“I only used to hear about world hunger on TV and in the newspaper, but I never got to feel it on a soul level”, says MSF psychologist Vardah Ahmed. The 26 year old hails from the bustling megacity of Karachi, four hours south and, in many respects, worlds away from rural Dadu, where poverty is rampant, and the average wage is the lowest in the country.
Psychologist reports on malnutrition intervention in Pakistan
In 2022, scorching heat waves broke records across South Asia, with temperatures surpassing 50 degrees in March and April. The unusually violent monsoon that followed, triggered floods that killed over 1,700 people in Pakistan and ravaged communities.
After the devastating weather events, attributed to climate change, MSF (Médecins Sans Frontières) set up a community-based malnutrition program in the remote part of Dadu district. 1,236 children under the age of two and 224 pregnant women and lactating mothers were admitted in the program.
Hunger comes with diseases, and with relationship problems among the family. It's not just a matter of eating food. It's much more emotional, like a soul deep thing.
Dadu district is no stranger to floods, be they brought by monsoon rains, glacier melting, the Indus river overflowing, or a combination of all factors. But for five months, between June and October of 2022, large parts of the region were completely cut off from the rest of the world. Not one, but two harvests were lost. In a rural area where most people do not own land but rent their arms and workforce to survive, no harvest meant no income to buy nutritious food. The ongoing high inflation added to the woes.
MSF had been managing a program in Dadu before the floods to support local authorities with treating the neglected disease of cutaneous leishmania. Once the floods hit, activities naturally morphed into emergency response. By December, two months after the water levels had receded, the medical team noticed an increase of malaria cases, while the rates of severe acute malnutrition among children tripled between September 2022 and February 2023. They therefore switched gears and designed a program to treat anyone sick with malaria, as well as nutrition activities targeting children under five, pregnant women and lactating mothers.
“Once, a man brought his malnourished child to us”, Vardah recalls. “She was severely anemic, on the verge of death, and we convinced the father she needed to be hospitalised. But the elders of his house refused, arguing that they don't have money to pay for food and accommodation in the city for an adult to accompany the child while she is hospitalised. So, they didn't go, and I don't know what happened to the baby. It was a hard day. I cried a lot that day”.
MSF treated 127.400 severely malnourished children at inpatient feeding centres (ITFC) across the world last year. But in Pakistan, the ITFC were managed by the ministry of health, so MSF focused on outpatient care. Each morning, teams climbed aboard MSF vehicles, and drove a couple hours in the scorching heat until they reached the location of one of the ten MSF ambulatory therapeutic facility (ATFC), usually set up in local health post, though those are often little more than four walls and a roof. There, patients could receive nutrition support alongside health promotion advice and psychological help.
“After exchanging with local health authorities and in close collaboration with them, we decided to focus on hard-to-reach areas where there was no one else, proactively seeking severely malnourished patients in the most remote and destitute parts of the district”, explains Rinako Uenishi, MSF’s project coordinator in Dadu.
Though activities were set up as close as possible to patients, the population is so spread out in this huge district that, still, some of patients lived 15-20 km away from the closest ATFC. In a region with no public transport apart from the few motorbike taxis, it meant those patients needed to walk the equivalent of a marathon round trip just to get access to the therapeutic food. “It is obviously not sustainable for vulnerable people, and we didn’t want to add yet another burden on them. So patients living in the most remote areas were given two weeks supplies of supplements”, explains Rinako.
“When I started counselling sometimes my eyes filled with tears”, says Anis Bibi, the manager of MSF’s health promotion team originally from the city of Hyderabad. “We can't just tell people to include meat, fish and these type of expensive things in their meals. They know what is good, but they can’t afford it. Once, a woman was listening to us patiently giving her advice on which nutritious foods to eat, and at the end she just said “I don't have one meal to eat”. That was really hard”.
Three quarters of the children admitted in the ambulatory feeding programs were under two years old. This is a sign of maternal undernutrition throughout the pregnancy and inadequate feeding practices such as ineffective or absence of breastfeeding. Supporting lactating mothers – 273 pregnant and lactating women were admitted in the program – is a way to ensure that, through breast milk, the youngest will receive the nutrition they need. “Mothers who work in the fields can’t breastfeed their children. It's the bitter truth. Because no mother will take their child in the field under 50 degrees heat. So they give bottles with water and a bit of sugar to the eldest child or the mother-in-law to give to the baby during the day”, Anis explains.
We can't just tell people to include meat, fish and these type of expensive things in their meals. They know what is good, but they can’t afford it
The provision of therapeutic food, though the cornerstone of the activities, is not as simple a task. Health promotion and psychological services are integral in the MSF medical approach. Without it, says Anis, the program risks failing. “At the start of the nutrition program, we were alarmed because the ratio of cured patients remained very small”, she recalls. “But soon we discovered that some of the people were thinking that the therapeutic food we distributed was like a candy that anybody can enjoy. So we organised a small group of health volunteer committees in the hamlets to explain again and again that this is a medicine for severely malnourished children only. The impact of those health volunteer committees was very, fruitful and our program cure ratio increased”.
Psychologist Vardah recalls one story that moved her particularly. “A woman was telling us that her husband was not letting her feed the therapeutic food to the malnourished child; he was giving it to his other, healthy children, from his first wife who had passed away. Through couple counseling, we made the man see how much the mental health of his wife was also important. Because if she's not happy, if she's not in a good state of mind, she won't be able to take care of your home. Three weeks after this session I saw the mother again. She was taking care of herself, her child walked better, and her weight had also increased. And so that's one of the success stories that I have for the mental illness”.