Public Health Professionals

“Insanity is doing the same thing, over and over again, but expecting different results.”

We, in Pakistan, are at least doing same things consistently with ‘malnutrition’; we do the survey, cry over the high rates, bully the government and come with same interventions (but with newer names). And then after few years, we repeat the cycle. In my lifetime, I have been quoting the famous 1976-77 survey and then so on; the latest is being undertaken or may be completed. We, all do the academic luxury by presenting it in 4-5 star hotels, presenting and writing the papers and beefing our CV, in addition to monetary benefits.

I don’t have any hesitation to admit that the only exam I failed was for my Diploma in Child Health (DCH) and the examiner was actually the teacher of my teacher (Prof.  Billoo) and just because I could’nt satisfy the examiner about management of malnutrition in a child; her exact words were “you can’t do a Pediatric practice without proper understanding & management of malnutrition”.  This is also true on a larger scale for Public Health practitioners for managing the malnutrition at a community/district/provincial levels.

Perhaps we all need to appreciate many dimensions related to malnutrition and its management.

  1. There can be a whole spectrum or pathway to malnutrition, starting from normal to at risk, getting into developing obvious signs of complications.
  2. There is a biological dimension & illness-malnutrition nexus.
  3. The social norms, taboos, maldistribution within family/society.
  4. A number of influencing &/or contributing factors other than just food insecurity and poverty.
  5. What intervention, how, by whom and how the malnutrition is being managed
  6. What percentage of time is being contributed to managing malnutrition by mothers, workers, doctors, nurse, hospitals?
  7. Are we doing enough with whatever resources we have got? How many success stories do we have on a small scale and how many have many have been scaled up.
  8. Is there a strong political will and commitment or is it just restricted to policies, strategies, big reports and a big push by the bi-laterals or multi-laterals (donors).
  9. Above all what are we focusing; on promoting good nutrition, preventing malnutrition or managing malnutrition.

As a “hopeful-pessimist” (or sarcastic), I don’t expect large and longer-term investment by respective provincial and even federal governments, except for knee-jerk responses or project-oriented (max for 5 years) by donors and lenders. Unfortunately, it appears that we act too late when the malnutrition (wasting or stunting has developed); the worst part is both are difficult to manage and need higher-cost.  Even disturbing ritual related to malnutrition is mis-interpretation & abuse of “growth chart” when it is used to pick up malnutrition and send the data at a higher level to be fed (in computer) and reported; neither instant action is taken by community health worker nor the manager except to put it in the report and present as needed. As big “nutrition advocates” we join the bandwagon of ‘multi-sectoral’ approach without appreciating the fact that at the end the malnutrition has to be managed by a health worker working at some level—from a community to hospital.

So do we keep on doing the same…… Let us think out of the box!!. Let us go back to basic of Public Health.

  • Why can’t we put our efforts on “positive-deviant” approach and understanding why in the same community some children are still healthy.
  • Why not put our efforts on maintaining the good nutrition of a child (and for that matter her mother’s).
  • Why not pick a child when the growth on “growth-chart” starts faltering rather than wait to let him/her slip into malnutrition? It is much easier and less costly to adopt this approach for promoting good nutrition.
  • Why can’t mother herself and mothers in a community be taught to handle nutritional status of their children by using social media and digital technology?
  • Why not address adolescent girls before their marriage rather than giving iron and nutrients at the time of pregnancy.
  • Above all, whatever we keep on doing, if we don’t address rapidly expanding the population, we will just keep on adding more malnourished children in our community.

Well, one can say, these all are being done!  However, I would contest that based on my observations, discussion and some actual work. For those having some academic flavour, please refer to my few papers (through the web) related to risk approach, P in GMP, undernutrition in squatter areas, intermittent growth monitoring, on rickets etc.  Even if all or something has been done, it must be a time-bound, projectized and small-scale approach.  Of course, more inputs are needed for discussions and actions.



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