficients and odd ratio of
educational categories show negative relationship between food insecurity and the educational level of
household heads, at national level. It is clarified in the role of education that working efficiency,
competency, diversification of income and being visionary, create helpful atmosphere to educate the
household dependents with long-term objectives to certify better living situation than the
uneducated/less educated household heads. Therefore, education diminishes the probability of becoming
food insecure in the households. Results are according to the theoretical actualities showing that
education expansion would lead to decrease problem of food insecurity which is also consistent with the
results of Aschalew (2016) and Tefera (2017).
Livestock has a negative impact on food insecurity of the households. It explain that if a household owns
livestock, it has less likely to become food insecure by 0.498 times relative to those households who do
not own livestock. These results are similar to [Bashir, et al. (2017), Nadlouv (1989), Zindi and Stack (1991)
Ref.1992].
The results reveal that land ownership is more significant negative determinant of household food
insecurity in Pakistan. It is shown that if a household is a land owner then the odds of being food insecure
are less by 0.59 times, as compared to those households who do not own land. These results are
consistent with those of Rutsch (2003) and Najafi (2003).

Foreign remittance is one of the key factors affecting food insecurity at household level in Pakistan. The
odd ratio of foreign remittance can be interpreted if a household is a recipient of foreign remittance. It
has less chance to become food insecure by 0.287 times relative to those households who are not
recipients of foreign remittance. This is the fact that an increase in income by remittance will lead to
positive change in the household expenditure. Thus, remittance leads to increase capacity of households
to consume more food stuff. These results are in line with those of Uraguchi (2017) Ref. 2010. The study
also estimates the impact of being a head of a family. The results show that households headed by females
have less poverty as compared to the households headed by males.

This study also tests the impact of poverty on food insecurity. Poverty is estimated by using national
poverty line of Pak.Rs.1,745/-. The coefficients of poverty show very strong positive significant impact on
household food insecurity. It can be seen that if a household is poor the odds of being food insecure
increases by 28.825 times relative to those households who are not poor. The odds ratio of poverty
explains very strong positive connection between poverty status and food insecurity in Pakistan.
Frequently the literature use food insecurity indicators as the proxy for poverty [Setboonsarng (2017) and
Klaver (2010)]. These results are similar to those of Brisson (2010) and Malik (2016). Urban and rural areas
of Pakistan have different social and economic characteristics and therefore the households in these
regions have varying chances of food insecurity. This study also estimates the determinants of food
insecurity at regional level in Pakistan. To check the determinants of food insecurity in urban and rural
areas, same variables are assumed, as sssss for the national level. The results are given in Table 4. Results
of the urban and rural levels are also statistical significant and consistent with national level. Education
level, except primary education, female heads and poverty status have some variables which significantly
affect the urban food insecurity more as compared to rural areas. The foreign remittance affect the food
insecurity, almost equally in both the urban and rural areas. On the other hand livestock ownership of
households affects food insecurity situation more significantly in rural areas as compared to the urban
areas.
Table no. 4