Thinking out of box – Malnutrition fiasco

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.



Measles and miseries: A gift or curse

Measles was described by Muhammad ibn Zakariya ar-Razi (860-932) or Rhazes – a Persian philosopher and physician, in the 10th century A.D. as a disease that is “more dreaded than smallpox”. Razes published a book entitled “The Book of Smallpox and Measles” (in Arabic: Kitab fi al-jadari wa-al-hasbah)[1]. Interestingly a lot of myths and misconception had been carried with Measles, especially calling it as “Sheetla Mata” (the gift of Goddess)[2] and/or “ouri Maata”. Interestingly while working in one of the Hindu communities in an urban squatter of Karachi, I had observed that the child who had developed Measles was put in a separate room and it was pretty cleaned with some ‘Naeem’ branches. In fact I had heard from my parents and some elder relatives that it is much better to allow the disease to come out rather than suppress it. I thought that these must be related to a particular ethnic group or religious group, however, while discussing just yesterday with one of the colleagues, I was told that in Sindh in Muslim families, this myth still persists.  However the children are managed differently. They are not give bath, the room is not cleaned, rather closed and to add to miseries, other children are also put in that room, so that they also “benefit” from this gift!!!

Almost 4 decades back, as a student and then as House Officer, I had seen not only the early signs but also all types of complications ranging from, Koplik’s spot, Maggots in mouth (because of unhygienic conditions and Pneumonia and meningitis.  Unfortunately, we are still having Measles complications being manifested as Pneumonia, ultimately leading to death.

The recent WHO estimates about the status of Measles in Pakistan are very disturbing to all of us. We are still grappling with communicable diseases, without realizing that quite a population has now also contracted non-communicable diseases and last but not the least, MNCH/RH issues and rapidly aging population.  Of course not to forget the rapidly increasing population which is adding more and more and children.

The government alognwith bilateral and multilateral partners have been coming up with lot of projects/interventions including the so called “surveillance system, the vaccination campaigns and yearly MNCH days etc etc. I really what had happened to all these efforts and suddenly WHO comes with the news that 65% of Measles cases in South East Asia are from Pakistan. It seems that our vaccination efforts has not made a difference due to ineffective surveillance system which has not been able to pick due to faulty data; ineffective vaccination; lack of awareness and willingness to vaccinate their children and above all no advocacy by our leaders to make a difference.

Considering a health systems approach, availability of vaccines by GAVI may be just one component, converting it into success will require the need to put attention on other components. We have yet to get rid of Polio, but if take that “single-targeted” approach for controlling the immunizable diseases, we may not achieve our targets in the so many future targets.  Let us do something out of box; there are examples of success stories from different parts of the world, it is high time that rather than inventing a new wheel, we try to adapt the wheel already prepared by someone



Political will or ill-will: The case for “Population” in Pakistan

The rapidly growing population in Pakistan, and its horrible consequences have been known & articulated by all the stakeholders including especially the Government and donors, besides the civil society.  A quick look at historical evolution to address this issue reveals that at the end of the day, it’s the political will or otherwise which makes a difference.

Modest but impressive beginning

In ’60s, FP (Family Planning was initiated by an NGO, which made a big difference to capture the attention of Government and later within some decades we had a formal Ministry of Population Welfare and a famous program of Village Based FP Workers along with mobile clinics etc.  Interestingly this was even before the existing Lady Health Worker Program

Good intentions but bad consequences

The Government appeared to have good intentions in having two ministries i.e. The Ministries of Health,  and Population Welfare at Federal level and similarly at the Provincial level.  Perhaps the rationale may be to have focus and desired emphasis on population issues.  However, this artificial divide resulted in compartmentalized approach by putting all the health related issues to Ministry of Health, except for FP; though some lip-service was still maintained.  This issue has further worsened by the devolution in Pakistan and each province is addressing this issue separately; some not paying attention because ‘their’ population is already very low and thus federal distribution of money is also less!!

Playing with Population data

The population have been produced but there had always been issues related to projections and of course fudging of the data at health services delivery levels because of stringent requirements and consequent punitive punishments.  Thus, usually, with few exceptions, the news was that all is well and we are slowly progressing in increasing our contraceptive use rates and the consequent indicators. It was untill when PDHS 2007 and later on 2012 revealed that all is not well.  I remember that the Ministry of Population Welfare held back the results for more than 6 months.  In the meantime several surveys and consultancies (Technical Assistance) work had been conducted to identify the reasons and suggest the solutions. Of course each time we came up with the ‘old wine in a new bottle’.

FP agenda further widened & its consequences

The ICPD agenda and further declarations coined the word for ‘Reproductive Health’ (RH) and then even Sexual and Reproductive Health and we joined the bandwagon as part of political will and international signatory.  I have all the fears that it further diluted the FP focus but opened up the doors for new interventions. This followed the advocacy for Adolescent Health, Abortion Rights, Women sexual and Reproductive Health and lot of talks on population bulge, the demographic dividends etc etc.

Failed efforts for integrating Health & Population

There had always been growing realization that population is part of health and why not the two Ministries be at Federal (before devolution) and Provincial levels be merged. There have been lot of efforts by the UN agencies to make it a reality and I know that even there was all the willingness to do it by the head of state, but just because of one of minister it was postponed and in a way cancelled.  There are some services provided by both the Departments’ outlets and outreach workers but still each one respectively reports to their parent department.  In addition, though some efforts had been made by the other sectors such as education, it has not made a big difference.

Should we keep on using the old wine in a new glass? The way forward

“We cannot solve our problems with the same thinking we used when we created them”, Albert Einstein.

One might be shocked when you start calculating the amount of money put by the Government as well donor agencies and international NGOs to address the issue of FP. Interestingly, most of the NGOs and implementing partners have always showed that they have made a difference in their 1-5 years project. Unfortunately, when money and inputs finishes, all goes to ground zero and no replication, what to talk about scaling up.  Perhaps, all the stakeholders and champions have to make some ‘hard’ and ‘bad’ decisions. It appears the existing government and may be the coming government will not have FP in their political agenda, as they have so many other ‘pressing issues’ to tackle.  But, the question is, has any bilateral, multilateral and Bank has to courage to make these steps; or should we leave it to civil society or at the last to people themselves.  Maybe, let us leave it to Allah, as now we have major populist Islamic dominance who are also not in favour of addressing FP issues.