Chaman; Safa and Marwa

Born in Afghanistan, 25-year-old Madeena moved with her family to Chaman, Pakistan, when she was 10 years old. One of 14 siblings, her parents couldn’t afford to send her to school. She was married off to her cousin (who had also migrated with his family at the same time) when she was only fourteen years old.

“I became pregnant as soon as I was married but due to a premature delivery I lost my first baby in my seventh month.”

Madeena’s body barely had time to recover when she fell pregnant again immediately after this trauma. Luckily, she delivered her first healthy baby at 16 years of age. Her next four children were born consecutively with no gap years.

By the time she was 20 she was a mother of five.

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Her pregnancies did not stop there. At 22, Madeena delivered another baby who died due to premature birth. Three years later, she found herself at the MSF facility delivering twin daughters, both born with Down Syndrome.

Almost as a promise of protection and devotion to her new-borns, Madeena named her girls Safa and Marwa after the legendary hills (from Islamic History) in the deserts of Saudia Arabia that Bibi Hajra ran desperately between to find water for her thirsty son thousands of years ago. Allah rewarded her act of love towards her child when He created the most mysterious source of water known to mankind; The Well of ZamZam that lies between those two hills. Today it is known as one of the holiest places for Muslims who believe in the spiritual power of the Zam Zam water.

Madeena has to be strong for her girls because life will be very challenging when she takes them back home. She mentions that she doesn’t have cemented house or a fixed roof and they live in a ‘katcha’ place where there is no access to water. They have to rely on tankers which means extra expenses.

“My husband is jobless. Every day he tells us he will go and look for a job but he never does!” 

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Safa and Marwa have been admitted to MSF due to severe malnutrition. Having been fed impure milk in the first 6 months of their lives, the twins developed a history of chronic diarrhea. They are now finally receiving the best kind of formula milk available at MSF to make them healthy again.

Dr. Muhammad Iqbal, a medical officer in the pediatric and nursery ward at MSF, describes this as one of the most common cases that he has dealt with since he arrived in Chaman 7 months ago.

“A good number of women do not know how to wean their children properly and that results in malnutrition. These women are extremely poor and have too many children at home who distract them from giving adequate attention to the new borns. They are simply too exhausted to give the care required.”

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In Madeena’s case, the fact that she has twins (and that too with special needs) could mean she is overwhelmed.

“I live in a house with twenty five people and yet I have no help at home. My eldest daughter is only 9 years old. What can she possibly do to help me at that age?”

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According to Dr. Iqbal, lack of family planning, poor economic means, poor hygiene, lack of health education and lack of early consultation are all factors that lead to malnutrition which is extremely difficult to overcome in the social fabric that is Balochistan.


Adnan Amir, a freelance journalist from Quetta in an article “Planning in Balochistan” (The News, 5thFeb 2017T) writes about how 160,000 pregnancies are unwanted in Balochistan every year which can be avoided if population control methods are effectively employed.

He mentions that according to Pakistan Social and Living Standards Measurement Survey (PSLM) of 2013-14, the literacy rate in Balochistan is 43 per cent (* dropped. to 41% in 2018 survey). According to estimates, 20-25 per cent population of the province is urbanised. In such a scenario, it’s natural that population control has not been effective in Balochistan.

He quotes Mehwish Quddus Alizai, who teaches Sociology in Balochistan University of Information Technology, Engineering and Management Sciences (BUITEMS) as Assistant Professor, who says “Cultural and contextual impediments, such as lack of education and awareness, male dominance and religious misinterpretation, restrict women’s choices to negotiate their family size and birth spacing.”

Photos and Text ©Khaula Jamil

On Assignment for Medicine Sans Frontiers / Doctors Without Borders

 

Dera Murad Jamali; Hot Tea Baby

While on an 8-day assignment for Doctors Without Borders/ MSF Pakistan in Dera Murad Jamali (Western District Balochistan), I decided to spend one day in the pediatrics ward at the DHQ hospital where the MSF facility is.

The ward mostly had children undergoing treatment for malnutrition. I was observing the doctors quietly go about their work when suddenly I saw some nurses frantically enter the room with a tiny baby in their arms. Quickly following them to one of the beds I saw them wrap the baby in golden foil.

The two-month-old baby’s face was patchy.

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“Someone dropped boiling hot tea on the baby’s face- we have to stablise her!”

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The baby was in severe distress and howling away. The doctors were doing everything they could.

She finally calmed down and I took a closer look at her tiny flakey face.

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I decided I would document her recovery and learn more about her family. What was going to be this baby’s future once the doctors saved her life? What environment was she going to go back to after this ordeal? What even put her in this position in the first place?

Two days later, I got my chance to sit down with the mother.

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Mori Bibi is not a new face for the doctors at MSF. She recently spent a month here with this same baby girl and was discharged few weeks ago. When her baby was one-month-old and suffering from malnutrition, Mori Bibi had no choice but to come to MSF. With babies that young, it’s the mother who needs to be treated by doctors because the baby is too small to be given anything other than formula or the mother’s milk.

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After one month whole of treatments, Mori and her baby were sent back home and asked to check in with the ATFC at the MSF facility every few days so that the baby could be monitored. Mori never came back.

 This is probably because of several reasons.

Mori is married to a much older man who is her father’s cousin. She is his second wife and is expected to work in the fields during the day, cook in the evening and feed her new-born all night whenever she cries. She has two other children aged 3 and 1 from her 4 short years of marriage.

“They weren’t so happy when I had a girl again. They prefer boys.”

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 Mori says she doesn’t have the time to feed her.

“I wake up at dawn and go to the fields to work with my husband. My mother in law keeps the baby the whole day and doesn’t bring her to the fields for me to feed her unless my baby cries a lot. I go home at lunch only to have a cup of tea and then return to the fields.”

When asked about what the baby is fed all day in her absence, Mori does not answer clearly.

“My mother in law makes her stop crying. She handles it.”

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I go back the following day to continue our conversation but Mori is fast asleep.
The doctors say that she falls asleep quite often and it’s quite hard to wake her up. They constantly have to remind her to feed the baby.

Mori looks constantly exhausted. This time in the hospital is probably the only chance she has had to rest in a long time. I wonder if she deliberately wants to stay or keep coming back for that reason.

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I finally find her awake the next day and she continues telling me her story;

“The family doesn’t really care if this baby dies. She’s a girl. The only reason I brought her here when they dropped tea on her face was because they were afraid people might talk if we didn’t.”

The nurses around me confirm that male children do get preference in most families when they fall sick. Families are willing to pay private hospital fees for them, but with female children- they’ll take them here or to the free clinics and let the chips fall where they may.

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“Mori’s baby was not only burnt. When we were tending to the burns we noticed she was covered in blood and stool. It looks like she had not been changed or washed in days. It was very hard cleaning her.”

Despite everything, Mori’s baby is recovering well. The new skin is starting to appear and the doctors are happy with the progress.

“No one at home may think much of her, but I think she is pretty,” says Mori with a small smile.

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According to Pakistan Census Report from 2017, more than 177,000 children die annually in Pakistan before their fifth birthday due to them or their mothers falling victim to malnutrition. Also, according to the the 2011 National Nutrition Survey more than 10 million children under five suffered from malnutrition. A total of 63% were anaemic, 54% were vitamin A and 40% were vitamin D deficient.

MSF has a fantastic program that is helping battle these statistics but without a serious focus on education and healthcare in marginalised areas, not much can change in Pakistan.

Photos and text ©Khaula Jamil

On assignment for Medicin Sans Frontiers / Doctors Without Borders

Dera Murad Jamali; Tetanus Baby

I arrived at the MSF facility in the District Head Quarter Hospital in the western district of Balochistan (Dera Murad Jamali) on the 16thof November 2018. A quick tour later, I found myself heading right for the nursery. The newborn babies are always the first ones I like to see when on a health assignment.

After seeing and getting a short history on the ten or twelve babies there, mostly premature or recovering from infections, I saw one baby behind a closed door in a dark room. She was in quarantine.

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Baby Aiza* (name changed) was born normal and healthy a few weeks prior of being admitted to MSF. On the sixth day of her birth, her family pierced her ears as per popular tradition in their community. After that the spasms started. She went into shock.

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Dr. Barkat, a consultant for MSF, has been monitoring her progress and told me she had greatly improved.

“When she first came, we couldn’t even stand in the same room as her for too long- even our breathing would trigger fits. We still keep her in a dark room because she is very sensitive to light and noise. It will take atleast another two weeks of antibiotics and hopefully she will improve some more.”

Since I was to stay in DMJ for one week, I decided to check up on Baby Aiza every day and document her recovery. I saw her mother come to check in on her every once in a while but she was suffering from a fever and too weak to be interviewed by me. I spoke to the baby’s grandmother who kept asking me when I thought they would be able to take her home.

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The day before I left DMJ, as per routine, I went to see the baby again. The room was bright and surprisingly empty.

The doctor on call looked at me and simply said, LAMA.

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LAMA. A dreadful word I had come to learn that stood for “Leave Against Medical Advice.” LAMA is fairly common occurrence in DMJ (especially in children suffering from malnutrition). Baby Aiza’s family stopped her treatment, which needed to go on for at least another two weeks, signed the documents and took her home.

As wrong as that may sound, women do not have the luxury of staying at hospitals while their child gets better. 100% of the time, they have at least 5 or 6 other children (if not 8 or 9) at home who need their attention. They possibly have to go back to work in the fields too. Their husbands need them back to take care of the house and also them. One of the doctors told me he had a case once where his patient who delivered premature twins had to stay at the hospital for several weeks. After some time the patient grew frantic and went into severe depression when she heard her husband had decided to marry another woman because he needed the help and attention at home.

Treatments at MSF facilities all over Pakistan are absolutely free. Mothers are given a common room right outside the nursery to stay for as long as they need to. Even their meals are free. And yet, it is time that becomes the thing that they cannot spare despite all medical expenses being taken care of.

How does one battle that?


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Some facts;

Pakistan is one of the 34 countries that have not achieved the neonatal tetanus (NT) global elimination target set by the World Health Organization (WHO). It is one of the most underreported diseases and remains a major but preventable cause of neonatal and infant mortality in many developing countries.

In a WHO report as recent as 24thJanuary 2019; Pakistan is one of 14 countries where Maternal Neonatal Tetanus is still a public health problem.

Photos and text ©Khaula Jamil

(On assignment for Medicine Sans Frontiers / Doctors Without Borders)

Dera Murad Jamali; Gulshan’s Story

It is a particularly hot day in Balochistan’s Western District of Dera Murad Jamali. Forty-year old Gulshan has come to the MSF facility to give birth to her tenth child. She feels tired and weak and wishes for the pain to end.

Inside the delivery room, Gulshan’s mother and maternal aunt are fussing around her trying to get whatever information they can from the doctors and nurses. This is after all, the first time in her twelve pregnancies that they have had to bring her to a hospital.

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Finally, a baby girl is born.
Gulshan’s mother explains their reason for not having a home birth;

“Last year she lost her baby in the eighth month of pregnancy and five months later when she became pregnant again we noticed she was very weak and sickly which is why we thought it would be better to bring her here for the delivery.”

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Gulshan got married as soon as she became a woman. This is determined by the first menstrual cycle and usually by the third or fourth, women in her community are married off.

“I think it has been around twenty five years since I got married and I started having children immediately.”

The concept of time and age is confusing for many women like her since none of them keep a track of it. They have no need to. Gulshan struggles to remember how many children she has and how old they are.

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“Two of my sons are working and one daughter is married with two children of her own, but the rest are still quite young.”

 Gulshan is exhausted. Her diet these past years has been basic potatoes and lentil with meat maybe once a week and no fruits of any kind at all. She has to make sure 12 mouths are fed before she eats and usually ends up with leftovers – sometimes not even that.

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Her 22-year-old son, Hamza, is outside the birthing unit waiting for his mother to be discharged. He will take his grandmother, aunt, mother and new born sister home in a rickshaw they have hired. At home, the entire family of nearly 25 people is waiting for their arrival.

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Gulshan’s aunt proceeds to give the baby an oil massage after which the baby is taken to her exhausted mother.

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The family has lots of plans for the baby.
On day 6 of her birth, they baby’s ears will be pierced as per tradition popular in Balochi culture. The MSF health educator explains to Gulshan’s mother and aunt that the baby is too small for such piercings and that there is a high risk of developing tetanus as a result which could cause her to go in shock.

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“But it is our tradition which we enjoy following, if they baby has fits then that is God’s will,” explains Gulshan’s aunt.

Tetanus in the first 28 days of life (neonatal tetanus) is an important cause of neonatal death. However, since babies affected by this disease usually are born at home and die there without registration of either event, the true burden is unknown. According to the doctors at MSF, it is a common cause of death in DMJ.

The family also plans on feeding the baby some herbal concoction.

“We will feed the mother and the baby ‘sutti’ so that the baby’s digestive system develops well.”

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These herbal concoctions are potentially dangerous for babies but its hard for health educators to convince families not to practice age old traditions like these.

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Lack of education is one of the biggest issues in Dera Murad Jamali. Pakistan Education Statistic 2016-17 launched by the National Education Management Information System (NEMIS) – a subsidiary of the Ministry of Federal Education and Professional Training revealed that 70% of the children in Balochistan were not in school.
This kind of illiteracy leads to men and women never learning about basic health practices that result in lack of proper hygiene, acute malnutrition and following of dangerous cultural practices that are harmful to children. In addition to that, lack of family planning lead to large families that are ultimately difficult to provide for. These factors also contribute to the high infant mortality rate in Pakistan.


MSF has been working in Pakistan since 1986. In eastern Balochistan, MSF runs an inpatient and outpatient therapeutic feeding programme and a paediatric care unit for children under five, as well as a neonatal ward in the District Headquarters Hospital in Dera Murad Jamali. In the nearby locations of Dera Allah Yar and Usta Mohammad, MSF also runs outpatient therapeutic feeding programmes.

Photos and text ©Khaula Jamil

(On assignment for Medicin Sans Frontiers/ Doctors without Borders)

 

Chaman; Green Tea Baby

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Arish was born on the 16th of October 2018 at the MSF birthing unit in Chaman, Balochistan. He went home with a healthy and clear bill from the facility.
Just 4 short days after his birth, he was back at the hospital in severe distress. His mother, Malika, was unable to produce enough milk to feed him.

“When I couldn’t feed him, I gave him green tea instead. My mother-in-law said it was the best thing to do and that’s what I had done with the rest of my 8 children also.”

 

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Green tea and black tea is poisonous for newborn babies. Their frail digestive systems cannot handle the components of tea, which are acidic for them. Malika admitted that in the past her new born children would fall ill after she gave them green tea and some of them even developed pneumonia, but then recovered. She didn’t realize just how lucky they were to have survived. Arish, unfortunately, may not be as lucky.

 

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This does not surprise Dr. Ziaullah, a graduate from the Latin American School of Medicine in Cuba and a full time doctor at the MSF facility at the DHQ Hospital in Chaman.

“You would be surprised by how common such cases are. They use black tea and green tea as go-to remedies for everything; burns/ cuts/ and also feeding babies. Arish’s condition is critical and we suspect neonatal sepsis.”

Normally after a baby is born, they will lose around 10% of their body weight in the first week. In Arish’s case, he has lost 50%. This makes his condition critical.

 

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When Malika realized there was something terribly wrong with her baby, she took him to a private clinic before bringing him to MSF. The doctor at the private clinic put Arish on antibiotics.

 

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“Antibiotics would not have been my first response of treatment for someone as young as Arish,” says Dr. Ziaullah. “If he had come to us, depending on his situation, we would have put an IVY to see if he improves first and not give him such an aggressive treatment- unless of course he was severely critical.”

On day 6, Dr. Farman who is a consultant with MSF, advised that Arish’s parents receive counseling to prepare them for the worst. A few hours later, Arish passed away in the nursery after a long and hard battle.

 

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“Lack of education is one of the biggest issues we face in Balochistan. These families follow their local remedies blindly and so many lives are lost as a result of it.”


In Pakistan, many mothers (particularly in Baluchistan) tend to feed their newborns tea, herbs or formula milk, one of the major factors behind a stunted growth rate in children of a staggering 44 percent according to a report done by UNICEF. The rate of growth stunting is among the highest in the world because of a lethal mix of risk factors (if the babies survive): bad nutrition, hygiene problems and unclean water, combined with a lack of education for mothers.

Many of these women work in the fields and do not have time to return home and feed their babies who are left at the hands of aged mother-in-laws who have no other choice but to substitute the mothers milk with tea and other herbal concoctions.

An article in Medical Express dated November 2016 reads;

“The government, which claims to be “aware of the problem”, has set a goal of reducing the rate of stunting to 40 percent by 2018—but the issue isn’t mentioned in its ten-year plan. Most interventions are funded by international donors.”

©Khaula Jamil


 

Reality Check; why they want boys

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I met her while she was sitting outside the birthing unit at the MSF facility in Chaman while her daughter in law was getting a check up. We started chatting and I asked her about her life. Samina Bibi is a mother of 7 sons and 6 daughters. She has 3 daughter in laws and 9 grandchildren between them. She tells me she has her hopes set high for a new grandson but judging by her daughter in laws complexion, she knows that they will be taking a baby girl home. I asked her if that mattered? She giggled and so did a bunch of women around her, “that’s like asking if I prefer lentil over meat for lunch!” Of course I knew she wanted a boy, but I wanted to set my assumptions aside and have her tell me why.

And she did.

“I grew up with brothers who went to school but I was denied education because it was more important for them to go. Women are treated like mazdoors so why would I want a baby girl who will have to live like this? We cook, clean and attend to sick people in the house then get married and have children and do the same thing our whole lives. We get very little respect. It’s better if it’s a boy, at least people will value his existence.”

To anyone who has ever thought that the reason the boy child is preferred only because he can eventually be the provider for the family, think again. In many parts of the society, women don’t want to bear baby girls in order to save them from lives of oppression. Education is our only savior, unfortunately it’s a vicious cycle when only the boys are sent to school and the teachers teach only one narrative.

Some facts: In 2013, 64% of rural female population in Balochistan never went to school. 75% of girls are out of school between the age of 5 to 16. The overall female literacy rate in the province is 26% and male is 37%. Consequently, 25% females have ever been to school compared to 60% males. Child marriage is common and most girls are married by the age of 14. Let’s let this sink in.

©Khaula Jamil

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