Field Notes

Field Notes 

An AKU doctor involved in relief efforts in flood-stricken areas of northern Sindh shares her experiences 

August 18, 2010

Day 1 in Khairpur

Khairpur at this moment is housing a huge bulk of displaced people from Larkana, Jacobabad, Shikarpur, and many other smaller villages like Thul, Ghouspur etc. The number of registered displaced people is crossing 50,000. Around 120 camps are housing people in small clusters, with 250 to 300 in smaller schools and 5000 to 8000 in larger schools.

In all camps by far majority is of children. The statistics are mind boggling; for example a camp in Ghari Mori, district Khairpur, housing 280 people, has 44 men, 67 women and 169 children. Out of the total number, almost all children are sick, with disorders like stunted growth, severe malnourishment, diarrhoea and skin problems. The need for a qualified child specialist cannot be stressed enough.

When it comes to women, almost all are anaemic, weak, malnourished, or perpetually pregnant or breast feeding and the sad part is that there is no milk and yet the baby is still latched, always. Almost 20 to 25 per cent of the women are pregnant. In each camp my team categorically screened pregnant women and started referring high-risk women to the hospital. The high risk population included grand multiparas like 11th gravidas and beyond, with doubtful presenting part. The big question is do we have resources to close this loop? Do we have adequate qualified staff at the hospital to look after these women?

As the saying goes, every cloud has a silver lining, so the silver lining of this tragic scenario could be that these women who have never seen a hospital in their life will be experiencing institutional delivery. In other words we are now looking at a population who will never ever come to a hospital. These are potential maternal deaths which we can save. We cannot and should not miss out on this opportunity.

Another thing that I am going to engage the stakeholders in is postpartum IUCD, for women who are going through a second or third pregnancy and tubal ligation in higher order pregnancies.  In these women, who are completely unaware of family planning, this intervention is not just for health purposes but can also prove to be a life-saving initiative. 

I am expecting the qualified OBGYN and Child Health Community to come forward and be a part of this historical event.

The burden of responsibility is on our shoulders!

Day 2 in Khairpur Relief Camps

One of the most important health care programmes in rural Pakistan is that of Lady Health Workers (LHWs) and Lady Health Visitors. They are the primary health care providers in a community.  Therefore, a morning meeting with these health care providers was a must. At this meeting we emphasised that women and children were the worst hit and required more attention. As LHWs they can look after health needs and re-enforce hygiene as most of the ailments are due to a breakdown of sanitation facilities. At every camp, we were giving out soaps, detergents, brooms and begging the occupants to keep things clean.

At the next stop, we met with local female doctors and urged them to take on the responsibility as working as the home team. Khairpur has a large number of lady doctors working under different heads, so only a little bit of organization and motivation was needed. I noticed that the doctors were comfortable in the hospital premises only. Once you take them out of the hospital setting, they are lost. The need for community obstetrics and gynaecology could not be emphasised more.

My humble observation is that disease is not because of floods, but due to the current fragile health condition of children, most being stunted and malnourished.

I think if we could implement some basic sanitation and hygiene practices, we could cover half or more of the disease outbreaks. That is why UNICEF is building pit-latrines – which are very useful under the circumstances.

Camp management is an art which is multidimensional.  Health, food, sanitation are only part of the picture. But maintaining dignity and self-esteem is an even bigger challenge and we are still a far cry away from managing it.

Coming back to my domain of women health in general, and maternal health in particular, none of this population is educated, and more tragically, none have any intention of sending their children to school as well. On average there are 10 to15 children per women.

When I asked Amerah at Tehri camp, how old are you, she had no idea. Nothing unusual as none of them know their age. When I ask her, how many children she said “jam” in Sindh, meaning a lot. Still how many,  I asked “Maybe 15 or 16.”

This is the story of majority of the mothers. Grand multiparity is by far the most common risk factor. When asked how many more do you want, Amerah looks towards the sky and says “Allah ji marzi”. Cynically, this translates into till death do us apart.

If we wish to break this cycle between Amerah and death, then family planning rather than limitation in her case has to play a role. In Kandiyaro camp, a mother who gave birth to a baby boy after 14 girls, declared this flood “Mubarak” and named her son Sailab Khan. Now before next year some Tofan Khan is born, some form of intervention has to be done to save the life of this mother.

The good news is that two post-natal patients in Burgari were asking what could be done to improve their health and health of their children. Think birth control!

So, I keep my stance of positive thinking and believe that this population will go back in a better condition if we can, at the least, intervene at health and education levels.

Today, we covered seven schools and screened almost 49 pregnant women; almost half of them were full-term pregnant with risk factors. These women were very enthusiastic at being examined. All wanted their pulse, blood pressure to be checked, and abdomen palpated for foetal parts and auscultation of foetal hearts. They felt pampered and special and followed our advice as a sign of thankfulness.

In other words, this population is docile and will not be a barrier to positive health intervention. Therefore, health and education community should be planning and looking at making this disaster into a fruitful opportunity.

Will keep you posted, tomorrow we go to Larkaro (new name for Larkana) and Sukkur Camps.