The road journey to Thar was enticing and exhilarating. The view was simply breathtaking with deep green foliage, flowing springs, chirping birds and contented cattle feasting on the freshly grown fodder. The air was fragrant and people were rejoicing the rain cycle which ended the three-year drought which played havoc with their lives, health, farming and cattle.
This was my third visit to the district in many years. The initial visits were done at the height of the drought to report deaths of women and children due to vagaries of weather, malnourishment and hunger. The last three winters were very severe and claimed many lives, especially of women and kids. Katahu Jani, a journalist and analyst based in Mithi said that the recent rains were the heaviest rains in the desert after 1976 and people are jubilant that the vicious circle of drought has been broken.
Despite living in the 21st century, Tharis are still dependent on rain for subsistence farming. Thar is the one of the poorest of 120 districts with the lowest Human Development Index, according to the Economic Survey of Pakistan. (2015).
The harsh last four winters claimed so many lives of the most vulnerable ones. According to Dr Bharat Kumar, the deputy district health officer in Mithi, the total number of deaths for children under the age of five years was 326 in 2014, 398 in 2015, 479 in 2016 and 248 till September in 2017 as the mortality rate will increase as weather will become colder. These figures show the steady rise in children mortality rate in Thar.
Inter-generational nutritional deficiencies
These deaths, however, are directly connected to women, their status in society at large, and the gender discrimination they faced in getting access to food, healthcare, education and employment opportunities. Women in Thar are the real victims as they have to suffer multiple kind of discrimination due to their gender, class, sect and religion. Even their access to food is limited due to the patriarchal set up. According to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) and the Food and Agriculture Organisation (FAO) fact-finding report conducted in 2016 that women and children eat less than men in the district and it is the major contributing factor in their malnutrition.
Quoting again from the OCHA and FAO report which concluded that due to prolonged droughts women and children eating patterns have been significantly changed as people eat one or two meals a day compared with three meals earlier. This makes women and children weak and susceptible to various diseases.
There was a lot of hue and cry in the regional and mainstream media on these deaths and it put the government on defensive. The Supreme Court of Pakistan took suo motto notice of these deaths and asked the Deputy Commissioner (DC) to present a report on the reasons for the tragic loss of lives. In the submitted report the DC mentioned that about 80 children [by June 2017] have died so far this year in Thar because of the absence of reliable transport, early marriages and malnutrition.
Health facilities in the district
Initially, the government vehemently denied responsibility for the crisis, claiming that these deaths are normal and occur every year. Another excuse for the government is the topography of the district in which nearly 1.6 million citizens live in 2,325 villages which are spread over 22,000 square km. However, the extensive reporting and the pressure from different quarters forced the government to take corrective measures and it increased health facilities and budgetary allocations. The Sindh government claimed that the health department got a considerable increase of Rs6.4 billion, as Rs65.9 billion were earmarked for 2016-17 health expenditures.
As District Health Officer, Dr Shafiq ur Rehman Memon in Mithi said that the total budget allocations under his command for the year 2014-15 was Rs31877600, for 2015-16 was Rs35065360 and for 2017-18 is Rs39847000. Explaining further, Dr Memon says that the government increases the health budget by 10 percent every year which shows its commitment to the people of Thar and their health and nutrition needs. However, it is also an open secret that the government formed three commissions to find out reasons for the Thar crisis, but none of the report was made public.
In order to investigate the reasons that why the death rate for kids is increasing despite the fact that the government is providing more funds and facilities in the district in the last four years [from 2014 to 2017] especially for women and kids, this scribe visited Thar. Even recently one woman and her child died in the District Hospital Mithi during childbirth as there was only one gynaecologist in the hospital against the vacancy of three – one gynaecologist resigned recently and the other one was posted out – those expectant mothers who managed to reach the hospital on time were not given timely medical care due to non-availability of lady doctors.
While on paper there are 250 dispensaries in the district, only 160 are functional. In addition, since a majority of Tharis reside in remote villages, accessing basic medical services is difficult. Chief executive of the NGO Hands, Shaikh Tanveer Ahmed points out that 20pc of health facilities are non-functional.
Lack of family planning facilities
In addition to providing children with a nutritious diet, health experts point out that better family planning should lead to improved health for women and their babies.
Lewanti Bai, 45, who works as an assistant district coordinator for the National Programme for Family Planning and Healthcare, a government-run initiative that trains women to provide healthcare services at a community level, said that an important reason for high the infant mortality rate are large family sizes and a lack of birth spacing. While they are working on increasing awareness about family planning, it’s proving to be an uphill task, as Lewanti Bai adds, “only 40pc of the district is covered by LHWs, and there is one LHW for 1,000 people.”
Dr Deesha Kumari, a gynaecologist working in District Hospital Mithi, believes that they are also working towards ensuring better family planning practices among Thari women, through more frequent medical follow ups, as she pointed out, “when women deliver a child we ask them to come back after every six weeks for family planning, and if they fail to do so, we do not take their case in this hospital.”
There isn’t much resistance from society — the older generation of Thari women seem very supportive of family planning. For instance, Sukhio, a resident of a remote village, and a grandmother, says that she “gave birth to 13 children out of which only eight survived, but advises [her] daughters and daughters-in-law to practice family planning and have fewer kids”.
Rahdha, a young woman from Bolri Bheel, is a mother of nine kids and looks stressed and fatigued from multiple reasons which include backbreaking labour of collecting fodder for animals, cooking and washing, and carrying water from long distances. She doesn’t want more children but there is no one to guide her which shows the failure of the population panning department.
Healthcare scenario
It became very difficult to verify and get data as the government of Sindh advised the relevant officials to not share any data with the media. The relevant officers as District health Officer, District Food Officer and Deputy Commissioner refused to entertain our Right to Information applications on different pretexts. Thus the report is based on data provided by different sources.
During a visit to the District Hospital Mithi, it was observed that most mothers displayed symptoms of chronic malnourishment. Such women, unfortunately, often live in far-flung areas of the desert where transport facilities are few and far between, so seeking medical intervention is beyond their reach.
Rukmani, a young mother from Lobhar village said that her kid was suffering from diahorrea and high fever and was critical of the services provided in the District Headquarter Hospital Mithi.
According to Dr Sikandar Raza Hanjano, a paediatrician working in District Hospital Mithi, “these girls are married off at an early age, have repeated pregnancies, and don’t have a nutritious and balanced diet, which results in underweight and weak babies, who often die from preventable diseases.”
Endorsing his views, Dr Bhawan Rai, who is also a paediatrician working at District Hospital Mithi, says, “If the mother is weak, then the child will also be weak and will be [born] prematurely.”
Dr Abha Chandani, Women Medical Officer at District Hospital Mithi elaborates different causes of death of new born babies in the district which includes birth asphyxia, pre-term, low birth weight, respiratory distress syndrome, pneumonia, delivery of babies through Daais (traditional birth attendants) that caused neo-natal sepsis and diarrhoea.
There is no doubt that there is improvement in the medical facilities at the District Headquarter Hospital Mithi but the problem is that the government is focusing too much on this hospital and ignore Taluka hospitals and Basic Health Units (BHU).
A doctor serving in the District Hospital Mithi – who requested not to be named due to the government’s policy of not sharing details with the media – explains that there are 300 vacancies for doctors in the district which remain vacant for the past many years. The health department hired 100 doctors on contract, yet these vacancies are still technically vacant. “With the up gradation of the District Hospital Mithi there are more vacancies which have never been filled. As far as gynaecologists are concerned there is only one gynaecologist in the District Hospital Mithi. Imagine one doctor to serve 800,000 women. No wonder the mortality rate is so high,” he concludes.
According to the government of Sindh figures, DHQ Mithi is a 174-bed hospital which has a total budget of Rs156,861,00 out of which non-development budget is Rs95,657,000 and development budget is Rs61,204,000. It provides 24-hour emergency services and has 30-bed paediatric ward 20-bed neonatal and 10-bed Nutrition Service Centre. Its nursery has 22 incubators for new born babies. However, keeping in view the long distances and difficult terrain there should be an integrated network of Taluka hospitals and Basic Health Units.
Analysing the data showed that the government has taken many steps to alleviate the suffering of the people in Thar through budgetary allocations and appointment of more doctors but these are cosmetic reasons as the basic reason of the children’ death is the low nutritional and social status of women as well as inter-generational nutritional deficiencies and until and unless the government of Sindh is ready to address these structural problems it is not possible to end these deaths.