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Childhood diarrhoea in Pakistan
Newsdesk
Childhood diarrhoea in Pakistan Natural disasters, poor education, and weak infrastructure maintain high rates of diarrhoea. Can civil society fill the gap left by the loss of the Ministry of Health? Talha Burki investigates. For the Punjab study on maternal perceptions of diarrhoea see http://www.iwmi. cgiar.org/Publications/Working_ Papers/working/WOR25.pdf For the WHO on breast feeding see http://www. who.int/ immunization/newsroom/ newsstory_rotavirus_vaccines_ immunization_programmes/en/ For The Lancet Series on Pakistan see http://www. thelancet.com/series/healthtransitions-in-Pakistan
AFP/Getty Images
For the paper by Bhutta and colleagues see Series Lancet 2013; 381: 2207–18.
Statistics on Pakistan’s burden of diarrhoeal diseases are hard to come by. The country’s disease surveillance mechanisms are woefully inadequate. Nor is there a working civil registration system for births and deaths. Still, estimates suggest that roughly 45 000 children are killed by diarrhoea every year. Such diseases form a significant proportion of the mortality rate in children less than 5 years of age of 72 per 1000 births. They account for roughly half of the workload of the already-overloaded community doctors—experts reckon Pakistan’s shortfall of health-care workers is approaching 200 000—and help to explain why Pakistan has the third highest burden of maternal, fetal, and child mortality in the world. The country faces a daunting array of problems. It is prone to natural disasters—the past 10 years have seen catastrophic flooding and a 7·6-magnitude earthquake. The war in Afghanistan has spilled over into northern Pakistan, and an insurgency in Baluchistan has left swathes of the impoverished province almost impossible to access, with predictable consequences for a population with some of the worst health indicators in the nation. 44% of children are stunted. Female literacy rates, which have a direct bearing on infant health,
Acute diarrhoea continues to have a devastating effect for the children in Pakistan
190
are about 45%. Far too many girls drop out of primary school—when they become mothers, their children will be twice as likely to die before their fifth birthday as those whose mothers have completed primary education. Poor education means that an episode of diarrhoea, incidence of which in Pakistan averages around 3·21 per child per year, is not always acknowledged as a consequence of contaminated water. A 2001 study in a village in southern Punjab found that mothers associated diarrhoea with
“‘We have stood still in Pakistan while others have moved on; we’ve the slowest rate of reduction in child mortality in the whole of Asia’”... eating too much hot food in summer, or too much cold food in winter. Cholera was thought to be caused by consuming water and melon. Millions of rural Pakistanis rely on irrigation or river water, or bore wells. In these areas, people typically live in compounds. The men work in the fields, and defecate openly, as do children (roughly half the rural population practices open defecation). Women might sneak off at night, or use so-called flying toilets (plastic bags). “There are some pit latrines, but a flush system is hardly available, and disposal of faeces is a challenge—in many places, faeces are not disposed of well”, outlines WHO’s Shamim Ahmad Qazi. Pit latrines are not always set up properly. They might overflow, for example, or they might not be built at the recommended 30 m minimum distance from sources of drinking water. The women in the Punjab study held erroneous beliefs about breastfeeding: some thought that breast milk could be spoiled by adverse weather
conditions and by pregnancy. They often ceased breastfeeding within a couple of months of falling pregnant again, or replaced some breastmilk with water. Such attitudes might not be typical of Pakistan, but what is beyond dispute is that breastfeeding rates are far from ideal. Just 37% of mothers exclusively breastfeed their children until age 6 months. Lack of breastfeeding is associated with a 165% increase in the number of diarrhoea episodes for children less than 6 months old; these infants are 15 times more likely to die from diarrhoea than are those who are exclusively breastfed. Breast milk has curative powers. “Breast milk is also an excellent rehydration fluid and should be given to children still breastfeeding along with ORS [oral rehydration salts]”, according to WHO. It is not the only intervention with insufficient coverage. “Provision of ORS and zinc, and hand washing are less than optimal”, explains Qazi. The government began promoting ORS in the 1980s, yet it is only used in the management of about 40% of cases of diarrhoea. Zinc coverage is even worse: it hovers at about 3%. WHO reckons that 100% coverage of ORS would cut diarrhoea mortality by 93%, while zinc can cut mortality by 23%. Bangladesh, which broke from Pakistan in 1971, manages to provide zinc to over half of its patients with diarrhoea, part of a package of measures that have reduced the proportion of deaths in children attributable to diarrhoea to under 5%. “We have stood still in Pakistan while others have moved on; we’ve the slowest rate of reduction in child mortality in the whole of Asia”, affirms Zulfiqar Bhutta (Aga Khan University, Karachi). The backdrop to all this is the appalling condition of water www.thelancet.com/infection Vol 14 March 2014
provision and sanitation. “The state of sanitation in the urban slums are unspeakable; in fact, they may potentially be worse than rural places because they’re living in more congested environments”, Bhutta told TLID. Water pipes and sewage pipes often run alongside each other, rather than on opposite sides of the road, or at a suitable distance; mixing between the two is common. Ensuring a supply of chlorinated, filtered water is a prerequisite, but in many places, including most of the southern province of Sindh, this does not usually happen. But clean water at source is not enough. “The entire water pipeline must be secure”, stresses Priyanie Amerasinghe of the International Water Management Institute (Hyderabad, India). Many of Pakistan’s problems are a function of poverty. The past few years have been especially destructive. The floods of 2010 and 2011 left huge numbers of Pakistanis destitute. Coupled with sharp increases in the price of food, this has led to a significant rise in poverty levels. In a Lancet paper, part of a series on Pakistan, Bhutta and colleagues pointed out that “poverty is more than mere income and assets and can evoke a sense of fatalism and hopelessness”; mothers of ill children may not always seek medical care, for example. Compounding the problem is a population boom that shows little sign of abating. At its formation in 1947, Pakistan was home to fewer than 30 million people; today the population is just short of 200 million. Female fertility rate is 3·4 births. Aside from the additional pressure on straitened resources, overcrowding has implications for infectious disease. The more children, the less time mothers can focus on each child’s health; children who come later in the birth order are more likely to be undernourished. Still, none of this struggle is insurmountable—other countries www.thelancet.com/infection Vol 14 March 2014
have made advances in the face of comparable constraints. “Everyone agrees that they are effective interventions for managing diarrhoea”, points out Qazi. Bhutta adds that by targeting interventions, Pakistan could reduce its diarrhoea mortality by 70%. But this will require political commitment, and such commitment has rarely been forthcoming. In another paper in the Lancet’s series on Pakistan, Nishtar and coauthors stated that “health is one of the most corrupt services” in the country. Certainly it has been long neglected. The government spends less than 0·5% of GDP on health care; this is unacceptably low. Most goes to large hospitals. “There has not been investment in the basics—there is no interest in primary care”, affirmed Bhutta. The 18th Constitutional Amendment (2010) devolved health care to Pakistan’s five provinces, and dissolved the Ministry of Health (Pakistan is now the only federal country in the world without a centralised structure overseeing healthcare). There is no reason why devolution need not work—it could be particularly beneficial for the marginalised Baluchistan—but there still seems to be little political will to tackle waterborne diseases. “There really needs to be a focus at the level of the provincial governments, after devolution, on scaling up appropriate treatment and interventions and implementation of [WHO’s] integrated action plan for pneumonia and diarrhoea”, concludes Bhutta. Perhaps Pakistan’s best hope is the 100 000 or so Lady Health Workers (LHWs). The programme was established in 1994 to tackle, among other things, maternal and child health and nutrition, with a focus on rural areas. Today, they cover over half the rural population, advising on preventive services and educating the community on good practices. “They are trained to manage diarrhoea”, confirms Qazi. This training
N Durrell McKenna, Wellcome Images
Newsdesk
Many people in northwest Pakistan live in poverty
is sorely needed. A 2012 survey of community pharmacies in Pakistan found that just 8·4% dispensed ORS after the researcher had outlined a simulated case of diarrhoea. The LHWs have already shown success in increasing rates of breastfeeding. They are not always paid on time and they face shortages of medicines and equipment—provision of ORS and zinc to community workers in Pakistan is sporadic and inconsistent—but they are an important tool in efforts to improve public health in underserved parts of the country. Pakistan’s energetic civil society also offers glimmers of hope. A few years ago, public protests proved instrumental in reinstating a Chief Justice, against the wishes of Pakistan’s military dictator. Bangladesh’s success in tackling diarrhoea was driven by non-governmental organisations that were determined to bring about change. This was matched by progress in empowering women and educating people on family planning. “I suspect that in Pakistan, the real gains are going to come out of civil society”, Bhutta told TLID. Pakistan has a reasonably free press; they too could have a role to play. “In Pakistan, when there is public awareness, things can change”, said Bhutta. “But at the moment, unfortunately for public health and nutrition, there don’t seem to be many advocates.”
For the paper by Nishtar and colleagues see Series Lancet 2013; 381: 2193–206. For the survey of community pharmacists see http://www. emro.who.int/emhjvolume-18-2012/issue-6/ article-14.html
Talha Burki 191
Childhood diarrhoea in Pakistan Natural disasters, poor education, and weak infrastructure maintain high rates of diarrhoea. Can civil society fill the gap left by the loss of the Ministry of Health? Talha Burki investigates. For the Punjab study on maternal perceptions of diarrhoea see http://www.iwmi. cgiar.org/Publications/Working_ Papers/working/WOR25.pdf For the WHO on breast feeding see http://www. who.int/ immunization/newsroom/ newsstory_rotavirus_vaccines_ immunization_programmes/en/ For The Lancet Series on Pakistan see http://www. thelancet.com/series/healthtransitions-in-Pakistan
AFP/Getty Images
For the paper by Bhutta and colleagues see Series Lancet 2013; 381: 2207–18.
Statistics on Pakistan’s burden of diarrhoeal diseases are hard to come by. The country’s disease surveillance mechanisms are woefully inadequate. Nor is there a working civil registration system for births and deaths. Still, estimates suggest that roughly 45 000 children are killed by diarrhoea every year. Such diseases form a significant proportion of the mortality rate in children less than 5 years of age of 72 per 1000 births. They account for roughly half of the workload of the already-overloaded community doctors—experts reckon Pakistan’s shortfall of health-care workers is approaching 200 000—and help to explain why Pakistan has the third highest burden of maternal, fetal, and child mortality in the world. The country faces a daunting array of problems. It is prone to natural disasters—the past 10 years have seen catastrophic flooding and a 7·6-magnitude earthquake. The war in Afghanistan has spilled over into northern Pakistan, and an insurgency in Baluchistan has left swathes of the impoverished province almost impossible to access, with predictable consequences for a population with some of the worst health indicators in the nation. 44% of children are stunted. Female literacy rates, which have a direct bearing on infant health,
Acute diarrhoea continues to have a devastating effect for the children in Pakistan
190
are about 45%. Far too many girls drop out of primary school—when they become mothers, their children will be twice as likely to die before their fifth birthday as those whose mothers have completed primary education. Poor education means that an episode of diarrhoea, incidence of which in Pakistan averages around 3·21 per child per year, is not always acknowledged as a consequence of contaminated water. A 2001 study in a village in southern Punjab found that mothers associated diarrhoea with
“‘We have stood still in Pakistan while others have moved on; we’ve the slowest rate of reduction in child mortality in the whole of Asia’”... eating too much hot food in summer, or too much cold food in winter. Cholera was thought to be caused by consuming water and melon. Millions of rural Pakistanis rely on irrigation or river water, or bore wells. In these areas, people typically live in compounds. The men work in the fields, and defecate openly, as do children (roughly half the rural population practices open defecation). Women might sneak off at night, or use so-called flying toilets (plastic bags). “There are some pit latrines, but a flush system is hardly available, and disposal of faeces is a challenge—in many places, faeces are not disposed of well”, outlines WHO’s Shamim Ahmad Qazi. Pit latrines are not always set up properly. They might overflow, for example, or they might not be built at the recommended 30 m minimum distance from sources of drinking water. The women in the Punjab study held erroneous beliefs about breastfeeding: some thought that breast milk could be spoiled by adverse weather
conditions and by pregnancy. They often ceased breastfeeding within a couple of months of falling pregnant again, or replaced some breastmilk with water. Such attitudes might not be typical of Pakistan, but what is beyond dispute is that breastfeeding rates are far from ideal. Just 37% of mothers exclusively breastfeed their children until age 6 months. Lack of breastfeeding is associated with a 165% increase in the number of diarrhoea episodes for children less than 6 months old; these infants are 15 times more likely to die from diarrhoea than are those who are exclusively breastfed. Breast milk has curative powers. “Breast milk is also an excellent rehydration fluid and should be given to children still breastfeeding along with ORS [oral rehydration salts]”, according to WHO. It is not the only intervention with insufficient coverage. “Provision of ORS and zinc, and hand washing are less than optimal”, explains Qazi. The government began promoting ORS in the 1980s, yet it is only used in the management of about 40% of cases of diarrhoea. Zinc coverage is even worse: it hovers at about 3%. WHO reckons that 100% coverage of ORS would cut diarrhoea mortality by 93%, while zinc can cut mortality by 23%. Bangladesh, which broke from Pakistan in 1971, manages to provide zinc to over half of its patients with diarrhoea, part of a package of measures that have reduced the proportion of deaths in children attributable to diarrhoea to under 5%. “We have stood still in Pakistan while others have moved on; we’ve the slowest rate of reduction in child mortality in the whole of Asia”, affirms Zulfiqar Bhutta (Aga Khan University, Karachi). The backdrop to all this is the appalling condition of water www.thelancet.com/infection Vol 14 March 2014
provision and sanitation. “The state of sanitation in the urban slums are unspeakable; in fact, they may potentially be worse than rural places because they’re living in more congested environments”, Bhutta told TLID. Water pipes and sewage pipes often run alongside each other, rather than on opposite sides of the road, or at a suitable distance; mixing between the two is common. Ensuring a supply of chlorinated, filtered water is a prerequisite, but in many places, including most of the southern province of Sindh, this does not usually happen. But clean water at source is not enough. “The entire water pipeline must be secure”, stresses Priyanie Amerasinghe of the International Water Management Institute (Hyderabad, India). Many of Pakistan’s problems are a function of poverty. The past few years have been especially destructive. The floods of 2010 and 2011 left huge numbers of Pakistanis destitute. Coupled with sharp increases in the price of food, this has led to a significant rise in poverty levels. In a Lancet paper, part of a series on Pakistan, Bhutta and colleagues pointed out that “poverty is more than mere income and assets and can evoke a sense of fatalism and hopelessness”; mothers of ill children may not always seek medical care, for example. Compounding the problem is a population boom that shows little sign of abating. At its formation in 1947, Pakistan was home to fewer than 30 million people; today the population is just short of 200 million. Female fertility rate is 3·4 births. Aside from the additional pressure on straitened resources, overcrowding has implications for infectious disease. The more children, the less time mothers can focus on each child’s health; children who come later in the birth order are more likely to be undernourished. Still, none of this struggle is insurmountable—other countries www.thelancet.com/infection Vol 14 March 2014
have made advances in the face of comparable constraints. “Everyone agrees that they are effective interventions for managing diarrhoea”, points out Qazi. Bhutta adds that by targeting interventions, Pakistan could reduce its diarrhoea mortality by 70%. But this will require political commitment, and such commitment has rarely been forthcoming. In another paper in the Lancet’s series on Pakistan, Nishtar and coauthors stated that “health is one of the most corrupt services” in the country. Certainly it has been long neglected. The government spends less than 0·5% of GDP on health care; this is unacceptably low. Most goes to large hospitals. “There has not been investment in the basics—there is no interest in primary care”, affirmed Bhutta. The 18th Constitutional Amendment (2010) devolved health care to Pakistan’s five provinces, and dissolved the Ministry of Health (Pakistan is now the only federal country in the world without a centralised structure overseeing healthcare). There is no reason why devolution need not work—it could be particularly beneficial for the marginalised Baluchistan—but there still seems to be little political will to tackle waterborne diseases. “There really needs to be a focus at the level of the provincial governments, after devolution, on scaling up appropriate treatment and interventions and implementation of [WHO’s] integrated action plan for pneumonia and diarrhoea”, concludes Bhutta. Perhaps Pakistan’s best hope is the 100 000 or so Lady Health Workers (LHWs). The programme was established in 1994 to tackle, among other things, maternal and child health and nutrition, with a focus on rural areas. Today, they cover over half the rural population, advising on preventive services and educating the community on good practices. “They are trained to manage diarrhoea”, confirms Qazi. This training
N Durrell McKenna, Wellcome Images
Newsdesk
Many people in northwest Pakistan live in poverty
is sorely needed. A 2012 survey of community pharmacies in Pakistan found that just 8·4% dispensed ORS after the researcher had outlined a simulated case of diarrhoea. The LHWs have already shown success in increasing rates of breastfeeding. They are not always paid on time and they face shortages of medicines and equipment—provision of ORS and zinc to community workers in Pakistan is sporadic and inconsistent—but they are an important tool in efforts to improve public health in underserved parts of the country. Pakistan’s energetic civil society also offers glimmers of hope. A few years ago, public protests proved instrumental in reinstating a Chief Justice, against the wishes of Pakistan’s military dictator. Bangladesh’s success in tackling diarrhoea was driven by non-governmental organisations that were determined to bring about change. This was matched by progress in empowering women and educating people on family planning. “I suspect that in Pakistan, the real gains are going to come out of civil society”, Bhutta told TLID. Pakistan has a reasonably free press; they too could have a role to play. “In Pakistan, when there is public awareness, things can change”, said Bhutta. “But at the moment, unfortunately for public health and nutrition, there don’t seem to be many advocates.”
For the paper by Nishtar and colleagues see Series Lancet 2013; 381: 2193–206. For the survey of community pharmacists see http://www. emro.who.int/emhjvolume-18-2012/issue-6/ article-14.html
Talha Burki 191