DERA MURAD JAMALI (BALOCHISTAN) – The room 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”. Dr Barkat 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 Médecins Sans Frontières (MSF) in the District Headquarters Hospital in Dera Murad Jamali, East Balochistan. According to national data from 2011, malnutrition contributes directly or indirectly to 35% 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.

Premature babies

“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 2013, 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,” says Jongel. “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.”

Creating awareness

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 Organization (WHO) recommend that children be exclusively breastfed and not given other liquids or food for the first six months of life. But according to the National Nutrition Survey, in Balochistan nearly four women out of every ten 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 twenties. 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 soon the hospital and get back to their village, located close to rice fields.

A ray of hope

Other children have not been as lucky as Lal Kahu’s son. They did not receive treatment in time. In 2013, 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.